A "straw man" argument is when you create an opinion that is ridiculous or false, then argue against it. Think of a debate between a congressman and a scarecrow, with the congressman being allowed to tell you what the scarecrow would say if it could talk. The idea is to make one position look stronger by making it appear that the only other choice is untenable.
The straw man in the health care debate is the argument that we shouldn't meddle with the health care system because the majority of Americans already have fine health care. Why risk making things worse for 80% of the country just to try to improve things for the other 20% ( some of whom, admittedly, are choosing to spend as much on cigarettes, alcohol and street drugs each month as it would cost to get health coverage)?
Why is that a specious argument? Well, the fact is that we aren't being given the choice of keeping things just the way they are. Things are changing all by themselves, and not in a good way. Those 80% of people are in for a rude awakening if the American people, through the democratic process, don't take control of their own future.
I spoke to someone recently who works at a big health insurer. Her job is to collect deliquent accounts, the premium money from the employers who are using that company to insure their workers. She's facing a possible layoff.
Who lays off collection agents during a recession? A company that has a lot fewer accounts to collect from, that's who.
Insurers are hemorrhaging subscribers. And the people they are losing are the young healthy people who aren't making high incomes yet -- exactly the low risk people companies prefer to insure. And the more healthy people decide to "go bare," the more premiums have to rise to cover the sick people who "can't afford not to have health coverage." People who are already sick will make sacrifices to continue to pay their premiums that healthy people may not be willing to make. Costs are going up at a steeper and steeper rate. Small companies see it first, because they don't have enough workers to absorb risk if one of their employees get sick. But it's going to spread through the entire market, with entire market sectors suddenly dropping employee health coverage once one big competitor does.
Repeat: You aren't going to have the choice of keeping your current coverage if things don't change. Your insurer will eventually (say in 10 years) make the decision to drop out of the health care market and invest its money in more profitable ways. Insurers are financial institutions at their core. Losing money isn't what they do.
A lot of people assume that "big insurers" and "big pharma" are opposed to health care reform. In fact, they were right there at the table from the beginning this time around. Their futures depend on it. They need to see it happen, and they want to make sure the final product is favorable to their own interests. As we all do.
Give up the notion you can keep things as they are. Understand that if insurers are afraid of competing against a public choice, they are expecting that in the future their coverage will be less attractive than Medicaid is now. If, in the future, your health insurance plan is so bad you're wishing you had the choice of being on Medicaid, you will be very sorry your only participation in the current debate was to wave a teabag and say you're against any change.
Showing posts with label health care reform. Show all posts
Showing posts with label health care reform. Show all posts
Thursday, September 10, 2009
Wednesday, September 9, 2009
Covering illegal immigrants
President Obama's speech to a joint session of congress last night was marred by a Republican congressman who seems to have flunked "Raising Your Hand Before Talking in Class" in kindergarten. It was unprecedented in the U.S. Congress, which generally maintains decorum better than a lot of other legislative bodies.
It was particularly unfortunate that his shouted insult was directed to the first African American president of the United States. Many people will conclude, rightly or wrongly, that he would not have behaved that way to a president of his own race. It will just create a distraction by inflaming tensions that are completely off-topic to the health care debate.
But lets look at the substance here. What will health care reform mean in terms of the care given to illegal immigrants?
Probably nothing. I mean, let's get real. Look at what happens now.
Illegal immigrants are not eligible for government health coverage, no matter how ill or how poor. The only assistance the government is offering is a trip back to their own countries to get care there.
So any care they get they must pay for themselves. Few are able to get jobs that pay health benefits. They usually work for the employers whose wages and benefits are too low to attract legal residents.
Those jobs tend to be dirty and dangerous, and they tend to involve long hours. People are going to get sick. But they don't have the time or money to go to a doctor.
So they wait. And they get sicker. And eventually, they go to an emergency room.
Now, emergency rooms by law cannot refuse to treat emergencies. It's a federal crime to turn away women in labor or people with true emergencies because they can't pay. And some bureaucrat in an office thousands of miles away gets to play Monday morning quarterback after the fact to decide what was an emergency. So ER doctors are going to err on the side of caution in treating problems that might conceivably in some rare circumstances actually be symptoms of a true emergency. And they'll tend to avoid even asking about insurance or legal status rather than give someone any reason to suspect their decisions are based on financial considerations. So even those doctors who are so jaded by people who abuse emergency rooms that they have forgotten the compassionate impulses that attracted them to the field of medicine are currently treating illegal immigrants.
They just aren't geting paid.
And that care is costly, both because an ounce of prevention costs less than a pound of cure, but also because the lack of a "medical home" -- a primary care doctor who will coordinate care -- means that a lot of tests will be duplicated each time they show up at a hospital.
What will change in the new system? Like I said, probably nothing. No one ever lost an election because he lacked compassion for undocumented immigrants. And since the government doesn't need to worry about trying to get this population cared for more cheaply when it can already get doctors to provide this care for free, why would politicians or either side of the aisle bother to try to change things?
Everybody needs to chill. There are more important details to argue over than the one everyone already agrees on.
It was particularly unfortunate that his shouted insult was directed to the first African American president of the United States. Many people will conclude, rightly or wrongly, that he would not have behaved that way to a president of his own race. It will just create a distraction by inflaming tensions that are completely off-topic to the health care debate.
But lets look at the substance here. What will health care reform mean in terms of the care given to illegal immigrants?
Probably nothing. I mean, let's get real. Look at what happens now.
Illegal immigrants are not eligible for government health coverage, no matter how ill or how poor. The only assistance the government is offering is a trip back to their own countries to get care there.
So any care they get they must pay for themselves. Few are able to get jobs that pay health benefits. They usually work for the employers whose wages and benefits are too low to attract legal residents.
Those jobs tend to be dirty and dangerous, and they tend to involve long hours. People are going to get sick. But they don't have the time or money to go to a doctor.
So they wait. And they get sicker. And eventually, they go to an emergency room.
