The Nubbin



One need think about the implications of this video only for a moment to understand the essential issue: a system that depends on private insurance is potentially no system at all. That insurers routinely deny coverage for any number of reasons means that, in addition to the forty-seven million who have no insurance, there are potentially millions more who only think they do, despite paying premiums.

Insurance companies do not provide medical care. They collect money, invest it, dole it out when they have no way not to. Even for the so-called "non-profits," it's a money-making business, the basis of which is taking money intended for health care, keeping as much of it as possible for as long as possible, returning to the system as little as possible. If it can also be said of physicians and hospitals that they profit from the ill health of others, at least those entities are providing actual care. If we're serious about real health care reform (and it's evident that the "we" is the populace, but not its elected officials), it ought to be the case that any citizen who gets sick can receive care, regardless of the timing of their illness or where it falls in the fine print. Period. And, of course, the same ought to apply to well-care (assuming we know what interventions actually add to health. As opposed to prophylactic spine manipulations, homeopathy, and other forms of woo.) The criterion for coverage: you exist. Other countries do it; why not us?

This is the central idea, the raison d'etre, of a single payer plan. Same rules for everyone. Guaranteed coverage. No wondering, no legions of people spending dollars intended for health care trying to find ways out of spending dollars intended for health care.

And, taking it all the way, what if this care were not only guaranteed but free (or nearly free) of premiums? So what if certain taxes were raised to pay for it? Wouldn't that be more than offset (or at least evenly offset) by freedom from those premiums? And by the fact that there'd no longer be an unnecessary and very expensive intermediary between people and the care they get?

To me it's obvious. Inevitable, even. Although watching Congress I conclude it won't happen for a few more decades, assuming we still exist by then; and only after a complete failure of the current system. The opposition continues to parade their hand-crafted talking points, designed to scare and distract. There simply are no salient arguments I've heard that make a case for maintaining the intermediary of hundreds of insurance companies, other than what amounts to "we need them because we have them." What good are they adding? What particular and essential need do they fill? For the billions and billions of dollars, intended for health care, that insurance companies make, take, and keep, what do consumers get that justifies their existence? The "public option," they tell us, "is just a way to get rid of insurance companies." And that would be bad, how?

Seriously. Somebody tell me. I can't think of a thing.

And yet, if you listen to our Congresscrowd -- practically all of 'em -- you'd think it's the insurance companies that are responsible for everything that's good about American health care. "The best health care the world has ever known," as one of them recently said, ignoring the price we're paying compared to the rest of the world, the millions with limited access to it, and the fact that we are at the bottom end of most measurable health criteria.

This might be a good time to insert a cartoon that Ellen sent me:

I think it is the essence of the contrary argument. Although, as I've said, were we to go all the way to provide universal coverage under a single payer, taxes would be offset. For those who love insurance companies, there ought to be a way to provide them the option.

Or, if they want the same result without all the paper work, whenever they get sick they could run into their bathrooms and do this.

More Solutions, Long Post

Free health care isn't free. The money has to come from somewhere; the question is how to get it into a bucket, and then how most effectively to get it back out, to where it's needed. People frame it in all sorts of ways, depending on their political persuasions. Andrew Sullivan says that in arguing for government to pay, liberals would have us all be permanent supplicants. Brilliant. And it fits nicely onto a bumper sticker. But it's fatuous. If the ultimate virtue is the taking of money out of one's own pocket and paying directly for one's health premiums, then probably less than 10% of Americans are virtuous. (No comment.) Premiums are paid by employers, by governments, but by only a few individuals themselves (I'm among them.) We're already supplicants. (Well, not me.) If there were universal coverage, taxes would go up somewhere, but premium expenses would go down. The money that goes into the bucket, in other words, would be mostly a wash. Left hand or right hand, it comes and goes. My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over. That would be good, by whatever method the money is taken from us, and by whichever agency it's given back in the form of health care. Package it with a name that makes you happy. Money comes from us one way or another, gets centralized somewhere, and returned in the form of plaster and penicillin. In what way does having insurers in the middle help that happen?

