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In this post, I suggested that Congress should set the following goal for a robust public health care plan:
The goal should be to create a public option that is as attractive to consumers, efficient in its operations, and fair to providers, as Congress can make it. Congress should be designing a plan that consumers and providers will actually want to use, and then let the private plans respond if they can to retain their market share. . . .
Congress’ job is to authorize, fund and create the most attractive, sustainable public plan this country can produce, and then put in place the mechanisms to hold it accountable for doing its job.
So what criteria should a robust public plan meet? Here’s an initial list, and I hope others will contribute more/better ideas.
Suggested essential elements (updated 4:30 a.m. FDL from comments):
1. Choose a design that can eventually cover everyone — universal health coverage should be the national commitment and goal, so start with a framework that can get there over time.
2. Cover everything that’s important to consumers — a basic plan that includes all "medically necessary" services (including dental, vision, mental care, prevention, etc) — services health care consumers typically need.
3. Guarantee open, non-discriminatory access and choice of providers — everyone is free to choose the public plan; no exclusions, no waiting periods for sign up. Prior conditions are irrelvant — the goal is universal care. Preserve choice of providers.
4. Employ open architecture to allow gradual expansion — the system should anticipate and be able to accommodate the eventual inclusion of other health delivery systems, such as Medicaid, SCHIP, to eliminate needless duplication and inefficiencies among disparate systems. Americans should not receive significantly different treatment or quality of care just because they started under a different system.
5. Minimize needless billing; minimize co-pays and deductibles — fund it primarily through easily collectible, fairly imposed taxes (simplifying reduces administrative costs while reducing consumer out-of-pocket costs, frustrations and worry)
6. Minimize hassles in accounting/making payments to providers — they’re providing essential services and expertise, so cover their reasonable costs, recognize their value and compensate them in ways that attract committed, quality healers to the profession. [Examine, address regional disparities, to discourage regional surpluses, shortages, which also means fixing Medicare payments too.]
7. No-cost shifting — if you expect employers to contribute to health coverage, think of it as a source of funding for the system; the value of that contribution belongs to and goes with the employee, whatever choice the employee makes. (like "Play or Pay")
8. Include an accountable public oversight entity with the responsibility to improve care, service, incentives for best practices, administration and cost efficiency. Give it enough research/oversight funding, staffing and teeth to do it’s job and empower plan administrators to implement needed reforms, bargain for/set rates/prices. We’re talking about up to 1/6 of the economy and the imperative to make this work and afforable.
9. Don’t design the system to accommodate or shield the inefficiencies and abuses of private insurers. They’ll either figure out how to adapt, survive and retain customers by providing value (e.g., better or incremental coverage) or they’ll lose business by consumers voluntarily choosing something better. Either way, the American people win.
10. "It’s the economy, stupid" — the economic goal is to get national health care costs under control, not simply to mimimize federal budget outlays.
11. Within two years of the Plan’s commencement, convert all federally funded Congressional health plan coverage to the Public Plan. [h/t selise]
Others?
60 Comments
Outstanding analysis – thanks Scarecrow
6. One of the problems with the Medicare architecture is that it regionalizes reimbursement. When the scheme was initially set up, it looked at the number of physicians and rates in each region. This has had two effects. It has run up costs dramatically in ‘overserved’ heavily urbanized states (NY, CA, FL), and limited physician incomes in ‘underserved’, rural states.
Limiting physician incomes has made it increasingly difficult for those ‘underserved’ areas to attract physicians. Medical residents are not generally dummies, so they say, “Hmmmmm. I can practice in New Mexico and make 200K/yr, or I can practice in Boca Raton and make 380K.” (Those numbers are pulled out of thin air, based on conversations I’ve had with physicians.) Fortunately, some do have a commitment to practice here. Some come to do their mandatory service for their med school tuition and fall in love with the place. But drawing them is difficult.
It would be one thing if Florida and California got better outcomes, but the numbers don’t back it up.
So fixing the reimbursement issue with Medicare has to be fairly high on the list.
Funding preventive diagnostics in the bundle of covered services is also crucial.
cover all “medically necessary” care including mental health care, dental, vision.
other random thoughts:
* choice of healthcare providers
* low limit to annual total out of pocket expenses
*
You guys and your insomnia…
OK, me too.
I watched some clips here, here, here, and here of the House hearing on rescission from last week – CEO’s of the greasiest sort, trolling for mercy from the committee and praying NOT to be pinned. Liars all.