Now, emergency rooms by law cannot refuse to treat emergencies. It's a federal crime to turn away women in labor or people with true emergencies because they can't pay. And some bureaucrat in an office thousands of miles away gets to play Monday morning quarterback after the fact to decide what was an emergency. So ER doctors are going to err on the side of caution in treating problems that might conceivably in some rare circumstances actually be symptoms of a true emergency. And they'll tend to avoid even asking about insurance or legal status rather than give someone any reason to suspect their decisions are based on financial considerations. So even those doctors who are so jaded by people who abuse emergency rooms that they have forgotten the compassionate impulses that attracted them to the field of medicine are currently treating illegal immigrants.
They just aren't geting paid.
And that care is costly, both because an ounce of prevention costs less than a pound of cure, but also because the lack of a "medical home" -- a primary care doctor who will coordinate care -- means that a lot of tests will be duplicated each time they show up at a hospital.
What will change in the new system? Like I said, probably nothing. No one ever lost an election because he lacked compassion for undocumented immigrants. And since the government doesn't need to worry about trying to get this population cared for more cheaply when it can already get doctors to provide this care for free, why would politicians or either side of the aisle bother to try to change things?
Everybody needs to chill. There are more important details to argue over than the one everyone already agrees on.
Friday, August 28, 2009
Ad hominem political arguments and health care reform
My clock radio went off the last two mornings playing audio clips of people praising the recently deceased U.S. Senator Ted Kennedy. No one trotted out those people for comment while conservatives had been heaping contempt on him for as many years as I am old enough to remember. But that's how things go when you die.
To be sure, he was an easy political target. He was the poster boy for why drinking, driving and philandering are a bad combination. And he was politically powerful enough to survive what would normally have been a career-ending scandal. His satisfied constituents reliably sent him back to Washington for term after term.
He passed a lot of bills to protect the powerless in society -- the sick, the disabled, the children. But he never lived to see universal health care passed. It had literally been his life's ambition.
And conservatives used that fact to try to inflame opposition to universal health care. Just call something "Teddy Kennedy's (fill in the blank)" and the Ditto-Heads (their own term for themselves!) would line up against it without understanding anything more.
In rhetoric, the study of the use of language for persuasion, it's called an "ad hominem" argument -- an argument "against the person." Rather than arguing the facts of someone's point of view, you attack the person holding that point of view.
It's reminiscent of a quote from Adm. Hyman Rickover: "Great minds discuss ideas, average minds discuss events, small minds discuss people." (Adm. Rickover actually attributed it to an "unknown sage," but no one has been able to trace it definitively to anyone earlier.)
Politicians and the marketers creating their political ads have studied rhetoric, and they know exactly what they're doing and why they're doing it. They think you're stupid.
Since Sen. Kennedy was diagnosed with a brain tumor, he'd been dragging himself into Washington long after it became unwise to do so, even collapsing at an event during President Obama's inauguration. He saw the light at the end of the tunnel. Had a bill been passed by the original August deadline, he would have lived to see his dream fulfilled. A lot of conservatives would have hated to have had that happen.
But they've now turned their vile towards Speaker of the House of Representatives Nancy Pelosi. She is singled out for their scorn among all the people backing reform. Her sin seems to be simply being a woman in a position of power, which to a lot of people means "a shrew." People who have no idea what she actually stands for or has accomplished are distanced from health care reform by ads calling it "Nancy Pelosi's plan." (Reform opponents at least had the good sense to realize it would have looked bad for an ad calling it "Teddy Kennedy's plan" to be running when he finally died.)
Health care reform is an important issue, too important to be argued through ad hominem attacks, either against Nancy Pelosi or against any of the congresspeople on the conservative side. We live in a country where no one without health insurance would ever be left to die on the side of the road after a car accident, yet there may be little assistance forthcoming to pay the hospitals and medical providers who stepped forward to care for that uninsured person. If you want to live in a civilized society, to know that you can get care in a disaster and that you won't have to look at people lying on the street dying in front of you if they suffer a catastrophic illness, you have to share the cost of being in a civilized society.
Let's keep the arguments civilized, too, shall we?
To be sure, he was an easy political target. He was the poster boy for why drinking, driving and philandering are a bad combination. And he was politically powerful enough to survive what would normally have been a career-ending scandal. His satisfied constituents reliably sent him back to Washington for term after term.
He passed a lot of bills to protect the powerless in society -- the sick, the disabled, the children. But he never lived to see universal health care passed. It had literally been his life's ambition.
And conservatives used that fact to try to inflame opposition to universal health care. Just call something "Teddy Kennedy's (fill in the blank)" and the Ditto-Heads (their own term for themselves!) would line up against it without understanding anything more.
In rhetoric, the study of the use of language for persuasion, it's called an "ad hominem" argument -- an argument "against the person." Rather than arguing the facts of someone's point of view, you attack the person holding that point of view.
It's reminiscent of a quote from Adm. Hyman Rickover: "Great minds discuss ideas, average minds discuss events, small minds discuss people." (Adm. Rickover actually attributed it to an "unknown sage," but no one has been able to trace it definitively to anyone earlier.)
Politicians and the marketers creating their political ads have studied rhetoric, and they know exactly what they're doing and why they're doing it. They think you're stupid.
Since Sen. Kennedy was diagnosed with a brain tumor, he'd been dragging himself into Washington long after it became unwise to do so, even collapsing at an event during President Obama's inauguration. He saw the light at the end of the tunnel. Had a bill been passed by the original August deadline, he would have lived to see his dream fulfilled. A lot of conservatives would have hated to have had that happen.
But they've now turned their vile towards Speaker of the House of Representatives Nancy Pelosi. She is singled out for their scorn among all the people backing reform. Her sin seems to be simply being a woman in a position of power, which to a lot of people means "a shrew." People who have no idea what she actually stands for or has accomplished are distanced from health care reform by ads calling it "Nancy Pelosi's plan." (Reform opponents at least had the good sense to realize it would have looked bad for an ad calling it "Teddy Kennedy's plan" to be running when he finally died.)