The always-thoughtful Eric worries: "The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly." He makes an important point, but, like my concern about monolithic control of reimbursement, it can be addressed (so says me, the non-politician, non-economist, non-systems-wonk) by having at the top panels of consumers and providers making reality-based (remember that bygone concept?) decisions. If such a structure were in place, given that we're now talking about a single entity instead of hundreds, it would be possible for providers and consumers actually to have control. This makes a strong argument for single-payor, as opposed to our current situation, wherein we're divided and conquered. How should such panels be constituted, by whom, with what feedback loop attached to the citizenry? I'm thinking, I'm thinking! But I'm guessing people much smarter than I could figure it out.

I haven't seen "Sicko" yet, but I've seen M. Moore's other movies, so I'm guessing that at its center, he has the problem right, and that in examples and solutions he's overplayed his hand with anecdotes and shot himself in the foot with hyperbole. Speaking of which, in a review of the film James Christopher of the London Times says, "What he hasn’t done is lie in a corridor all night at the Royal Free watching his severed toe disintegrate in a plastic cup of melted ice. I have." Interesting: in my opinion, universal health care has no business covering the re-implantation of toes. Fingers, yes (depending on which ones). Toes, unh-uh. If surgeons use big toes to replace thumbs, -- and they do, they do -- that they are otherwise dispensible, foot-wise, is spoken to. A thing to which it is spoken.

And that gets us to the nitty-gritty. The bucket isn't bottomless. We can decide how much it holds, but at some point we also have to decide for what kinds of care the contents will be doled out; unless we want to make it bottomless, which we could in theory, but won't and can't in fact. Keep the costs down, we all say, except (you know what's coming) when the care in question is for us or our loved ones. "Spend a little as possible on them, and as much as needed on me" is a plan, all right, but is hardly a workable one. (Less so in the minds of one political party than the other). But let me be clear (since I've given myself the soapbox): I'm OK with tiers in the system. Not tiers of joy, to be sure. But this is America; plus I've said in my previous post that I think payments to providers ought to reflect quality of work: if I'm asking for rewards for the quality of my work, I can't begrudge it elsewhere. It's not without moral unclarity (if health care is a right, it doesn't automatically follow that people should be barred from obtaining different levels thereof), but the idea that there might be a difference between basic coverage given to all, and that available to those willing and able to spend more is one I can accept. It's just the way it is: a system that is the same for everyone with no avenue for opting up won't fly, pragmatically, at this point in the US; but one that provided everything for everyone under all circumstances will bankrupt us, absolutely, eventually. Heck, we're heading there (bankruptcy) already, on more than one track.

It's either/or. Either we decide as a nation that we're happy spending whatever it takes on health care, or we address the issue of rationing (ok, let's call it "prioritizing.") Some countries do it openly: in England, on "the National" it was true at least at one time that, for example, a person of a certain age with a certain percentage of body burn got supportive care only: pain medication, comfort. Some do it de-facto and maybe even cynically: in Canada you have to wait a long time for certain procedures, which means some don't get them, even though it's not specifically proscribed. A few years back a British orthopedic surgeon responded to outcry over long waits for hip replacement by saying that the line wasn't as long as it looked, since some people die while waiting for the operation. Probably the hardest thing any health care worker does is deciding when further care is inappropriate. It goes on all the time; it's just not formalized. Somehow, sometime, on paper and in public, it needs to be. A comatose hundred-year-old in kidney failure doesn't get dialyzed. A ninety-five year old? Not him, either. Sixty? Sixty-five? OK, eighty-five? And if the idea is repulsive -- which it is -- and if it simply can't be addressed (certainly Congress never will), then let's just agree that the best we'll ever do is nibble at the edges. Which, to date, has pretty much meant nothing more than continually lowering reimbursement to doctors and hospitals. Turnip. Blood.

Outraged comments on posts such as this notwithstanding, people willing to work extremely hard under lots of stress to provide an excellent product have a natural inclination to expect some sort of commensurate reward. Certainly no doctor expects to get as much as a mid-level executive for Healthcom, or as much as a second-string second baseman. But something that reflects work and which doesn't continually drop would be nice. The price for the current approach has been, and will continue to be, burnout of the best, and the looking elsewhere than medicine by the sorts of people you'd like to see choosing it as a profession. The problem with us goddamn doctors is that we're also human beings. Tell me what you think a colon resection is worth, then stop lowering the amount every year. And if you won't let me charge more on my own because I do a better job (every other professional does), then show me a way you'll try to figure out if I'm better and slip me a little something. If not, don't expect everyone to keep striving. It doesn't work that way anywhere else; increasingly, it's not working that way in medicine, either. Which makes the next paragraph, probably, wishful thinking.