But as I watched them discuss rescission criteria, I was struck by this: how could an insurance company call themselves anything but a mill for thievery while denying coverage to anyone? They insist that they would only provide a universal ‘product’ irrespective of pre-existing condition if the entire country were mandated.
Like we couldn’t see that coming. These scumbags are very difficult to watch.
yeah, well, my favorite public plan is the single payer one. put the private health care insurance companies out of business. they’ve had decades to clean up their act, when do we get to say “enough!”?
but i was trying to play fair with scarecrow’s questions….
oh, shoot. i forgot my most important item for the public option plan. i want to create an incentive not to underfund it. so here’s my suggestion:
* all members of congress must get their health insurance through the public plan. no other options for them.
Absolutely terrific philosophical framework, Scarecrow!
and thanks to BC’s and Selise’s amendment recommendations.
To expand upon BC’s comments on Medicare. I was excited last week to learn about Sen. Bingaman’s proposal to help resolve the Med D donut hole problem, and was hopeful with the weekend news that a deal had been struck with the industry (I’ve yet to get the details on what that really means) I’m reminded that you, I think, observed, but at what cost? We still need to know that.
Since been thinking about that and have concluded that Med D needs to be radically refashioned so that all Medicare pharmaceutical and durable equipment, etc. costs be negotiated (ala VA practices) so that all those costs can be drastically reduced, and thus totally eliminate the whole donut hole function and reality.
Medicare payment problems are humonguous on many fronts and BC is right that that has to be a high priority.
Liked Selise’s “all medically necessary” care vs. your “important to consumers” (although they may be identical in many cases) and I’ll give some particulars out of my experiences in dealing with neuropathy issues:
1) There are many (actual percentage of the 20 million PNers among us is unknown)folks with autoimmune disease related neurological disorders (including several neuropathies) for whom IVIG plasma services are the absolutely best and thus critical for their ongoing functionality and, for some, actual life maintenance. There has been a long standing problem with Medicare’s access and reimbursment cost policies that have severely limited availability of appropriate services in the best medically appropriate delivery structures. The kicker is that IVIG is extremely expensive and treatments are usually long term. One of the big problems has been that the different company’s IVIG brand products vary so Medicare’s efforts to limit access to X and no access to Y or Z, etc. can create acute crises when the matches aren’t right and some “experimentation” to find the right product can take some time. (But hell that goes on with all kinds of disease states and medication families, whether one is talking about cancer treatments or hypertension treatments.) Anyway, Dem Rep. Steve Israel (2nd District of New York – parts of Long Island) has sponsored a bill that would begin to address these problems and provide a framework for correcting them. The bill was developed with the Plasma Alliance non-profit, representing several patient advocacy/education groups serving a broad range of folks who need IVIG treatments. If anyone is interested in learning more about this issue, go to http://www.plasmaallliance.org/advocacy/html. But this is an instance of “MEDICALLY NECESSARY” CARE that needs to be protected and insured/assured. We do long term kidney dialysis all the time at huge costs, but Medicare has been actively rationing the IVIG treatment options.
2) The talk about “excessive tests” concerns me a great deal when it comes to diagnosing and treatment neuropathies. I know that most doctors know very little about doing the kinds of studies that can define the some 200 causes of some 100 types of neuropathies. And way too many don’t even know about the most rudimentary simple office tests that establish the probability of the condition, regardless of the type/cause.
So, when I hear talk about the need to curb “excessive” diagnostic tests, I’m really scared because I suspect that many HMOs and PPO’s (including those considered models) have policies that limit the kinds of tests that can begin to produce functional probabililties for developing appropriate treatments to prevent further deterioration, if not reversal of the neurological disease states. We have said for years that probably one third of us PNers will never be appropriately diagnosed and thus categorcially dismissed as having “idiopathic” neuropathy. But the functional day to day practice is that most internists and neurologists aren’t making any serious efforts to even find out possible/probable causes. If it’s a cost containment policy dictating these practices (I think it’s actually probably more doctor ignorance and laziness)what I know is that the long run costs of progressive disability probably far outweighs those initial costs that were denied.
