Thursday, July 7, 2011

Healthcare in America: Sacred Cow or Cash Cow?

Envious of conservatives who control moral politics with "pro-life," "tax relief," and "family values," progressives have embraced George Lakoff's linguistic framing strategies.

President Obama won the hearts and minds of independent and progressive voters with his message of "hope" and "change." Yet the Obama administration repackaged his rhetoric with conservative ideology and pragmatism.

This is certainly true in regards to the Affordable Care Act, conceived (and now disowned) by Mitt Romney. Obama rejected single payer activists from the negotiation table. Ironically, the current snapshot of the Obama administration is framed by "socialized medicine," "death panels," and "Obamacare."

Rays of hope for single payer financing shine on Vermont, where a new law creates Green Mountain Care Board, a public board that "can wield traditional tools such as fee-for-service rate setting, controls on the acquisition of technology, and reviews of both health insurers’ rates and hospitals’ budgets."

Anya Rader Wallack, Ph.D., special assistant to Vermont Governor Shumlin, further writes in the New England Journal of Medicine: "we must align incentives for payers, providers, and consumers so that the risks and rewards embedded in provider payment systems, benefit designs, and cost sharing all promote a higher-value health system and better health." Without elaborating upon the pitfalls of over-utilization, she explains "the project will expand to include 'anchor' specialists attached to advanced primary care medical homes, with bonus payments linked to both quality and total cost of care."

Like Harry Potter's peers who dare not utter Voldemort, she seems to go out of her way to avoid using "accountable care organization," "triple aim," "capitation," "managed care" and other policy lingo that drives shivers down the spines of health care crusaders.

The name she and other single payer activists also avoid: the RUC.

In the current issue of Health Affairs, Brian Klepper and Paul Fischer write:

"the Relative Value Scale Update Committee (RUC), a secretive, specialist-dominated panel within the American Medical Association (AMA) that, for the past two decades, has been the Centers for Medicare and Medicaid Services’ (CMS’) primary advisor on valuation of medical services... It has systematically under-valued primary care and operated without regard for financial conflicts of interest. Its influence has compromised care quality and facilitated the primary care labor shortage."

Unlike other developed countries, the United States does not control specialty growth. For decades, policy makers have worried about a "specialist glut." And yet, the Accreditation Council on Graduate Medical Education and the American Board of Medical Specialties enable medical schools to keep pumping them out and in many new flavors: Hospice and Palliative Medicine, Undersea and Hyperbaric Medicine, Female Pelvic Medicine and Reconstructive Surgery, Pediatric Transplant Hepatology, Medical Biochemical Genetics (to name a few).

Medical school debts compel idealistic medical students to follow the money down the specialty path. Consequently, our nation is glutted with well-paid specialists who are threatened that they might sink if they are "anchored" to a primary care physician with fee-for-service rate setting.

Current health plans don't afford the undervalued primary care doctor time to help individuals sort our risks and benefits for any care they receive. Accountable Care Organizations, with information technology to automate screening tests, will indiscriminately do that for them.

Consider this review of Overdiagnosed: Making People Sick in the Pursuit of Health by a family practitioner. "Recently I was told that I do not have enough time to explain risks and benefits of screening to my patients. I try to take the time, but many have been convinced by media and friends that 'good medicine' means 'early detection.' My risk and benefit speech is not what many want to hear. It's so much easier just to be told what to do."

If quality is measured solely by the tests done, we will surely see more false positive and false negative test results without improved health. That's because the Affordable Care Act promises free preventive care and punitive cost-sharing for the follow-up testing and treatment. After all, cost-sharing is the antidote to consumer appetite for too much care.

And if this happens, health care will surely go down the path of education reform as No Patient Left Behind.

I hope, as Anya Wallach does, that the less-than-perfect single payer financing in Vermont will create savings and improve outcomes through reforms that include fee-for-service rate setting.

Instead of a new frame, we need to create a new image of health care that puts the focus on primary care physicians as advocates for individual and societal health. Rudlolf Virchow, a mid-nineteenth century German doctor who is remembered for advancing public health wrote, "The physicians are the natural attorneys of the poor, and social problems fall to a large extend within their jurisdiction." Single payer activists and the Physicians for a National Health Program should demand we Replace the RUC!