Health care reform is an important issue, too important to be argued through ad hominem attacks, either against Nancy Pelosi or against any of the congresspeople on the conservative side. We live in a country where no one without health insurance would ever be left to die on the side of the road after a car accident, yet there may be little assistance forthcoming to pay the hospitals and medical providers who stepped forward to care for that uninsured person. If you want to live in a civilized society, to know that you can get care in a disaster and that you won't have to look at people lying on the street dying in front of you if they suffer a catastrophic illness, you have to share the cost of being in a civilized society.
Let's keep the arguments civilized, too, shall we?
Tuesday, August 25, 2009
Report from the White House Conference Call Briefing for Physicians, August 25, 2009
The White House Office of Health Reform hosted a conference call for physicians last evening. 2,700 physicians joined in the conference call, and 400 submitted questions in advance, evidence of how serious physicians are about trying to make sure this is done right. It was not open to the press, and the idea was that doctors could speak freely, though there wasn't much time for open questions.
Much of the conference was a general overview of the goals of reform as well as addressing the most common questions that had been submitted. They wanted to reassure physicians that they "get it:" Doctors are spending too much time on paperwork and bureaucracy, and that hurts patients by reducing the time we can spend with them. It's not what we went to medical school for. Keeping the current system isn't an option anymore, as the costs are spiraling out of control. Malpractice costs have to be reduced, although a simple cap on non-economic awards has had unintended consequences in some jurisdictions. The payment system is broken, and it's insane that we have to endure the annual handwringing ritual while we wait for congress to come up with another band-aid fix for the automatic pay cuts created by the "sustainable growth rate" formula (SGR).
Some of the features of the new system they wanted to highlight:
-- Insurance companies will no longer be able to exclude pre-existing conditions, nor can they limit coverage or terminate policies once people are sick.
-- There will be limits on out-of-pocket expenses, so that high deductibles and co-pays don't prevent patients from being able to obtain services that are otherwise supposed to be covered by their plans
-- Annual and lifetime caps on coverage will be prohibited, so catastrophically ill people won't suddenly find themselves with no coverage because they've passed some arbitrary maximum amount of expenses
-- Preventive services that can be shown to save money for taxpayers will be completely free to patients, with no copays or deductibles. The assessment of cost effectiveness will include not only what such preventive services save in future medical costs -- the impact that insurers already look at, although their focus may be on short term cost-effectiveness only -- but will also include the overall cost to society in non-medical costs and lost productivity. It's a big shift from Medicare's current policy of not paying for preventive care except in a very limited number of procedures.
-- There will be more emphasis on "global payment formulas" rather than paying per procedure. If you find that spending more time on one visit keeps your patients healthier than five short visits, go for it. Under the current system, Medicare and most other insurers significantly underpay for long visits, but short ones tend to be paperwork-intense and unsatisfying for doctors and patients. The idea is to reward quality rather than quantity of service.
-- There will be money to increase the numbers of primary care physicians, both through loan forgiveness with programs like the National Health Service Corps and through medical school scholarships
-- The planning already includes an "SGR fix" -- no more pretending that expenditure won't exist and acting surprised when it has to be added to the budget.
Obviously, whether these lovely promises will work will depend on the details of implementation. For those of us working with managed care in the 80's and 90's, we know that a well-run capitated health plan can reduce paperwork overhead, provide superior results in patient care, and allow physicians the choice of how best to budget their time to keep their patients healthy. We also know that in recent years capitation has been used by commercial insurers as a means to dump more of the insurer's costly bureaucratic tasks on physicians and their staff while keeping reimbursements stagnant, making a government-run option actually look like a better alternative.
It will be important to have flexibility to reward mini-centers of excellence, so physicians who become particularly competent in managing a particular illness aren't penalized by having large numbers of sicker, more time-consuming patients without being compensated for it. (Currently, insurers usually have programs for a small number of common, costly diseases like asthma, heart failure, and diabetes, but they have nothing for less common conditions like deafness or paraplegia that could be better managed if a few primary care doctors had a significant number of similar patients and could justify special equipment and services for them.)
It will be important to resist the urge to micromanage quality control, creating a whole new mountain of paperwork to suck up time and money. Whenever possible, quality control should flow from patients being educated about how to recognize quality, and then letting them make choices for themselves and their family members that reflect their personal experience with health care providers.
Much of the conference was a general overview of the goals of reform as well as addressing the most common questions that had been submitted. They wanted to reassure physicians that they "get it:" Doctors are spending too much time on paperwork and bureaucracy, and that hurts patients by reducing the time we can spend with them. It's not what we went to medical school for. Keeping the current system isn't an option anymore, as the costs are spiraling out of control. Malpractice costs have to be reduced, although a simple cap on non-economic awards has had unintended consequences in some jurisdictions. The payment system is broken, and it's insane that we have to endure the annual handwringing ritual while we wait for congress to come up with another band-aid fix for the automatic pay cuts created by the "sustainable growth rate" formula (SGR).
Some of the features of the new system they wanted to highlight:
-- Insurance companies will no longer be able to exclude pre-existing conditions, nor can they limit coverage or terminate policies once people are sick.
-- There will be limits on out-of-pocket expenses, so that high deductibles and co-pays don't prevent patients from being able to obtain services that are otherwise supposed to be covered by their plans
-- Annual and lifetime caps on coverage will be prohibited, so catastrophically ill people won't suddenly find themselves with no coverage because they've passed some arbitrary maximum amount of expenses
-- Preventive services that can be shown to save money for taxpayers will be completely free to patients, with no copays or deductibles. The assessment of cost effectiveness will include not only what such preventive services save in future medical costs -- the impact that insurers already look at, although their focus may be on short term cost-effectiveness only -- but will also include the overall cost to society in non-medical costs and lost productivity. It's a big shift from Medicare's current policy of not paying for preventive care except in a very limited number of procedures.
-- There will be more emphasis on "global payment formulas" rather than paying per procedure. If you find that spending more time on one visit keeps your patients healthier than five short visits, go for it. Under the current system, Medicare and most other insurers significantly underpay for long visits, but short ones tend to be paperwork-intense and unsatisfying for doctors and patients. The idea is to reward quality rather than quantity of service.