3. The standard treatments for most neuropathies (aside from IVIG treatments for a small number of PNers,) is an ever increasing supply of neurontin or lyrica meds for PN pain and/or other PN distresses. (These are produced by Pfizer, a huge donor to politicians, a huge media advertiser, and a huge funder of the anti public option campaigns.) There are other real options, but some are rather expensive – like neurosti-mulation implants. But they do have the potential for restoring major functionality as an alternative to staying drugged beyond functional capacity as the disability continues to progress. In the cost containment schemes, the neurostimulation option could well be denied but the outcome for the patient can mean ongoing hell and potentially many years of high cost medications.
4. There are other alternatives, but Medicare and most HMO’s and PPO’s will deny coverage because they are considered “experimental.” I’m very concerned about the proposed “evidence based effectiveness” studies that would result in lists of very limited fundable treatment options. I know what that can mean for a variety of current and potential treatment options that could have a very negative and widespread impact on the neuropathy community. There are some PN treatments that had been Medicare approve for reimbursements in the past but since been excluded. Medicare used to pay for a particular product that we know has radically transformed the lives of thousands of patients because it was extremely effective for some types of neuropathy for reducing pain, reversing sensory loss, improving balance and gait problems and accelerating wound healing. If this were readily available at affordable prices, it could radically change the lives of many, many PNers, as it had in the past.
Enough, but these are some of my concerns about what needs to happen in my personal and broader advocacy/education activity world.
My poorly made point was that insurance companies by definition restrict coverage, and even under mandates will seek to provide less because the system is still for-profit. I should have underlined, bolded and italicized “anyone.”
Even if mandates allowed an insurance company to directly bill the government, they would still restrict service. It is in their marrow.
Even before seeing these carnival barkers who call themselves CEO’s, we knew that. While there is profit in the system, there will be by definition, no competition. But there will be plenty of collusion.
Updated to include
Oh, that becomes the 11th Commandment.
I assume outlawing rescission and prior condition exclusion would be part of the larger package. I’m just trying to define the public plan itself.
These are good points, but keep in mind this list has to remain generic; it can’t possibly include all the permutations for every ailment. I need to think more about how to express the generic problem of administrators and overseers deal with innovation, experimentation and acceptance.
is there a way to prevent the effects of adverse selection?
is there a way to capture all the administrative savings of a single payer system with a public option plan?
also, the exchange in MA has added administrative overhead.
Those are the Pay or Play accounting rules hacker is working on.
http://www.law.berkeley.edu/chefs.htm
Eventually, but if you start with a system in which most people are covered by private insurance and paying too much for its administration, you can’t get the national savings right away. So you have to provide a mechanism to move people from that system to where you want to be.
The policy choices are to force that transition against opposition, or provide a voluntary mechanism that could get you there, but with no guarantees. I don’t view either path as easy.
do you have a link to the rules? i thought the pay or play was to deal with employer’s contributions (and not adverse selection)?
putting aside the issue of private insurance competition via denial of care…
but not all the multi payer administrative overhead is on the insurance side. it’s also on the provider side. that’s one of the reasons i don’t see how the savings in administrative overhead we’d get with single payer could be captured with a public plan.
here’s an example to illustrate (sorry about the length). from an interview with Uwe Reinhardt: How the U.S. measures up to Canada’s health care system
and here’s the woolhandler and himmelstein paper: Costs of Health Care Administration
in the United States and Canada (pdf).
from the abstract:
Understand, point taken. You are right of course. Had thought about that. Will think on more principles I would like. Thanks,
Blessings to all
I suggest radical insurance reform as part of any discussion of retaining private for-profit insurance. Amid all this talk of “level playing fields,” no one seems to be talking about forcing private insurers to operate under the same constraints as a public plan. At a minimum, they should have to offer the same minimum set of services to the same population. Any outfit representing itself as a health insurer should:
* accept all comers
* accept all healthcare providers
* charge one flat premium for all subscribers
* cover all medically necessary services
* pay providers on a schedule and terms that are at least as generous as the government plan.
* maintain reserves sufficient to cover all outstanding obligations.
If you can do the above and make money, terrific. If you can’t, you are only posing as an insurance company and need to stop.
one thing i would add is that no reform should take funds from programs for the needy until after cost savings are shown. this is one of the things that has bugged me the most about the effect of MA reform.
the insurance companies are very good at adverse selection. i don’t know how to prevent that in practice.
One last suggestion as to what the public plan should cover (for the moment): eliminate all out-of-pocket costs for the public plan. No copays. No coinsurance. No maximum benefit.
