Wednesday, September 16, 2009

Northern Myth Busting

We shouldn't generalize about the state of health care from individual anecdotal accounts. But these blog posts in part 1 and part 2 back from February of 2008 by Sara Robinson are good testimony from someone who has seen both the Canadian and US systems from up close. Moreover, in debunking and occasionally confirming claims about the Canadian system she cites facts and statistics that corroborate her first hand experiences. In a word she says Canadian care is at least B grade for every Canadian, while for much higher cost US care is A grade for some Americans, and C or D grade for many.

More recently on September 10, 2009 she described her efficient and worry-free hospitalization and treatment in Canada on the very day of President Obama's health care speech to Congress.

But if you've time and appetite to look up just one item I'd recommend this entertaining link sent to me by single payer advocate Jonathan Starr. It features Canadian Steven Lewis exposing US health care myths and deficiencies with music, sarcasm, facts and humor.

At the bottom of this clip is a link to a longer and more serious expose titled "Universal Health Care Message to Americans From Canadian Doctors & Health Care Experts." Canadian health care is overall better and more cost effective than that in the US, though I prefer private insurers to be allowed to offer competing choices as in many European countries. That private competition is what all serious US reform proposals envisage anyway, though private insurers rightly fear most people will opt for the the public option if they're allowed to do so.

What about opponents of changes in US health care? Here is a clip of town hall protests on 8/29/09 against health reform in Spring Valley, CA. As I commented to some friends it's scary if these are "ordinary Americans". They remind me of the 2006 movie "Idiocracy" where future generations become retarded.

Too bad that Democratic leaders like Senate Finance Committee Chairman Max Baucus seem to have heeded such sentiments. After wasting months seeking a bipartisan solution he came up with an ineffectual Senate bill without a public option that's a sellout to the insurance industry. Surprisingly he still didn't get any of the Republican members of the "Gang of Six" to sign on.

The only way I'd view Mr. Baucus' efforts positively (or even Mr. Obama's to date) is if this bill has been conceived just get something past the Senate including their own Blue Dogs. And then the plan is to introduce effective changes like a strong public option through the reconciliation process solely with Democratic support.

Wednesday, September 9, 2009

CDC Can Do More on Swine Flu

Looking up the CDC website on swine flu guidance reminded me of an old joke about a balloonist who was swept away by the winds and got lost.

He lowered himself next to a tall office building. He wrote "Where Am I?" on a placard and held it up for the people inside the building windows to see. Those people responded with their own placard that said "You Are in a Balloon 100 Feet Up in the Air." That answer was however enough for the balloonist to know that he was at the Microsoft headquarters in the Seattle suburb of Redmond. For going by its help feature in its products only Microsoft could provide an answer that was completely correct and yet so irrelevant and useless.

How's this related to swine flu? About two weeks ago I briefly came down with the sniffles and a mild fever that lasted less than a day. Then over this Labor Day weekend we drove to Pittsburgh where Anita's nephew had similar symptoms. We isolated the affected person (me and our nephew) and considered the obvious question of whether to seek testing, and if yes, where.

Testing would help the authorities to compile statistics and monitor the spread of the disease. Patients testing positive would know what to watch out for and be extra careful about exposing others. Recovered patients presumably acquire immunity, and needn't worry about subsequent exposure, or getting inoculated when the swine flu vaccine becomes available.

On the other hand, patients arriving in large numbers in medical facilities could put providers and other patients at risk, and strain scarce resources. Also, uninfected patients can acquire the H1N1 virus from others in the very clinic that they visit.

Weighing these pros and cons we looked at the CDC and other official websites for guidance. Despite all the other information crammed in there, we found nothing addressing these obvious questions. Countless other patients and American families may be similarly confused and frustrated.

The closest answer I got after clicking through links and menus was an indirect one, under "Home Care Guidance: Physician Directions to Patient / Parent." It said that you should see a doctor or seek medical help if you develop certain serious symptoms, presumably meaning that you shouldn't if these don't occur. It needs to be a lot more explicit and easy to find.

