AMA luvs obAMA (maybe)

The President would have made a great gigolo. He wowed a group of aging professional dowagers who came prepared initially to resist his seductive rhetoric but soon not only accepted it but displayed a passion that their august bodies had not experienced in decades.
The American Medical Association known for valuing pence above passion accepted his promises. In the fashion of the best Chicago hustler he promised everything but delivered nothing.
He promised them freedom to practice their profession and pay them a fair wage for their efforts. Never was the wage nor the efforts needed to earn that wage disclosed. They were assured that if they electronically displayed their professional skills so that these skills could be compared with their peers that their cyber electronic confessions could earn them further financial absolutions and prevent them from ever sinning again.
He even resurrected the memory of a fellow but competitive political hustler (Newt) to assure them of the sincerity of his promises.
He did not assure them of protection from the legal beagles who preyed on them when they erred, explaining that fair trade practices allowed for unreasonable and extraordinary damages to be extracted to promote free trade.
But was he appealing to a majority of practicing physicians?
"Twenty-five years ago, AMA represented a substantial percentage of American physicians. Today, only 25 percent of active, practicing physicians belong to AMA. Previously, when AMA lobbyists and leadership advocated for physicians, they could claim they represented all American physicians. Today this is not the case.
During the past 25 years, the changes ......have affected AMA as well. With more federal and state governmental hassles, increased paperwork, increased work for less pay and the continued demeaning of American physicians, today's physicians have come to believe that some of their problems have been created by a weak AMA that is not looking out for their interests. As a result, more and more physicians sought solutions to their problems through their specialty societies and/or their local, state and county medical associations.
AMA was slow to respond to many of these changes because they had been firmly committed to maintaining geographic state medical associations, without acknowledging the significant potential input of specialty societies, other practice arrangements and changing physician demographics. Physicians saw few benefits in belonging to AMA, and membership began falling." .
This free fall persists and few of my acquaintances find that membership in the AMA is of benefit to them financially, professonally or intellectually.
A trade association which had earlier criticized a public health insurance mandate promised to accept it with the ills it can bring as long as the price was right.
Healthcare is too important a public need that it be bartered by any street corner professional who seek only their profit and not their customers needs. The President would do well to protect the consumer from them.

It's Now or Never: Healthcare Reform.

It's Now or Never।










There is an increasing acceptance that a bill reforming our current healthcare mess will be signed by the President by October.

However like one on a blind date one hopes this new piece of legislation like the unseen date will be acceptable and attractive.

Nearly a decade ago Hillary Clinton attempted to fashion a similar piece of legislation. Her complex legislative proposal was crafted behind closed doors and its rejection by Harry and Louise

Obama’s approach is different he prods Congress to pass healthcare legislation using surrogates like Peter Orzag and Rahm Emmanuel to make Congress accept ideas he champions as their own.

Central to providing care for the uninsured is a proposal that would create a “public plan” one similar to Medicare with government financial subsidies. This proposal though supported by liberals is opposed by the Republican minority who argue that it would destroy “competition” in the health insurance marketplace. They seek to transfuse their anemic political future with opposition to it. This opposition is also shared by some Democrats who have offered a c.ompromise which will create private health cooperatives. These entities would be operated by local business and community groups with no federal or other subsidies.
The American Medical Association also opposes such a measure . Their opposition may be tempered by remarks and concessions that the President will offer when he addresses this body on June 16^th .

American healthcare when appropriately delivered is the envy of the world. A failing of this system is its costs. These can only be truly appreciated when compared with comparable economies.

The McKinsey Global Institute has done such a comparison.

The findings are dramatic. This country spends more on healthcare than it does on food and our healthcare costs exceed all personal spending in China! Adjusting for our economic advantages we spend more than any of the member nations of the Organization for Economic Cooperation and Development (OECD) our life expectancy and infant mortality statistics are inferior to most of them. If we were able to reduce our costs to levels equivalent to these nations we would have savings of $650 billion on an annualized basis.

Two third of this excess is from outpatient care. While the United States has more successfully shifted healthcare delivery from in hospital care to ambulatory settings any cost savings have been negated by excess utilization. Payments are directed to quantity not quality and the former grows exponentially. High profit margins for outpatient ventures lead to their proliferation and overutilization, both fertilized by lack of price consciousness by patient and low or absent co pays.Inpatient care is shorter in the United States but the savings negated by larger volumes of high cost procedures and greater supply and fixed hospital outlays.

Healthcare administration and insurance is five times more expensive than that of the OECD average with private health plans accounting for $63 billion of the excess (poor argument for the preservation of these plans) and the public payers for $28 billion. Duplication of management, regulatory excess and lack of an adequate information technology support are cost drivers. Less money is spent in this country for long term care and out of pocket expenses are higher explaining some of the inpatient excess. Less than expected outlays are also evident for durable medical equipment where costs are largely not covered by insurance. Personal responsibility for costs tends to slow their growth.