To me, one of the most compelling arguments for the public plan is the vast reduction in billing and accounting overhead that comes when you stop nickle-and-diming every one involved in the process. Why ask providers to collect copays and why try to track copays, coinsurance, and maximum benefit levels in the insurance office?
The argument that copays limit costs by discouraging unnecessary use is nonsense, in my view. To contain overall health costs, people SHOULD see the doctor whenever they think they need to, so that problems can be caught early. Nobody sees the doctor for fun.
Costs are much better controlled by statistical means. This is especially true once we eliminate cost-shifting and group-shopping from the equation. A plan (whether public or reformed private) that covers everyone in the population is by definition a randomized group. Statistical hotspots–such as, say, unusually large numbers of colonoscopies billed in Arkansas or of dental implants in Massapequa–could be investigated. The investigation might reveal fraudulent activity or substandard/incompetent medical care. Or it might reveal an environmental issue causing a spike in colorectal diseases or premature tooth loss. Either way, you would gain valuable public-health information.
Eliminating out-of-pocket costs would also address an issue that has gotten little attention in this debate: privacy. A system that manages medical costs on a person-by-person basis with individual accounts is necessarilly intrusive. Our entire medical histories are placed in the hands of organizations with little or no incentive to protect privacy. Privacy just costs them money and interferes with accounting efficiency. I have a horror story to share later on just this topic–people who don’t work in the data processing world have no idea! Unofrtunately, work caals at the moment.
Excellent discussion all around.
The mechanisms for adverse selection all depend on being able to differentiate between subscribers.
1. You select an employer or industry as a way of limiting yourself to a defined population, and get your actuaries to refine/redefine the selection until you minimize the number of people that may actually use services.
2. You discriminate against all pre-existing conditions.
3. You discriminate against particular conditions that are either expensive or prevalent in your target group.
A public program does not engage in any of the above practices, so it gets stuck with the castoffs of private insurance–the people that actually need care and thus generate costs rather than profits.
So what I am suggesting is to level the playing field between public and private plans for real: force all private plans to operate as the public plan must, with none of their cost-shifting mechanisms allowed.
As a proposal, I suggest that this has the benefit of neatly skewering the Congressional clients of private insurance who are now calling for “fairness”. Give it to them, and make them sorry they asked.
the insurance companies have experience getting around that kind of regulation. here’s a bit from bill moyers a few weeks ago:
my bold. stairs, night time meetings, etc…
i agree.
this also gets to the issue of underinsurance. for too many people, copays, etc mean forgoing needed health care.
I doubt that signup dinners and and stairs are all that effective at screening the population. The methods that I outlined–all perfectly legal at present–are hugely successful. As a practical matter, you just can’t get insurance without belonging to a group that can be profiled or with a pre-existing condition.
Besides, regulation is not about making misconduct impossible. The you-just-can’t-stop-it argument is a fallacy that deregulators love, because it misses the point. Regulation makes misconduct more difficult, riskier, and thus more expensive. Some outfits will always cheat, because they are wired that way. But they may have a short life. Get the weight of the regulations right and cheating is just not worth it–it cuts into the bottom line too much.
Selise — this is a larger question than I answered, and I’ll be writing about this more. turns out the “Exchange” can do a lot to solve this problem.
http://www.urban.org/publications/411877.html
“So what I am suggesting is to level the playing field between public and private plans for real: force all private plans to operate as the public plan must, with none of their cost-shifting mechanisms allowed.”
Yes. One of the first rules of designing workable markets is to require everyone to meet the same standards for participation in that market — and then require that everyone be in THAT market, not tooling off on their own.
What a marvelous thread. Excited about Robspierre list and comments. Adore the final “conclusion” at 31. Wow, those two statements are so powerful. Thanks!
It was exciting to see reference to the Urban Institute documents. Had totally forgotten about them, but now remembering they were a favorite resource when I was in grad school in Urban Affairs. So glad they’re addressing health care reform issues, but it should be a natural for them, given the urban health care crisis realities. Will spend some time there. Thanks so much for that reference.
For a simple list of principles go to http://healthcareforamericansn…..ve…. Like what’s evolving her much more.