-- There will be money to increase the numbers of primary care physicians, both through loan forgiveness with programs like the National Health Service Corps and through medical school scholarships
-- The planning already includes an "SGR fix" -- no more pretending that expenditure won't exist and acting surprised when it has to be added to the budget.
Obviously, whether these lovely promises will work will depend on the details of implementation. For those of us working with managed care in the 80's and 90's, we know that a well-run capitated health plan can reduce paperwork overhead, provide superior results in patient care, and allow physicians the choice of how best to budget their time to keep their patients healthy. We also know that in recent years capitation has been used by commercial insurers as a means to dump more of the insurer's costly bureaucratic tasks on physicians and their staff while keeping reimbursements stagnant, making a government-run option actually look like a better alternative.
It will be important to have flexibility to reward mini-centers of excellence, so physicians who become particularly competent in managing a particular illness aren't penalized by having large numbers of sicker, more time-consuming patients without being compensated for it. (Currently, insurers usually have programs for a small number of common, costly diseases like asthma, heart failure, and diabetes, but they have nothing for less common conditions like deafness or paraplegia that could be better managed if a few primary care doctors had a significant number of similar patients and could justify special equipment and services for them.)
It will be important to resist the urge to micromanage quality control, creating a whole new mountain of paperwork to suck up time and money. Whenever possible, quality control should flow from patients being educated about how to recognize quality, and then letting them make choices for themselves and their family members that reflect their personal experience with health care providers.
Monday, August 24, 2009
End of Life Counseling vs. "Death Panels"
"...there are no 'death panels' in the Democratic healthcare bills, and to say that there are is to debase the debate." -- Charles Krauthammer
Thank you, Mr. Krauthammer, for bringing a bit of sanity to this discussion from the conservative point of view. As has been pointed out, this part of the health care reform bill only included incentives that had previously been non-controversial and which had bipartisan support -- before people started looking for any shred of evidence to back up their assertion that the purpose of healthcare reform was to pull the plug on Granny.
Krauthammer goes on to say, however, that living wills are of no value (though he has one himself), that ill people will change their minds anyway when the time comes, that family members will just ignore the living wills and use their own judgment, and that just bringing up the topic pressures patients to choose to forgo care.
It's true that a lot of people think there should be only one "right" answer to the question of using heroic measures to keep a terminally ill or vegetative person alive. But that's exactly why such documents are useful. If you happen to want to be kept alive at all costs, it's a good idea to put it on paper rather than assume that if the situation arises, people will know that's how you feel.
In fact, there are a lot of misconceptions about the whole topic. With the limitations on Medicare funding, nobody would be offering to hand out extra money to doctors unless they felt the need were very strong.
Counseling about advanced directives should start with young adults. After all, anyone could end up in a coma from a car accident, pregnancy complication, or other sudden event. It may even just be a temporary situation where decisions must be made about emergency procedures. But someone will have to make those decisions, and in those situations, it's especially hard on loved ones to bear that responsibility without any guidance or confirmation of their authority to do so.
Leaving the discussion until people are diagnosed with terminal illnesses certainly would imply that patients are really just expected to gracefully give up on life support. And often, the first time the issue is raised is at the time of a terminal diagnosis. That's why an incentive to move the discussion out of the oncologist's office and into the primary care doctor's office is an excellent idea.
The most important thing you can include in your advanced directive is the choice of a person to make decisions for you. No piece of paper can ever anticipate all the possible situations that could occur that might require slightly different decisions. Usually, the most appropriate decisions will first try to bring the person through what may be a reversible process, then -- when it becomes apparent that medical science can't make him better but can make him worse -- to change the focus to measures that make sure the person is not in physical or emotional discomfort. We can't always cure people, but that doesn't mean physicians no longer have any treatment to offer at that point.
While hospital personnel will informally use the legal next of kin as a spokesperson if there is no one designated, legally, they have no grounds to do this. The courts consistently rule that such a person should be appointed by the courts, not the doctors. Should there be any disagreement about the decisions being made for you, especially among family members who may be equally closely related to you, it can end up as a nasty court battle. That can exhaust your family's financial resources (that are needed to care for YOU) and can permanently destroy the bonds among family members (who would otherwise be cooperating to help care for YOU). If you have designated one surrogate decision maker (as well as a backup person), if you have informed your family members of your choice, and if you have discussed your preferences with your surrogates, it takes a lot of the pressure off them and everyone else.
What's more, you may happen to know that your legal next of kin does not see eye to eye with you on these matters. You may know he/she may be prone to faint in hospitals. You may have different religious beliefs than your family members. You may have a friend or life partner your family doesn't get along with but who you want to be with you if you are ill. You make even decide the best choice of surrogate should be someone outside the family. The best time to make these decisions is when you're feeling well and still have plenty of time ahead of you. Once you've created your advanced directive, you will continue to communicate your feelings and opinions with your surrogates and other family members. You may even re-do the document as you get older or in response to other people's experiences. That's why the law paid for periodic discussions of end of life issues rather than pressuring people to sign their lives away on some document, as if it might be used to override their own wishes later.
Most people don't think about end of life issues unless they are nudged. That's why the incentives to have doctors do some nudging could help.
Now what about the objection (such as was raised by Betsy McCaughey on The Daily Show) that having the law have a very specific list of topics that should be discussed would be a financial incentive for doctors to get people to agree to forgo care? Well, let's be realistic here, folks. If the law offers to pay people without specifying what has to be included, especially for a topic many of us are uncomfortable talking about in the first place, you're going to have doctors handing out brochures and calling it a discussion, just as you currently have pharmacists asking you to sign a log form and calling it counseling. If anyone objects to particular items in the list, sure, let's discuss that, but do Republicans really want to say that patients should be kept ignorant about any of those items?
There is also the idea that people will be pushed to have living wills in hopes it will be a big money saver for Medicare. And I'm sure there are people outside of medicine who feel that way. After all, there are statistics that 50% of Medicare expenditures are during the last year of a person's life. But the reality is that it usually isn't anything as clear cut as a comatose person being kept alive on a ventilator for months.