Monday, October 26, 2009

The Fake Debate

Robert Samuelson’s Opinion published today in the Oregonian frames the debate concerning “HEALTH CARE REFORM” in realistic and compelling terms. He outlines the debate rather simply as between: “genuine competition among health plans” and, “strict regulation of doctors, hospitals and patients under a single payer system”.

The author seems to side with the first choice by excusing the Health Insurance Industry as, “-----simply the middlemen”. He seems to logically settle the argument with the identification of “the fragmented delivery system and open-ended reimbursement” as the true villain regarding costs and quality.

The additional questions that need to be asked are: Why have the competing insurance companies not been able to solve the problems over several decades of near total control (including anti-trust exemptions)? Are they not the source of complexity, fragmentation, and of failure to regulate any component of the current system?

Gerald R. Schwarz MD

Thursday, October 22, 2009

Oregon's values: Is health care a basic human right?

From a blog of the Democratic Party of Washington County...

Derrick's Progressive News

Independents 35%, Democrats 33.7%, Republicans 22.5%

Why are Dems only 33.7%?

Money in the politics of health care reform are staggering--and I believe it is why we distrust government and party politics.

Why don't we learn from the prescription drug industry giveaway?

I attended the 2009 Archimedes Movement conference last Friday. Dr. Bruce Goldberg, Director of Oregon's Department of Human Services, spoke at the Archimedes event on Friday. Oregon state and federal leaders tout a "robust" public option without specifics for cost containment... and certainly without universal coverage.

TR Reid's research of universal health care in all the other developed countries shows that cost containment would follow--and Alex Preker, a leading health economist at the World Bank agrees.

I asked Dr. Goldberg why our elected leaders don't define health care as a basic right. He suggested that Oregonians don't have those values.

Yet that contention is not supported in the two decades that the Oregon Values Survey has been done.

Nor is it consistent with the Health Values Surveys of 1996, 2000 and 2004--where 85% of Oregonians somewhat or strongly agreed that "All Oregonians should be guaranteed basic and routine health care services."

Rural centrist Blue Dog Rep. Mike Ross (D. Ark) suggested opening Medicare to those under 65 without insurance. Yep! I can agree with that.

It is an affront to all American that we do not have universal access to affordable basic health care.

We can beat money in politics with our voice and our votes.

Monday, October 12, 2009

My open letter to President Obama

Dear President Obama, 
You accepted the Nobel Peace Price with humility, recognizing that it can be a "means to give momentum to a set of causes." America faces economic and environmental crises of global proportions, due to laissez faire erosions of governmental controls of capitalism. The Supreme Court will be making decisions regarding corporate personhood in Citizens United v. Federal Election Commission.

You nominated Cass Sunstein as the head of the Office of Information and Regulatory Affairs. He revered President Roosevelt and believed that FDR's Second Bill of Rights was the greatest speech of the 20th century

Every American is entitled to:
The right to a useful and remunerative job in the industries, or shops or farms or mines of the nation;
The right to earn enough to provide adequate food and clothing and recreation;
The right of farmers to raise and sell their products at a return which will give them and their families a decent living;
The right of every business man, large and small, to trade in an atmosphere of freedom from unfair competition and domination by monopolies at home or abroad;
The right of every family to a decent home;
The right to adequate medical care and the opportunity to achieve and enjoy good health;
The right to adequate protection from the economic fears of old age, and sickness, and accident and unemployment;
The right to a good education.
President Obama, our elected leaders, unlike those in all other developed countries, have never wrestled with this basic question: Do all Americans have a basic right to health care?  
President Roosevelt stated, "The one supreme objective for the future, which we discussed for each nation individually, and for all the United Nations, can be summed up in one word: Security. And that means not only physical security which provides safety from attacks by aggressors. It means also economic security, social security, moral security -- in a family of nations."  
In regards to health care, Administrator Sunstein needs the green light to direct Congress in regulatory matters that address our basic right to health care. Our nation will falter without addressing these moral and economic imperatives.