Blessings to all
For a simple list of principles go to http://healthcareforamericansn…..ive… is the correct info. Sorry See the Nay-saying DiFi article today with the petition to complain about her behavior.
how then do you explain what has happened with medicare advantage?
of course adverse selection can be prevented — with a single payer system. maybe there are other ways. but i think the people advocating keeping a multi payer system have the responsibility to describe how it is going to be done in that system.
and i don’t think what you’ve outlined will do it. happy to change my mind if you can give me an example of where it has actually worked in practice. but without evidence, i’m not going to discount himmelstein who has done a lot of research on healthcare policy issues, including coauthorship with elizabeth warren on the medical bankruptcy studies.
p.s. here’s a simple example to explain another of the many ways adverse selection can happen without explicit differentiation between subscribers: my employer gets a group plan for employees that is not too expensive because the insurance company competes on premium costs (by limiting approvals for expensive procedures, has coinsurance or limits coverage to a small subset of docs, etc). so long as my family is reasonably healthy, everything is fine. then somebody gets really sick and treatment by the most knowledgeable local specialist isn’t approved (or the coinsurance bills are too much, or there’s just trouble getting treatments approved, etc). that’s when i realize i need better insurance and move over to the public plan.
and we end up with more of the sickest, most expensive patients in the public plan.
thanks for the link. if i’m reading that right, it looks to me like exchanges don’t prevent adverse selection but rather that for an exchange to work, it all comes back to regulatory reform — ie risk adjustments. both of which add to administrative overhead.
but maybe i’m reading it incorrectly or not getting the point you were hoping i’d see? i’ll look forward to your future writing on this point.
I read this morning on whorunsgov.com that Mr. Obama is planning to drop the public option in order to get “bipartisanship.” There needs to be some knocking on the WH door about this.
Here it is:
“According to a report in Bloomberg, President Obama is open to compromising on health care reform by eliminating the public option from his plan. White House Chief of Staff Rahm Emanuel met last night at the U.S. Capitol with Senate Democrats and told them Obama is ”open to alternatives” to a new government insurance program in order to get legislation overhauling the health-care system to his desk, said Senator Kent Conrad of North Dakota”.
”His message was, it’s critical that you do this,” Conrad said.
“Senate Finance Committee Chairman Max Baucus of Montana said Emanuel urged the senators to seek Republican support and didn’t discourage them from pursuing the use of non-profit cooperatives, an idea Conrad has proposed”.
Other issues likely to come up:
Providers – does this include alternative medicine? Chiropractors? Massage therapists (Oooh, there’s one that the GOP can make hay with)?
Payments and audits – an immense administrative expense is the micro-managing of fee-for-service (coding each item down to an aspirin) and then auditing that for discrepancies. Cost accounting was supposed to decrease costs; now, it is a major cost in itself. How to handle that so that the public (it is taxpayer money involved somewhere in the process) and providers are satisfied with the payment and audit provisions.
Mornin’ Scarecrow and Firedogs,
just published a diary to help those a little intimidated or nervous about making phone calls
.
‘ “What Should a Public Health Plan Option Include?” ‘
The public?
TOO RADICAL!!!!!
.
One missed item on your list is to shift the focus to prevention. One reason that US health care costs are so high is that so many defer care until they are really sick, because they don’t have a doctor they see regularly and don’t enter the system until they’re in an emergency room.
You’d think that insurance companies would have an incentive to keep their insured customers healthy, but because coverage is employer-based, many of their customers will be someone else’s problem in a few years. And doctors get paid for services provided, and get paid less for the patients that they keep healthy.
Screw the Republicans. If they said they wouldn’t vote for anything unless it included killing the firstborn of every family in America would Democrats cave in the name of bipartisanship?
Sadly, I think they would.
What the public plan will not include is republican support. Per Grassley
http://thinkprogress.org/2009/…..blic-plan/
I’d also point out that the Medicare part D donut hole aspect didn’t start in private insurances until Part D was active for about 6 months, than the private insurances started gouging patients that exact same way.
My biggest concern aside from simplified billing for preventative care and maintenance care which helps the most is regulating drug pricing or bargaining the prices down. I see first hand the constantly inflating charges for medications. It also makes no difference how long the med has been around in terms of things from the last 20 years. The only ones that remain the ‘cheapest’ are drugs with at least 30 years worth of use already. But new drugs, and the most recent ones are the ones that cost small fortunes, which put them out of reach for most patients. Especially when the ‘gap’ or ‘donut’ is reached.
That needs to be eliminated. I see so much pain on my patients faces when they reach that. It annoys the bejesus out of me too, since my own fairly decent employer based plan does the same thing. Meanwhile i dont’ get paid well enough to pay off that initial deductible much at all.