There's one thing to do before playing the rationing card. Doctors, as a group, have a hard time with it; but it's coming, and it needs to arrive. To the extent that it has arroven (yes, I know), so far it's pathetic. I refer to finding out what works, why some doctors get better results than others, why some can get the same results as others at half the cost. Determining, in other words, "best practices." Finding that out and putting in place methods to encourage the good and eliminate the bad. Care, that is. What we have so far, referred to by the much unloved acronym "P4P" -- which stands for "pay for performance" -- is, at best, silly; and at worst, counterproductive, because it's so stupid. An example of bureaucracy at its worst, the list of parameters seems to have been generated by a committee with little input from actual practitioners. Big surprise. I know medical quality is hard to quantify, to solidify into a checklist. But for surgeons, for example, the archetype is getting pre-op antibiotics into the patient no longer than an hour before surgery. Funny. In training, we were told to get it infused at least an hour ahead of time, so tissue levels could rise and equilibrate. Yeah, you can measure it and write it down. But what goes on much before that -- in terms of selecting and planning an operation -- and after that -- in terms of carrying it out and in providing post op care -- has volcanically more impact that the ticks of the antibiotic clock. Everyone knows that. Getting a handle on it is where the action is; but if it's possible at all, it'll take a hell of a lot of work. Thousands of records will need to be reviewed, outcomes compared, methods dissected. Necessarily, judgment will be called into question, egos will be threatened. Worse, errors in data collection and analysis will be made; conclusions may be wrong sometimes, or tainted. The various specialty societies and colleges will need to be at the helm, and it'll take time and will generate lots of heat (with good planning, maybe enough to reduce oil imports), but in my opinion it has to be done. All doctors and nurses know it: there are good ones, and better ones. And some bad ones. Crazy maybe, but I think most docs -- given the right incentives and handled in constructive ways -- will respond to information that allows them to do a better job, even if it means admitting that they may not have been in the past. Scream, yell, get pissed off, feel insulted. Then lie awake at night and think it over, look yourself in the mirror when you get up. And make some changes. Been there. Done that.

To the extent that people running for president are addressing health care at all, keeping the money-changers between consumers and providers seems to be a given, which strikes me as feckless and crazy. Why should a national health-plan include a layer which provides no care, is clearly dispensable, and which serves to suck huge amounts of money out of the system? It's like paying someone to put the key in your car before you start it.

So my thoughts distill to three things, needed in this order: a single-payor system that includes real and actual control at the top by providers and consumers; a no-holds-barred effort to find and encourage (enforce) best practices, which recognizes and rewards excellence; and, when all the money that's possible to save has been saved, the toughest of them all: prioritizing care; deciding which expenses make sense, and which don't -- rationing. (Alternative to number three: stop complaining about costs of health care.)

(I suppose it's not trivial that if the insurers were really to go away, there'd be lots of decent people without jobs. But that's hardly a reason to keep a useless system going. Maybe some of those displaced would be willing to do those jobs that, you know, Americans don't want to do. That way we could solve immigration, too.)

My Solution

Fourth of July. Birth of a nation. Childbirth. Health care. Seems a good day to step into the breech. As it were. Is our health care system salvageable? Does it have a pulse?



Several years ago, the clinic at which I worked signed an exclusive contract with a fairly large HMO; shock waved around the medical community, who felt we were trying to take over the town. A few years later, we threatened to fire the HMO, and that shock waved around the nation.

We'd come to the point at which the latest cut in reimbursement, announced via the usual one-way communique, was simply too much. Receiving the backside rather than the ear of the HMO, we sent letters to all our patients who were members (around twelve thousand, at the time) announcing the plan, along with toll-free numbers through which we'd help set them up in other plans. The HMO caved. It was, I'm told, written up in several health/finance magazines and hit the Wall Street Journal, as I recall. High fives.