The new health care and CDC leadership under the Obama administration has been in place for quite some time, with Director Thomas Friedan confirmed in May 2009. They should have personally scrutinized their agency's website and confirmed there are no glaring omissions. They don't seem to have adequately done so, but this is fixable. Having worked in government these are the obvious added steps I would take in regard to swine flu were I directing CDC or the HHS in regard to the flu:

1) Prominently feature in the Frequently Questions (FAQs) and other parts of their website, as well as in briefs to the media
  • Advice to persons with typical symptoms and parents on whether and when to get tested for swine flu, and when not to
  • Similar advice on when to seek medical help or visit a doctor, and when to hold off out of concerns of spreading or contracting infection
  • Some information about the cost of testing, the best places to go to (doctor's office, clinic or hospital emergency room?) and the reliability of the tests. Add more "layman" information about the benefits - and the downside or risks - of anti-viral treatments like Tamiflu and Relenza.
2) Have an interactive feature on the website where users can enter their address or zip code. They then get a listing with addresses and contact information of nearby medical facilities that have special swine flu treatment arrangements and / or accept patient samples for testing. To keep pricing transparent and competitive, such facilities should disclose their prices for standard testing and treatment, and this information should also be displayed. If an interactive feature is beyond CDC's scope they can at least provide links to state and local government resources that provide this information. It will specially help the uninsured, and many insured patients as well.

3) Engage and coordinate efforts with large providers and test labs to expand capabilities to handle swine flu patients. The CDC can also issue standard guidelines and practices (e.g., separate windows and rapid turnover waiting areas for flu patients in emergency rooms with proper signage, to limit cross-infections) that help providers and patients alike. The CDC can even use its power to disseminate information to have "suggested prices" for testing and treatment. Coupled with inviting providers to include their prices in the links on the CDC website as at (2) above, this will encourage lower prices.

4) Orchestrate a system to enable healthy family members to get sterile vials or containers from labs, collect patients' samples like nasal swabs, and submit these for testing. This way patients being tested get to stay at home and again limits inconvenience and the spread of infection.

5) Encourage or help set up a system of home visits to patients by health workers. Such workers should have either already contracted and recovered from H1N1 infections, or have been vaccinated after this treatment becomes available, so that they are immune.

Similar steps can be taken to disseminate detailed information about the swine flu vaccine which is expected to be widely available very soon. The CDC and the HHS are large organization with multiple responsibilities. So ideas like these may not have been considered. I hope they are responsive once they see them. Since H1N1 flu has now spread worldwide, other countries can also adopt similar practices.

Wednesday, September 2, 2009

Another Red Herring

This cover story in the current Atlantic "How American Health Care Killed My Father" by David Goldhill has attracted a lot of attention. David Brooks in the NY Times in a September 2 column even calls it "brilliant." But I find its conclusions about required steps to be misleading and adding to the confusion about health care reforms.

It has some nuggets of insight. Like health insurance is currently not just insuring against unforeseen events as other kinds typically do, but generally paying for almost all care however routine or minor. Or that patients don't concern themselves with expenses or limit needless treatment, when someone else (the insurer) is picking up the tab. Or that hospitals restrict competition by lobbying against new entrants and through consolidation, and deliberately overprice emergency room care to inflate their charitable services component. Or that for hospitals and providers, the real customer is not the patient - it's the payer of their bills.

Goldhill summarizes at one point: "A wasteful insurance system; distorted incentives; a bias toward treatment; moral hazard; hidden costs and a lack of transparency; curbed competition; service to the wrong customer. These are the problems at the foundation of our health-care system, resulting in a slow rot and requiring more and more money just to keep the system from collapsing. "

Goldhill then suggests starting completely afresh, taking a lot more time to think and plan, and "to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system." His outlined solution is to essentially tweak the marginally successful system of individual consumer health savings accounts (HSA) coupled with catastrophic insurance that has been in place since 2005.

Even some smart and logical people seem to have been swayed by Goodhill's logic. Here for example is the reaction of Hari, a seasoned Silicon Valley engineer:

"Despite some flaws in the solution the author proposes, I actually agree with his description of the fundamental problem of why medical costs are so high, medical care is not commensurate with cost and all solutions from insurance to government will eventually lead to cost overruns. I actually think that a combination of private HSA savings account, catastrophic-only insurance and government maintenance of Medicaid is the way to go..."