Medicare For All (universal single payer) must include coverage for medically necessary otc drugs – like Loratadine (Claritin) that is prescribed by PCPs, but not covered. Also, I have post-shingles pain & last year I hav acute adverse reactions to Lyrica @ high doses. I needed to buy several months worth of 4×4 gauze pads, stretch gauze bandages, topical antibiotic oinment – for almost a whole year. In addition, I was prescribed Lasix to help bilateral leg edema – but the MD didn’t tell me that I need at least 1 glass of OJ/day to prevent leg cramps.
There was a clinic in Philly mentioned on BBC World Radio Business Daily that is a model. They assure adequate & healthful nutrition to cope with meds/Txs, assure proper use of supplements to support the nutrition, & wellness training – exercise, etc. If we can find out that clinic’s name you’d have a good prototype for a transformation into a medical system from our dysfunctional status quo.
From Scarecrow …
As a RN, I never thought of my patients as ‘consumers’. So first off, start calling people either ‘people’ or ‘patients’ or ‘customers’.
I swear, the word ‘consumer’ has denigrated the level of discourse and of patient care.
I don’t have any other suggestions, but I know the whole profit motive at the patient care level has ruined patient care.
Per Krugman today:
Per HuffPo:
what really bugs me about this is just yesterday during his presser, Obama was making the case for the public option.
Okay, I’m getting pissed. Obama asks us to shill for his plan and then stabs us in the back?
The lack of a real public option is a non-starter and I’ll put even more effort in shilling against his plan if that’s what it comes down to.
How to do cost/quality control
12. No top-down cost control. The public option, or single payer, will exist solely to pay out on claims for medical services that meet the standard of care as defined by existing institutions and practices: professional organizations, state licensing authorities, consensus conferences and current medical practice. We won’t have government trying to take on this role and do the “managed care” approach that failed so spectacularly when the industry tried it.
Controlling quality and cost (and the two are inextricable, since invasive equals expensive, and interventions that aren’t needed are the greatest threat to both quality and cost) needs to be bottom-up, it needs to be left to the patient. The patients, who have an overwhelming interest in avoiding unnecessary interventions, have to be given control despite their lack of medical expertise, by making their primary care providers work for them. This will be accomplished by giving the patient the ability to greatly increase the fee a primary care provider receives for services if that provider is his or her consistent and ongoing choice as his or her primary provider.
Yes, costs are out of control. But whenever an unnecessary intervention is ordered, the much bigger problem with that than the monetary costs incurred, is the fact that a patient is being put to unnecessary physical cost and risk. Overtreatment is primarily a quality problem, and we should not make controlling costs a priority at all, because fixing the quality problem will also fix the cost problem. The problem is that quality is out of control, and fixing the quality problem that allows systematic overtreatment is what we need to be doing first and foremost.
All this talk about controlling costs is especially perverse, because politically, we need to be seen as worrying about quality, not cost. And we certainly need to avoid the idea that costs will be controlled top-down. If we say we have a cost crisis, what that tells those 180 million Americans who do have insurenace is that they are going to seeing medical rationing under any new plan. If we say that we are going to have some sort of govt agency imposing cost/quality controls, that tells these folks that the new plan will involve “managed care” on steroids, bureaucrats getting between them and their care providers.
Reform will be defeated this year, as it was in 1993, unless we can explain to voters/patients in that middle ground, those who have some insurance, however threatened and however crappy that insurance might be, how our plan solves the problem of the old regime collapsing under the weight of rising insurance premiums. Part of our answer should be that we will get cost savings where it is legitimate to talk of money first, that we will save money by cutting out the private insurance middlemen and going to single payer. Bad enough that the administration seems to have abandoned this best, and also politically most astute, solution of single payer. But they will absolutely kill any chances of even a public option unless they stop talking about cutting costs where it is not legitimate to talk of money first, when we are talking about the medical interventions that patients need, and who decides what they need. We need to put up a plan that unequivocally says that the patient decides, and then gives the patient the tools needed, the expert advice of a physician whose level of remuneration they control, to guide their choices.
I have argued more than once that single-payer is the only practical approach. We are not arguing that. The question is how do we make it clear that this is the case? We make it clear by constantly forcing the discussion back to fundamentals, by leveling the field of debate.