For a while. Of course, it ended up only a holding action. We were able, on some occasions, to negotiate less onerous cuts; it's not as if we turned the tide. There is, however, a lesson. Our ability to get insurers to listen turned on two things: we were excellent, and we were big. Patients wanted to see us; lots of them. In that, I think, are some of the seeds of solution for the US health care crisis.

Let me say it up front: I favor some form of a single-payer system.* It's my view that the many problems with such a system can be overcome: it's not single payer per se, as I see it, to which people seem to object. It's some of the accouterments. Before getting to that, I'll state what I think is the obvious: having countless health insurance companies -- many of them for-profit -- sucks gazillions of dollars out of the health care realm, in form of profits to shareholders, salaries of executives, and tens of thousands of workers in cubicles. Both in the bowels of the insurers' buildings, and in hospitals and clinics and medical offices around the country, people input data, make calls, argue for and against payments, follow differing contractual rules within and between companies; in short, money that could be spent on care of the sick is diverted into pockets of those who provide no actual service to those in need of it. They are money handlers, nothing more. Medicare, for all its faults, has by far the lowest overhead of any payer in the country. By real far. The only way to get the most money going to actual health care is to be rid of the multiple middle men. And women. There are many other needs, as well. But to me, that's where it starts.

The biggest problems with Medicare are that it treats providers like shit, has stupid rules, and responds little, if at all, to input from those who know what's going on. It not only doesn't recognize, but actually deincentivizes excellence. No small things; but there's no reason a single payer has to be that way. What I'm saying, basically, is this: let's have a single payer, and let's make it smart and responsive. I think it's not categorically impossible. Faint hope, I realize. But if we take it out of the hands of politicians (after they approve it), eliminating the kind of politics-based governmental incompetence with which we've been regaled of late, there's at least a theoretical possibility of finding a workable approach.

Which brings us back to the preamble of this post: when the HMO relented, it was because we were big, and excellent. I'm aware it's also because they had competition, and that a monolith has none. But there's a point: when providers are able to have a say in the process, the system works. Better, anyway. The most destructive aspect of Medicare, from the point of view of a hard-working physician who has the ethic of excellence above all, there's nothing more demoralizing than being told, year after year, that that hard work doesn't matter; that there's another cut in reimbursement on the way. That the excellence of one is regarded no differently, in terms of payment, from the mediocrity of another. So: it's surpassingly important that this imaginary system has reimbursement guidelines that result from input from the people that do the work. Is there any other professional group about which it can be said that over the past twenty years the trend of reimbursement for service is steadily downward? It's really and truly perverse, and the effect is obvious.

I can hear the keyboards tapping away in fury: you doctors are a bunch of egomaniacal, money-grubbing assholes. Well, sure. Nor do I claim to know what's a fair level of pay for a doctor, compared to other occupations. But I do know that a system which generally lowers that level, and which disallows the ability to set or bargain for one's own pay, and which pays the same for a given widget whether the widget from one maker is a better product than that from another -- that system is headed for self-destruction. And it's already selecting against the sort of people we'd like to see join up.

The solution to the US health care problem, then, begins with this: a single payer system which is responsive to those who provide the care, both in terms of setting fees, and in recognizing those who do excellent work. Competition is a good thing. So is doing a good job. Let's build it in. Impossible? Maybe. Will it be imperfect? Of course. There's a need to recognize the special situation of training institutions. And there's always the doctors who (some with justification, and some not) claim their complications are higher because they get the toughest cases. Being excellent attracts challenges. But there are ways to deal with that. Make it like figure skating: toss out the high and the low scores. Borrow from the gassy world of anesthesia and the splashy world of diving: set up degrees of difficulty.

I'm no economist, so I can't say how much money will be saved by eliminating the profit-taking and the inefficiencies of the myriad insurers. But it's significant.

As hard as it would be to make it work, it's the easy part. Really to get a handle on health care cost requires a hard look at best practices, along with the staring right in the face of prioritizing care. I'll talk about it, like unto spitting into the wind, next...


* Need a definition, here. "Single-payer," to me, means something akin to Medicare, as opposed to the Canadian or British system of government-run hospitals and salaried physicians. I still believe in fee for service, because when you have doctors employed by governments on uncompetitive salaries, you have, as we see in England, to import them. And they become terrorists.