The more common situation is something like this: A person who has been holding up well with a chronic illness or who is advancing in age gets hospitalized with a urinary tract infection. That's not hard to treat, and she comes home from the hospital within a few days. But a month or so later she's got pneumonia. Again, it's easy to treat, but maybe she's not functioning as well as she was when she comes home. Maybe she falls and breaks a hip, and it's back to the hospital for a hip replacement, then to rehab. But while she's at rehab she gets confused at night from all the room changes in strange environments, so it's back to the hospital for a cat scan to make sure she didn't get a bleed in her brain from the blood thinner she's getting. Maybe she goes back to rehab after getting some tests for her delerium, or maybe she goes back home. She's getting nursing visits, multiple medications for her usual illnesses plus a few extra to tie up loose ends from the hospitalization. There are follow up visits with the primary care doctor, the orthopedist, the neurologist, and whoever else. Little things continue to come up. And eventually some event occurs that causes death, maybe in a hospitalization for something that doesn't respond to treatment so well, or perhaps the person will simply be found to have died in her sleep at home.
You see it often: Death doesn't always come because of some untreatable illness. Even people with cancer don't necessarily die of the cancer itself. People really do die of old age, and people naturally approaching death just become more susceptible to all kinds of simple illnesses, all of which require money to treat. But you're only going to see that in retrospect. A living will wouldn't change what you're doing or save that much money. None of these hospitalizations would be considered aggressive life support, because you aren't going to know it's the last year of someone's life until they do die.
You have an advanced directive because it makes an inevitable part of life more civilized for you and for the people you love. It's a tool to serve your needs in whichever way you feel best suits you. It's a document to provide guidelines for your caregivers to encourage them to respect your wishes, not a contract to bind you to youthful ideas you might abandon when you're closer to death.
If after hearing all this information, you want to complete an advanced directive form for yourself, there are sample forms at http://www.caringinfo.org/stateaddownload for each state. Your own advanced directive may be more personal, but these forms will help guide you through your own state's legal requirements. Take it to your doctor to learn about what all the terms mean. (I can't tell you how many people don't want to be kept alive on a ventilator but don't realize that being put on a ventilator is usually part of getting CPR.) Then talk to your family and chosen surrogate decision makers. The piece of paper is to make things easier on you and your family, but it's only the beginning of the discussion.
Thank you, Mr. Krauthammer, for bringing a bit of sanity to this discussion from the conservative point of view. As has been pointed out, this part of the health care reform bill only included incentives that had previously been non-controversial and which had bipartisan support -- before people started looking for any shred of evidence to back up their assertion that the purpose of healthcare reform was to pull the plug on Granny.
Krauthammer goes on to say, however, that living wills are of no value (though he has one himself), that ill people will change their minds anyway when the time comes, that family members will just ignore the living wills and use their own judgment, and that just bringing up the topic pressures patients to choose to forgo care.
It's true that a lot of people think there should be only one "right" answer to the question of using heroic measures to keep a terminally ill or vegetative person alive. But that's exactly why such documents are useful. If you happen to want to be kept alive at all costs, it's a good idea to put it on paper rather than assume that if the situation arises, people will know that's how you feel.
In fact, there are a lot of misconceptions about the whole topic. With the limitations on Medicare funding, nobody would be offering to hand out extra money to doctors unless they felt the need were very strong.
Counseling about advanced directives should start with young adults. After all, anyone could end up in a coma from a car accident, pregnancy complication, or other sudden event. It may even just be a temporary situation where decisions must be made about emergency procedures. But someone will have to make those decisions, and in those situations, it's especially hard on loved ones to bear that responsibility without any guidance or confirmation of their authority to do so.
Leaving the discussion until people are diagnosed with terminal illnesses certainly would imply that patients are really just expected to gracefully give up on life support. And often, the first time the issue is raised is at the time of a terminal diagnosis. That's why an incentive to move the discussion out of the oncologist's office and into the primary care doctor's office is an excellent idea.
The most important thing you can include in your advanced directive is the choice of a person to make decisions for you. No piece of paper can ever anticipate all the possible situations that could occur that might require slightly different decisions. Usually, the most appropriate decisions will first try to bring the person through what may be a reversible process, then -- when it becomes apparent that medical science can't make him better but can make him worse -- to change the focus to measures that make sure the person is not in physical or emotional discomfort. We can't always cure people, but that doesn't mean physicians no longer have any treatment to offer at that point.
While hospital personnel will informally use the legal next of kin as a spokesperson if there is no one designated, legally, they have no grounds to do this. The courts consistently rule that such a person should be appointed by the courts, not the doctors. Should there be any disagreement about the decisions being made for you, especially among family members who may be equally closely related to you, it can end up as a nasty court battle. That can exhaust your family's financial resources (that are needed to care for YOU) and can permanently destroy the bonds among family members (who would otherwise be cooperating to help care for YOU). If you have designated one surrogate decision maker (as well as a backup person), if you have informed your family members of your choice, and if you have discussed your preferences with your surrogates, it takes a lot of the pressure off them and everyone else.
What's more, you may happen to know that your legal next of kin does not see eye to eye with you on these matters. You may know he/she may be prone to faint in hospitals. You may have different religious beliefs than your family members. You may have a friend or life partner your family doesn't get along with but who you want to be with you if you are ill. You make even decide the best choice of surrogate should be someone outside the family. The best time to make these decisions is when you're feeling well and still have plenty of time ahead of you. Once you've created your advanced directive, you will continue to communicate your feelings and opinions with your surrogates and other family members. You may even re-do the document as you get older or in response to other people's experiences. That's why the law paid for periodic discussions of end of life issues rather than pressuring people to sign their lives away on some document, as if it might be used to override their own wishes later.
Most people don't think about end of life issues unless they are nudged. That's why the incentives to have doctors do some nudging could help.
Now what about the objection (such as was raised by Betsy McCaughey on The Daily Show) that having the law have a very specific list of topics that should be discussed would be a financial incentive for doctors to get people to agree to forgo care? Well, let's be realistic here, folks. If the law offers to pay people without specifying what has to be included, especially for a topic many of us are uncomfortable talking about in the first place, you're going to have doctors handing out brochures and calling it a discussion, just as you currently have pharmacists asking you to sign a log form and calling it counseling. If anyone objects to particular items in the list, sure, let's discuss that, but do Republicans really want to say that patients should be kept ignorant about any of those items?