Most public discussion seems to assume that the conditions I have set are either being met or will be met by whatever plan–single-payer, public option, or private–is chosen. But the industry is mounting a bait-and-switch, apples-and-oranges disinformation campaign. The “level field of competition” they advocate is not level at all, because it takes the cost-shifting and subscriber caging tactics that you fear as its business model. Without it, profitting from health insurance is, I suspect, impossible.
So the bottom line is that the single-payer public plan meets the conditions I set forth by definition. Profitable private plans probably cannot and almost certainly will not in any case. Public option could go either way, depending on what it means.
Private, for-profit, so-called health insurance is a relatively new phenomenon that could not and did not exist prior to the era of deregulation. In this business, you are insuring against a dead certainty, so you can only make money by refusing to cover losses that are or appear to be covered by the policy, by short-paying your bills, and by getting rid of subscribers as soon as they seem likely to collect on all the premiums they pay. This isn’t a business. It is insurance fraud made legal.
The nature of for-profit health insurance becomes clear only when it is rigorously compared to real insurance (fire and casualty and life) and, more importantly, to a real health care system. So we need to insure that the various plans currently being debated are compared on their merits, feature for feature and point-for-point, and on their overall economics. That’s what Scarecrow is suggesting (I think). All I am adding is the suggestion that the same requirements be explicitly extended to ALL plans, not just ot the public plan or public option.
I’ll reiterate a point that I have parroted above. A proper, public plan–single-payer–should manage costs by economies of scale and standards of practice.
I don’t think it should look at costs on a patient-by-patient basis at all, except, perhaps, if an audit seems necessary. Make payments in bulk and examine the billings statistically to see if anomalies have to be explained. When anomalies arise, look for fraud and departures from accepted standards of care.
In the latter case, remember that we are paying for health, not procedures. If costs seem high for a given disease, we look for medically dubious procedures or practices that produce poor outcomes. We look for complications, extended treatment periods, and needless hospital stays that indicate substandard care or service. we get aggressive about malpractice. Practitioners and procedures with inexplicably poor outcomes get shut out of the system, just as public health departments shut down restaurants that make people sick.
I think that the virtue of this approach is that it puts the care recommendations back where it belongs, with doctors. A doctor gets paid to keep his patients healthy. If they don’t or if he recommends expensive tests and procedures that do not seem keep them as healthy as the less expensive methods used by colleagues, then he loses money.
Numbers 10 & 11 need to be up front because that’s the only language these yahoos understand. They don’t really care about the rest of us, you know. Otherwise, I fully agree with your list. Also, for funding, why not impose a national 1% sales tax on everything except fresh fruits and vegetables, prescription medications, and oh, maybe gym memberships to help with funding. While I know a sales tax is regressive, and I don’t generally favor funding government programs that way, this would tax (albeit at a very minimal level) some of the major good health inhibitors in our country like junk food. Also, I think it is inherently unfair that wage earners (of which I currently am not) have to foot the bill for everything in this country. All income should be taxed to cover this, not just wages.
Selise, I worked for an excellent non-profit HMO that included a lot of the reforms that are being discussed now, a large group practice in effect, with no insurance company involved. This was what used to be called “pre-paid” health care. Every HMO member had the same premiums and same good coverage. But they struggled to compete with for-profit plans that offered lower premiums (and crappy coverage). The healthiest people and their employers tended to choose those other, cheaper, plans instead of the good one, and the sicker people went to the good plan (This is an example where competition hurt, not helped). This is “adverse selection”. So the good plan decided they had to offer a range of plans including some cheap ones with more limited coverage, in order to compete for the younger, healthier members instead of just having the most expensive-to-treat members. The problem comes when that healthy person comes in with a major illness, and their cheap coverage doesn’t provide the treatment they need. Then what do you do? And the docs then spent time in the exam room having to figure out how to get the needed treatment instead of spending that time on actual medical care. Any new plan could encounter the same problems if it isn’t done right, and there are powerful people who don’t want it to be done right.
Who’s going to bell the cat?
You can’t be against providers following the standard of care, any more than you can be against motherhood. The controversial question is over who defines and enforces the standard of care. My position is that it would be a terrible idea, both in substance and politically, to have some executive agency define and enforce the standard of care, beyond, of course, patrolling for fraud, as Medicare does already. It would certainly be a bad idea to have the agency that does the paying be the same one that does this definition of the standard of care, since it would be tempted to arbitrarily deny some interventions because it fears the cost burden will make it look bad in its function as a money-saving agency. And even if you got that organizational question right, I really don’t want either the payer or the definer of the strandard of care to work for the president. We are going to get presidents as bad as Dubya in the future, and we don’t seem to be able to manage govt agencies except by giving the president an often completely unjustified “policy level” control over their operation.