Why is this HSA approach so deficient? Jonathan Starr, also an engineer and a single payer advocate, gave this apt response to Hari that captures a lot of my thinking as well:
"The author identifies some important concerns regarding cost-control, good-practice, and accountability. But, I do not agree with the solutions he offered, such as the ones you mention.

Regarding reliance on HSA accounts as a major part of paying for health care:
1) Assuming these are tax-deductible accounts, they are inherently regressive. The higher a person's income, the more that person can afford to put into such a tax-sheltered account. The higher the person's marginal tax-bracket, the larger the tax-deduction that person receives for any amount put into that account.
2) For most people, it is impossible to predict future medical needs, and how much they will cost, so it is impossible to determine how much any particular person should put into an HSA account.
3) Insurance, single-payer or otherwise, pools risk to make coverage available when some members of the pool need it. By pooling the financial resources of a large group, most of whom at any one time are healthy enough not to need to draw significantly on those resources, those who do need to draw heavily on the pooled resources are able to do so. With HSA accounts, there is no pooling of risk. Resources are distributed in as fragmented a manner as possible. So, financial resources in most accounts may sit around unused, while those people who need health care service exhaust their own little financial pool quickly. Pooling of risk through some type of insurance is a great innovation with enormous public benefit, all of which relying on HSA accounts forgoes.
4) Individual customers, with just their own HSA accounts, have little leverage, or expertise, for negotiating for favorable prices and rates for pharmaceuticals, medical equipment, and health care. Large aggregations of resources, such as in insurance plans (again, single-payer or otherwise), can have far greater expertise and leverage in negotiating and pressuring for such cost-reductions.
5) Fragmenting the customer pool reduces the capacity for aggregating information about health care outcomes and for advocating and enforcing best-practices.

In short, there is great power in numbers for controlling costs through bulk-purchasing and negotiation, and for gathering, evaluating, and distributing information and requirements about best-practices to control costs and improve outcomes. This is increased with large insurance programs, and maximized with a single-payer program; in contrast, it is minimized through reliance on individual HSA accounts, which maximize the fragmentation of the pool of end-users.

Also, the low-hanging fruit reducing health care costs is in reducing administrative overhead. Hospitals and other care-providers must pay large costs to handle the billing of innumerable insurance policies. If instead, they have to bill an exponentially larger number of individual people and HSA plans, that makes this administrative overhead even higher. Furthermore, care-providers must build into their price-structure higher fees to those who do pay in order to cover those who do not. If every person is being billed individually, the number who ultimately do not pay undoubtedly will increase. This not only increases the costs for collection, it also inevitably raises the fees that must be paid by those who do pay.

In a single-payer system, the need for such billing overhead is drastically reduced. There is a single program to deal with, instead of innumerable policies, or even more innumerable individuals. Furthermore, payment by single-payer systems are reliable, so that fees do not need to be padded to cover those who do not pay. In practice, one of the reasons doctors and other care-providers have been willing to accept the lower-than-market-rate fees paid by Medicare is precisely this reliability of payment.

If the HSA-based system still includes reliance on, or even just availability of, private insurance, then not only is there the administrative overhead that must be built into healthcare costs, there is also the profit, marketing, billing, lobbying, and administrative costs of the insurance companies themselves. This is more money that is paid nominally for healthcare, but actually goes to something else, which adds to the cost of the system.

Also, providing insurance, or even just administering HSA accounts, is a competitive burden on American companies. With a single-payer system, this burden is relieved; with everyone having HSA accounts, it instead could be increased."

President Obama is (finally) set to exercise leadership and press his own specific proposals for health care reforms for Congress to pass, rather than passively let a bill bubble out for him to sign. That's the good news. But he has already failed to strongly speak out for a strong public option (if not an outright single payer system) so that public support has eroded due to the propaganda and misinformation by reform opponents. There are signs that he's willing to drop insistence on this option that is vital to cost containment. If that happens it may be a big indicator not only of his success on health reforms, but of his vision and overall ability to lead.