Other observations of the McKinsey Study were that in 2006, 49 % of healthcare expenditures were paid for by public funds, Medicare (20%), other federal programs (14%),state and other public funds (15%). The costs of private health insurance increased as Medicare or other public programs restricted their payments. Industry and individuals already subsidize public healthcare.

A piece of medical policy reporting by a Harvard surgeon writing in The New Yorker entitled the Cost Conundrum has grabbed the attention of the administration where it is now required reading.

Its author Dr. Gawande writes

‘McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.’

He found

“Public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)”

“The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.”

“Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.”

A search for answers from the area physicians elicited

““Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.”

“The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.”

These observations make it increasingly apparent that the most expensive technological device driving up healthcare costs is the physician’s pen. Peter Orzag the principle architect of healthcare reform testified before Congress in July 2008 putting a wonks imprimatur on Gawande’s literary efforts.
Does increased spending buy quality?

“Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen”

“That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.”

“Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated”

Gawande’s observations have provided a cudgel for doctor bashing

The New York Times in a slanted editorial states

“Doctors largely decide what medical or surgical treatments are needed, whether it will be delivered in a hospital, what tests will be performed, and what drugs will be prescribed or medical devices implanted.”

“When President Obama speaks at the annual meeting of the American Medical Association on Monday he will need all of his persuasive powers to bring doctors into the campaign for health care reform. Doctors have been complicit in driving up health care costs. They need to become part of the solution.”

The editorial failed to make mention of the stake of prominent law makers in healthcare entities though this was reported in the same issue of that publication.
Forgotten also is the sweat equity of physicians burdened by the onerous demands of a for profit insurance industry that is reported in time and equated in unearned revenue .

“Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year”

Aside from the creation of a public plan and cooperatives, how will Obama reform healthcare and afford care to the 47 million uninsured. He is a pragmatist and is aware that this bill will have to demonstrate that it will eventually reduce healthcare costs.

Proposals advanced include an end to the subsidies to Medicare HMOs.

The subsidies are 12% greater than spending on Medicare fee for service enrollees and are estimated to cost $25 billion yearly. This subsidy should be easy to eliminate for legislators calling for a level playing field.
Other proposals include changes in the Medicare Prescription (Part D) program with preferences given to products proven to be most effective in their class

This proposal is vigorously resisted by the pharmaceutical industry.

Another proposal is the use of information technology to reduce cost

“Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records. They will also phase in requirements for full implementation of health IT and commit the necessary federal resources to make it happen. Barack Obama and Joe Biden will ensure that these systems are developed in coordination with providers and frontline workers, including those in rural and underserved areas. Barack Obama and Joe Biden will ensure that patients’ privacy is protected. A study by the Rand Corporation found that if most hospitals and doctors offices adopted electronic health records, up to $77 billion of savings would be realized each year through improvements such as reduced hospital stays, avoidance of duplicative and unnecessary testing, more appropriate drug utilization, and other efficiencies.”

This policies critics argue

“RAND’s vision of "gold in them thar hills" owes more to Merlin than to metallurgy. For believers, we offer the following investment opportunity. We have invented a floppy disc with a screen saver that says "Don’t Smoke." Since 450,000 Americans die each year of smoking, with each life worth $2 million, if we assume 100 percent compliance by eligible participants, such an invention is worth $9 trillion. And since we are willing sell the invention for only $800 billion—less than a tenth of its value—even minimalist assumptions for packaging, distribution, installation, and the like imply a return on investment (ROI) even better than that forecast in the RAND estimates.

The RAND researchers offer an attractive hypothesis; it should be tested first in one hospital (with its surrounding practices) and then in several hospitals. As Woody Allen might say, "At the moment it’s just a notion, but with a bit of backing I think I could turn it into a concept, and then an idea." To mount a national program to do in every hospital what has yet to be done in any hospital might benefit the computer vendors who paid for the RAND research, but it risks failure on a colossal scale.”

Physicians and hospital systems are reluctant to implement these capital intensive investments as any return on investment will not directly benefit them but the biggest beneficiaries financially will be the health plans who have no skin in the game. Yet there are examples where simple electronic medical exchanges are successful, one such effort is described in Western Colorado and new federal funding to support this is detailed. Communities such as ours should visit this idea.
Most recently Obama in an address promises further savings from reduction in costs associated with hospital waste and geographic cost variations. Orzag attempts to explain these savings and Jonathan Skinner the health economist attempts to provide a defense for these reductions but howls from the hospital industry (justified) and barbs from the editorial page of the Wall Street Journal criticize the findings that justify these cuts.
For these to be successful a new relationship between hospital administrations and their medical staffs will need to be crafted. This will depend on a shared responsibility for care and profit. Reform is inevitable a visit to an emergency waiting room is adequate proof of its urgency and the cries of anguish from those beyond the pale of the current system proof of its necessity