There is also the idea that people will be pushed to have living wills in hopes it will be a big money saver for Medicare. And I'm sure there are people outside of medicine who feel that way. After all, there are statistics that 50% of Medicare expenditures are during the last year of a person's life. But the reality is that it usually isn't anything as clear cut as a comatose person being kept alive on a ventilator for months.
The more common situation is something like this: A person who has been holding up well with a chronic illness or who is advancing in age gets hospitalized with a urinary tract infection. That's not hard to treat, and she comes home from the hospital within a few days. But a month or so later she's got pneumonia. Again, it's easy to treat, but maybe she's not functioning as well as she was when she comes home. Maybe she falls and breaks a hip, and it's back to the hospital for a hip replacement, then to rehab. But while she's at rehab she gets confused at night from all the room changes in strange environments, so it's back to the hospital for a cat scan to make sure she didn't get a bleed in her brain from the blood thinner she's getting. Maybe she goes back to rehab after getting some tests for her delerium, or maybe she goes back home. She's getting nursing visits, multiple medications for her usual illnesses plus a few extra to tie up loose ends from the hospitalization. There are follow up visits with the primary care doctor, the orthopedist, the neurologist, and whoever else. Little things continue to come up. And eventually some event occurs that causes death, maybe in a hospitalization for something that doesn't respond to treatment so well, or perhaps the person will simply be found to have died in her sleep at home.
You see it often: Death doesn't always come because of some untreatable illness. Even people with cancer don't necessarily die of the cancer itself. People really do die of old age, and people naturally approaching death just become more susceptible to all kinds of simple illnesses, all of which require money to treat. But you're only going to see that in retrospect. A living will wouldn't change what you're doing or save that much money. None of these hospitalizations would be considered aggressive life support, because you aren't going to know it's the last year of someone's life until they do die.
You have an advanced directive because it makes an inevitable part of life more civilized for you and for the people you love. It's a tool to serve your needs in whichever way you feel best suits you. It's a document to provide guidelines for your caregivers to encourage them to respect your wishes, not a contract to bind you to youthful ideas you might abandon when you're closer to death.
If after hearing all this information, you want to complete an advanced directive form for yourself, there are sample forms at http://www.caringinfo.org/stateaddownload for each state. Your own advanced directive may be more personal, but these forms will help guide you through your own state's legal requirements. Take it to your doctor to learn about what all the terms mean. (I can't tell you how many people don't want to be kept alive on a ventilator but don't realize that being put on a ventilator is usually part of getting CPR.) Then talk to your family and chosen surrogate decision makers. The piece of paper is to make things easier on you and your family, but it's only the beginning of the discussion.
Tuesday, August 11, 2009
Medical liability tort reform and health care payment
Yesterday, Charles Krauthammer's column was again slamming on "Obamacare." (Does anyone else think the Republicans might be very sorry they suggested that nickname for a program that could eventually be as popular as Medicare?)
I won't deal with his assertion that the Reagan tax reforms created tax savings and propelled a 20 year economic boom. I seem to remember Ross Perot's political career being based on the spiraling federal deficit that resulted from those reforms, but I'll leave that to more knowledgeable economists.
But I can speak on the issue of medical liability tort reform. To those unfamiliar with the system, it's a mess. Vast sums of money go to lawyers defending cases which 90% of the time are won by the doctors anyway. The system is fueled by the fact that when a plaintiff wins, the amount may be so astronomical that it offsets a lot of other lost cases for the law firm.
The problem is that there is little rhyme or reason to who wins or loses. Very deserving plaintiffs often lose, because if it were that easy to prove doctors incompetent, it would be easy to get them out of practice. Meanwhile, patients whose bad outcomes are the result of bad luck, their own failure to follow doctors' recommendations, injuries caused by uninsured third parties, etc., may win huge judgments against doctors who did nothing wrong.
Krauthammer's solution is to create a government agency that would review alleged cases of malpractice and award compensation from a pool funded by taxes on health insurance benefits. He feels that will solve the problem by removing the lawyers from the system.
Now, I'm all in favor of tort reform and removing the lawyers. But it's a bit Pollyanna-ish to think this sort of single-payer system will do it. (Did I just call Charles Krauthammer a Pollyanna?)
If you want to see how such a system would work, look at Social Security Disability and SSI. Not only are lawyers involved, a cynical person might say the Social Security Administration uses the presence of a lawyer as a test of the worthiness of an application -- "If you can't get a lawyer to take your case, it probably isn't worth our time, either." The system is widely regarded as coming up with inexplicable outcomes as far as who is awarded benefits and who isn't.
To deal with the medical liability mess, you have to look at the economic pressures fueling it. People who are gravely ill often have no insurance, because they lose their jobs. Medicare doesn't kick in until there have been two years of total, permanent disability. Medical assistance requires you to spend all your assets, and the state will probably put a lien on your home if you own it. Very few people have long term care insurance, and private disability insurance is often not what it's cracked up to be if you try to file a claim.
Meanwhile, the cost of medical care is priced in funny-money, because insurers refuse to pay the full cost -- they demand a discount, or they will send their insured members elsewhere. Meanwhile, uninsured people often can't or won't pay at all, and the prices are jacked up to offset the charges that are written off, which means even more people can't pay. To give you an idea of how crazy it has gotten, my recent one-day hospital stay and surgery generated a $56,000 bill, but the hospital accepted the insurer's contracted payment of $8,000.
So when a case goes to trial, a jury knows the plaintiff with a catastrophic medical condition may be facing the loss of his home, retirement savings, and children's educational savings. Once he goes on medical assistance, he may still have difficulty obtaining care, because medical assistance payment rates are so far below Medicare and private insurers that most doctors don't accept those patients. (No one ever lost an election by failing to look after the interests of welfare patients, so the payment rates have diverged widely over the years.)
