A friend of mine is adamant in his belief that the American
health care system simply cannot be fixed to operate with some semblance of humanity
and rationality. Bill has become convinced that “it will never, ever work.”
What does it matter if other health care systems in other countries are less
crazy, cruel, convoluted, or costly? He is convinced we are FUBAR and cannot
get to anything better from here.
This seems to me a nihilistic, despairing, and illogical
view. Yet, Bill is right that strong, interlocking structures hold the existing
order in place.
So many promising efforts in the past to reform things have
been distorted, stymied, and twisted, and have not improved matters. The
HMO movement comes to mind. Originally non-profit and medically-focused, it changed
into something quite different, angered patients and doctors, and was a
striking failure.
If the healthcare system is to be radically improved, it won’t
be easy, and figuring out how to weaken structural forces that buttress the
current system is a crucial part.
With this in mind, let’s consider the currently popular goal
of “Medicare for All.” The most popular “compromise” path – now espoused by
every candidate in the Democratic field but Sanders – involves adding a “public
option” to current ACA plans alongside private insurance. Pete Buttigieg and
now Elizabeth Warren have rhapsodized about how this would provide a “glide
path” to real single-payer reform, because people would prefer the “public
option” to private insurance plans.
But, giving people the choice between public and private
health plans simply won’t work. Real single-payer eliminates an unneeded,
expensive middleman – the insurance companies. A “choice” leaves the insurance
companies – and the additional layer of complication and expense they add –
firmly in place. If true single-payer is
implemented, administrative overhead would be reduced, because hospitals and
doctors wouldn’t have to deal with dozens of differing insurance plans and
their varied requirements. One set of billing procedures, forms, one drug
formulary and rules, etc. would majorly lessen overhead. Adding a new “public
plan” would only increase complexity, not reduce it.
A “public plan” that exists alongside private plans also
will not have the leverage to reduce medical prices, including pharmaceutical prices,
that the government would have in a true single-payer system. Without the cost
savings from overhead reduction and better pricing, the public plan will not realize
any of the potential gains that could enable substantial systemic improvement.
Crucially, if some are on private plans and some on public,
adverse selection is certain to occur. Insurance companies will game the system
as much as possible to retain the best risks and offload the medically needy
onto the public plan. Even before such games get into play, if people who work
for large employers keep their current plans, those people have a more
favorable risk profile than the population at large. Warren’s means-tested
initial transition plan extends coverage to those below 200 percent of the
poverty level – are these going to be good risks? So, the public plan will be
saddled with a population that will inevitably be costly.
For all these reasons, after implementation, the public plan
won’t be in a good position to present a favorable profile compared to
the cream-skimming private plans, which will offer sets of benefits designed to
attract younger and healthier people. This will raise the cost of the public
option and together with the lack of administrative savings, will be a financial
disaster.
The government will pick up more of the tab for the sick; people
will NOT prefer the “public option” to private insurance; and the leaders of
the insurance companies, pharmaceutical companies, and hospitals will continue
making our healthcare "system" complicated, expensive, and corrupt. The suffering it
imposes will continue. And my friend Bill will be confirmed – again - in his belief
that American healthcare will “never, ever work.”
The truth, of course, is that American healthcare does
work, superbly, for its overarching purpose – to make money for capitalists.
At that, it is indeed the very best in the world. But if we want it to work for
other purposes, we have to cut the Gordian knot, rather than try to untie it
gradually. The rapid, drastic, and successful implementation of the National
Health Service in Britain after World War II affords an example.
A tweet from @SableViews makes the point in a different way
that incrementalism can be a horrible strategy:
You can't leap a chasm in two bounds. So what does [Warren] suggest? Break the leap into two bounds so that M4A falls down the damn chasm never to make it to the other side.
"Getting to the other side" is possible – but it can’t be
done in the way proposed.
I have my doubts about Medicare being immune to the focus on profit that afflicts US Healthcare. My sense is that the people who make the regulations for Medicare are in the pocket of hospital and pharmaceutical corporations. The Medicare system is set up to reward poor health care.
ReplyDeleteThe whole RVU system is gamed to reward procedures over caring for patients. So more and more I see patients who have procedures donw by "specialists" who then turf any problems elsewhere so their corporate employer can maximize revenue from them.
When I refused to participate in "meaningless use" none of the private insurers docked my reimbursement, but Medicare did. Federal guidlelines forced docs to use EHR's. The Press Ganey score being tied to reimbursement seems to come from Medicare.
Clinical guidelines seem to be set by people with severe conflicts of interst and have become ever more Procrustean and more to do with pushing people toward taking more medications than being healthy. The website the NNT has a number of examples of practices that Medicare seems to pressure docs to do and are clincially inappropriate.
I have patients who are healthcare providers and the Medicare documentation requirements are overwhelming and pointless from a patient care perspective. The CPT coding system is asinine with complexity being determined by the number of "bullet" points which then direct the course of the visit rather than the patient's need.
So I conclude that even if no other option were available, Medicare for All would do nothing to change the current system, except make more money available to hospital corporations and pharmaceutical companies.
The problem ass I see it is greed. The cure for greed is enlightenment. In the absence of a cure, the treatment is taxation.
Dr. Joe, I agree with every specific criticism you have of Medicare. The RVU system is a very poignant example of how a reform designed to benefit PCPs was twisted by special interests and the AMA's appointments to the RVS Update Committee to do precisely the opposite of what was originally envisioned.
ReplyDeleteIt is important to realize that "Medicare for All" (where those who truly want it like Sanders and Jayapal are concerned) is not today's Medicare extended to cover everyone, but an IMPROVED Medicare for all. I am happy to tell you that the House Medicare for All bill https://www.congress.gov/bill/116th-congress/house-bill/1384/text (see section 903) ALREADY envisions eliminating meaningful use incentives, as well as eliminating value-based and pay-for-performance programs previously encouraged by the ACA and MACRA.
As well, if I understand Section 302b(2), Medicare Advantage programs will be abolished. This doesn't address every item you brought up (CPT coding, RVUs) but I think it is important to push for those sorts of reforms also as part of the health system overhaul.
Don't forget the benefits to patients also. Real M4A will eliminate people rationing their insulin because of cost, people unable to get treatment for cancer (unfortunately not uncommon in my home state of Texas where so many are completely uninsured), or people who rack up huge bills and lose their savings even though insured through co-insurance and surprise bills.
There's nothing magical about the reform, though. I never said a new system would be "immune" from lobbying interests making their hardest pitches. But the new structure can provide a framework where the public and doctors both have more leverage to keep those forces checked as they are NOT today - it will still be a battle to enact the system and to keep it functional once enacted - but it's do-able if we can "cut the Gordian knot."
Everyone please read
ReplyDeleteThe Public Option is a Poison Pill
https://www.thenation.com/article/insurance-health-care-medicare/
Covers many additional points beyond those raised by Roy Poses in this blog
Please note that the above post was written by Anne Peticolas, not me (Roy Poses).
ReplyDeleteThanks, Unknown! Great link at The Nation; and you are right it covers many more salient reasons than I went into about how a public option is a bad one. Very important that rational planning and global hospital budgets are not possible with a segmented system. Also loved the points it makes about Medicare Advantage; also about how German or Swiss or Dutch insurance coverage is not remotely like coverage offered by American insurers because of the different natures of the insurance companies, so cannot be a model for healthcare in the U.S. To get to sanity, we do need to eliminate private insurers in the U.S. - Anne Peticolas
ReplyDelete