Even if you could get all the organizational questions right, and our enforcers are disinterested professionals not answerable to the administration, any top-down system for deciding whether or not providers are doing quality care is inherently problematic outside of the very narrow field of interventions and consequences that lend themselves to easy definition. My job as a primary care provider can be summed up as “doing as much as possible of as little as possible”. Good luck devising objective indicators of whether or not I’m doing my job right. Even where you can identify objective indicators of success for a particular dsease, as in say, hemoglobin A1C levels for diabetes control, I can’t see any way you’re going to get past the inherent adverse selection of being a good doctor. Good doctors attract and keep the worst patients. Yes, they make more progress with them than a bad doctor would, but they are working with patients in whom progress is inherently difficult. Any system of judging by results is going to penalize the good providers, and create a huge disincentive to working with difficult patients, in favor of dumping them on someone else.
My patients, on the other hand, wouldn’t have any problem at all identifying and rewarding appropriate behavior in their primary provider, if only we give them the enforcement tools. But, as things stand, with primary care squeezed down by payment pressure, because our ill-defined service is most easily sold short, into almost irrelevance, patients have no real control over their primary care provider. None of us can afford to do anything but churn and over-refer, given that the time to do medical parsimony right (and, God knows, no one wants it done wrong) is an unaffordable luxury. Sure, if you don’t like me you can switch to some other harried chump, but the one thing you can’t do is switch to someone who can afford to do things differently.
Churchill one said that the only thing to be said in favor of democracy is that every other system we’ve tried is even worse. So, yes, the idea of putting the patient in charge of quality assurance is far from ideal. The only thing to recommend it is that everything else is even worse. At any rate, this discussion is moot, since, politically, we’re not going to get any reform if part of the package is “managed care”, only this time run by the govt instead of HMOs. And I don’t see how what you say on the subject will be seen by the public as anything but this sort of top-down approach.
Not that I’m criticizing, since you at least talk about cost/quality control, where the item we’re commenting on is notably silent on this salient issue. While I think that we need to change the frame of discussion from cost control to quality control, any reform proposal has to talk about costs at least so far as to explain how the proposal for reform gets us down from the current crisis, that private insurance costs too much to be affordable. At least you acknowledge the issue. But you have to more clearly define exactly how the cost/quality control will be enforced in any proposal, because the public is keenly attuned to what any proposal says or fails to say about that.
Unfortunately, the Progressive Community has “bought into” the frame of a “public option”, and therefore, there is no room to compromise upwards for a far better systemic such as single payer, and subsequently, we’re left to a “debate” between two competing insurance policies. Consequently, there is no “competitive price point” readily available via “delivered medical care”.
On the other hand, I opt for the “expansion of the VA’s medical and hospital systemic” on the premise that “delivered medical care” is where the actual conceptualization for “public policy” should commence. In doing so, the “cost” is secondary to any political ‘fix’ that is deemed necessary.
And any opportunity for “security” from any medical disaster, can be ameliorated via the expansion of the VA and which fits neatly into Universal Health Care for anyone. And equally important, a person’s job does not determine the ‘fix’ relative to success or failure.
And from perspective, determining the medical features for ‘delivered care’ is where to start, and eventually, ‘form follows function’ as to the actual implementation.
Jaango
I was trying to find a neutral term,, and not intending to impose some impersonal commercial tag. I don’t have a problem using other terms. But does “patient” imply I’m sick, or can it also refer to someone seeking advice about how to stay health?
could not agree more. which is why i have deep reservations about current efforts at reform that do not have credible and concrete plan for addressing this issue. and so i continue to support hr 676 (conyer’s single payer bill) and efforts to replace multi payer insurance with national single payer insurance and universal health care.
jaango – you go dude! please keep advocating for nationalizing health care providers and you’ll make people like me who are “only” advocating national health insurance look positively moderate. *g*
ah, perhaps i misunderstood. i agree with all the constraints you call for — i think they are necessary, although not sufficient to prevent adverse selection. perhaps if we say that, in addition to the items you list, we also add that any multi payer plan must prevent adverse selection?