Until you eliminate the problem with inequitable access to health care, juries are going to be sympathetic enough to hand out other people's money to plaintiffs whose injuries are nobody's fault. Shifting it to a government agency isn't going to help much, because the average person doesn't have the skills to prove that malpractice occurred without a lawyer and a lot of expert witnesses involved. If making false claims to the state board and getting a doctor's license revoked makes it easier to be awarded benefits, a lot of people will be desperate enough to do that, no matter what the consequences of removing doctors from practice will be on their community.
You have to remove the desperation before you can solve the problem. Health care reform is a prerequisite to tort reform, not a result.
I won't deal with his assertion that the Reagan tax reforms created tax savings and propelled a 20 year economic boom. I seem to remember Ross Perot's political career being based on the spiraling federal deficit that resulted from those reforms, but I'll leave that to more knowledgeable economists.
But I can speak on the issue of medical liability tort reform. To those unfamiliar with the system, it's a mess. Vast sums of money go to lawyers defending cases which 90% of the time are won by the doctors anyway. The system is fueled by the fact that when a plaintiff wins, the amount may be so astronomical that it offsets a lot of other lost cases for the law firm.
The problem is that there is little rhyme or reason to who wins or loses. Very deserving plaintiffs often lose, because if it were that easy to prove doctors incompetent, it would be easy to get them out of practice. Meanwhile, patients whose bad outcomes are the result of bad luck, their own failure to follow doctors' recommendations, injuries caused by uninsured third parties, etc., may win huge judgments against doctors who did nothing wrong.
Krauthammer's solution is to create a government agency that would review alleged cases of malpractice and award compensation from a pool funded by taxes on health insurance benefits. He feels that will solve the problem by removing the lawyers from the system.
Now, I'm all in favor of tort reform and removing the lawyers. But it's a bit Pollyanna-ish to think this sort of single-payer system will do it. (Did I just call Charles Krauthammer a Pollyanna?)
If you want to see how such a system would work, look at Social Security Disability and SSI. Not only are lawyers involved, a cynical person might say the Social Security Administration uses the presence of a lawyer as a test of the worthiness of an application -- "If you can't get a lawyer to take your case, it probably isn't worth our time, either." The system is widely regarded as coming up with inexplicable outcomes as far as who is awarded benefits and who isn't.
To deal with the medical liability mess, you have to look at the economic pressures fueling it. People who are gravely ill often have no insurance, because they lose their jobs. Medicare doesn't kick in until there have been two years of total, permanent disability. Medical assistance requires you to spend all your assets, and the state will probably put a lien on your home if you own it. Very few people have long term care insurance, and private disability insurance is often not what it's cracked up to be if you try to file a claim.
Meanwhile, the cost of medical care is priced in funny-money, because insurers refuse to pay the full cost -- they demand a discount, or they will send their insured members elsewhere. Meanwhile, uninsured people often can't or won't pay at all, and the prices are jacked up to offset the charges that are written off, which means even more people can't pay. To give you an idea of how crazy it has gotten, my recent one-day hospital stay and surgery generated a $56,000 bill, but the hospital accepted the insurer's contracted payment of $8,000.
So when a case goes to trial, a jury knows the plaintiff with a catastrophic medical condition may be facing the loss of his home, retirement savings, and children's educational savings. Once he goes on medical assistance, he may still have difficulty obtaining care, because medical assistance payment rates are so far below Medicare and private insurers that most doctors don't accept those patients. (No one ever lost an election by failing to look after the interests of welfare patients, so the payment rates have diverged widely over the years.)
Until you eliminate the problem with inequitable access to health care, juries are going to be sympathetic enough to hand out other people's money to plaintiffs whose injuries are nobody's fault. Shifting it to a government agency isn't going to help much, because the average person doesn't have the skills to prove that malpractice occurred without a lawyer and a lot of expert witnesses involved. If making false claims to the state board and getting a doctor's license revoked makes it easier to be awarded benefits, a lot of people will be desperate enough to do that, no matter what the consequences of removing doctors from practice will be on their community.
You have to remove the desperation before you can solve the problem. Health care reform is a prerequisite to tort reform, not a result.
Sunday, August 9, 2009
Paying for health insurance
Why do employers pay for health insurance?
One reason is that the corporate executives won't be able to get coverage unless they offer the same plan to all their employees. Otherwise they'd have to pay taxes on the benefit, and the insurers would charge them higher rates because the risk pool would be smaller and probably older and sicker.
The other is to attract and keep valuable employees -- the same reason they pay their employees more than minimum wage. If a company doesn't offer health insurance and a competitor does, the competitor will be picking off its best employees with the lure of health benefits. In the current market, where it's extremely expensive to get individual health insurance and you don't even get a tax deduction the way businesses do, that's a pretty powerful lure.
But if the competition doesn't offer health insurance, its costs are also lower, so it can attract more customers with lower prices for goods and services. There is a break point where the cost of the insurance doesn't make up for the benefit of having better employees. Once insurance costs get to that point, having a single business in a market drop health insurance could lead the others to quickly follow suit.
Most foreign competitors have no health care costs, either because they are in developing countries where employees get extremely low wages and benefits, or because their countries have national health plans that cost less in taxes than health insurance premiums cost in the U.S.
So those competitive pressures are already there, and they're driving jobs overseas. That's something people ought to keep in mind when they decide how to structure the new health plan. Current plans call for keeping the responsibility for most people's health coverage with their employers, then increasing that cost even farther by removing the tax deduction and by putting a surcharge on people with the highest income (a tax on a tax, for pity's sake).
Now those fabulously wealthy people can afford a little more taxes. And despite their protests, unless they want to move to a developing country, the taxes aren't going to be significantly different in other countries that already have national health plans. But many employers can't afford to pay more. In particular, unionized employers can't reduce wages without bargaining for it at the end of a contract, and raising prices may drive customers away without significantly increasing their gross income.
No one likes "taxes." People are willing to accept massive reductions in their potential take home pay under the current system. But if they actually get to see the money and then have to pay for something called a "tax," they're irate.
It's like the research that shows it's more effective to punish a child by giving him something and then taking it away than to not give it to him in the first place. If only the American public were willing to stop acting like children and accept a tax that wasn't hidden from them, the health care system would stop driving so many jobs overseas.
One reason is that the corporate executives won't be able to get coverage unless they offer the same plan to all their employees. Otherwise they'd have to pay taxes on the benefit, and the insurers would charge them higher rates because the risk pool would be smaller and probably older and sicker.
The other is to attract and keep valuable employees -- the same reason they pay their employees more than minimum wage. If a company doesn't offer health insurance and a competitor does, the competitor will be picking off its best employees with the lure of health benefits. In the current market, where it's extremely expensive to get individual health insurance and you don't even get a tax deduction the way businesses do, that's a pretty powerful lure.
But if the competition doesn't offer health insurance, its costs are also lower, so it can attract more customers with lower prices for goods and services. There is a break point where the cost of the insurance doesn't make up for the benefit of having better employees. Once insurance costs get to that point, having a single business in a market drop health insurance could lead the others to quickly follow suit.
Most foreign competitors have no health care costs, either because they are in developing countries where employees get extremely low wages and benefits, or because their countries have national health plans that cost less in taxes than health insurance premiums cost in the U.S.
So those competitive pressures are already there, and they're driving jobs overseas. That's something people ought to keep in mind when they decide how to structure the new health plan. Current plans call for keeping the responsibility for most people's health coverage with their employers, then increasing that cost even farther by removing the tax deduction and by putting a surcharge on people with the highest income (a tax on a tax, for pity's sake).
Now those fabulously wealthy people can afford a little more taxes. And despite their protests, unless they want to move to a developing country, the taxes aren't going to be significantly different in other countries that already have national health plans. But many employers can't afford to pay more. In particular, unionized employers can't reduce wages without bargaining for it at the end of a contract, and raising prices may drive customers away without significantly increasing their gross income.
No one likes "taxes." People are willing to accept massive reductions in their potential take home pay under the current system. But if they actually get to see the money and then have to pay for something called a "tax," they're irate.
It's like the research that shows it's more effective to punish a child by giving him something and then taking it away than to not give it to him in the first place. If only the American public were willing to stop acting like children and accept a tax that wasn't hidden from them, the health care system would stop driving so many jobs overseas.
Friday, August 7, 2009
How will we pay for a new health care system? Well, how do we pay for it now?
While we're talking about how we can pay for universal health coverage, let's talk about how we pay for health coverage in the present system.
Currently, we have a bizarre system in which employees pay for their health insurance as part of their total compensation packages. Yes, I know you've been told your employer pays for it. But it's money that would otherwise have gone in your salary. Think of it as a deduction from wages that is taken out before the wages are calculated on your pay stub. It's part of what your labor costs your employer.
You probably have no idea how much that insurance actually costs, either. And it costs a lot, much more than the extra taxes paid by people in countries with government-paid health care.
Employees also rarely have any choice about which insurance companies and products will be offered to them, and they certainly have no choice about which drugs will be on those companies' formularies or which doctors and hospitals will be in their network. They're several steps removed from the people who make the contracts that determine what those hospitals and doctors will be paid for each individual procedure or office visit.
And they accept having people make those important choices without their input because they think they aren't paying for it themselves. The consumer of the services has no choice in the purchase of the services.
And we wonder why market forces aren't controlling these costs?
Currently, we have a bizarre system in which employees pay for their health insurance as part of their total compensation packages. Yes, I know you've been told your employer pays for it. But it's money that would otherwise have gone in your salary. Think of it as a deduction from wages that is taken out before the wages are calculated on your pay stub. It's part of what your labor costs your employer.
You probably have no idea how much that insurance actually costs, either. And it costs a lot, much more than the extra taxes paid by people in countries with government-paid health care.
Employees also rarely have any choice about which insurance companies and products will be offered to them, and they certainly have no choice about which drugs will be on those companies' formularies or which doctors and hospitals will be in their network. They're several steps removed from the people who make the contracts that determine what those hospitals and doctors will be paid for each individual procedure or office visit.
And they accept having people make those important choices without their input because they think they aren't paying for it themselves. The consumer of the services has no choice in the purchase of the services.
And we wonder why market forces aren't controlling these costs?
Thursday, August 6, 2009
Cash for Colonoscopies?
It's interesting to see the unquestioned rush in the U.S. Congress to add funding to the "Cash for Clunkers" program. That's the one that pays part of the cost of a new car if the old one got really crappy mileage even when new. (Even a lot of SUV's don't qualify.)
After all, a lot of those cars are the same Hummers whose original purchases were subsidized with a tax deduction meant for farm vehicles. A large percentage of the jobs in the auto manufacturing industry have already moved outside the U.S., so it's not the most efficient way to stimulate the economy. And while I'm all for reducing emissions, manufacturing brand new cars instead of making old ones serve longer lives probably creates even more carbon emissions.
In contrast, health care reform has been met by decades of foot-dragging. Nobody is rushing to fund "Cash for Colonoscopies" or "Dollars for Delivery Rooms." It shows where our national priorities are -- the car is one of the gods of the American pantheon. No one questions socialized highways, either, but "Bucks for New Bus Routes" would meet howls of protest.
And I sure don't expect to see "Small Change for Class Size Reduction" any time soon, especially since education doesn't have a predominantly male work force
Just sayin.'
After all, a lot of those cars are the same Hummers whose original purchases were subsidized with a tax deduction meant for farm vehicles. A large percentage of the jobs in the auto manufacturing industry have already moved outside the U.S., so it's not the most efficient way to stimulate the economy. And while I'm all for reducing emissions, manufacturing brand new cars instead of making old ones serve longer lives probably creates even more carbon emissions.
In contrast, health care reform has been met by decades of foot-dragging. Nobody is rushing to fund "Cash for Colonoscopies" or "Dollars for Delivery Rooms." It shows where our national priorities are -- the car is one of the gods of the American pantheon. No one questions socialized highways, either, but "Bucks for New Bus Routes" would meet howls of protest.
And I sure don't expect to see "Small Change for Class Size Reduction" any time soon, especially since education doesn't have a predominantly male work force
Just sayin.'
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