Posts Tagged politics

Tiers of U.S. Healthcare

A recent U.S. presidential-candidate debate included proposals on Medicare-for-all, care for illegal immigrants and private insurance: supposedly a three tier system. Exactly which existing tiers would be removed, which would be funded and how would the budget for care work?

Consider the layer cake of U.S. healthcare, as it exists. Start at the top where little figures of a bride and groom might stand. That is the highly-privileged care provided to members of Congress and many government employees (“Cadillac” health plans with a large percent government subsidized plus pre-tax perks). That insurance provides good care (not as good as the care in the French system, but pretty good).

The next tier is the “CEO” or “rich guy” healthcare. They have so much money they don’t need insurance. They just buy what they want at big name hospitals with private suites staffed by nicely dressed doctors in suits and young nurses with little pointed hats. The motto is “whatever you want”. CT scans of everything happen at least once a year and heart tests proceed just because “you can’t be too careful”. And, heavens, the food you like is on your diet. Rating of care: poor.

The next tier is a hodgepodge of layers or “options” offered by many insurance companies like Blue Cross, UnitedHealthcare, Aetna etc. These are mostly provided through an employer group plan. And, sometimes purchased individually at a higher cost if the person is part-time or retired before age 65. Some plans have high deductibles and high co-pays that financially make care difficult to obtain. Some closed panels of providers limit where a person can obtain care and limit the options for moving or travel. The insurance companies scrape off 15% of the icing (administrative fees). Rating of care: fair to good.

Next is the Medicare tier divided into several layers including Medicare with a supplement (fee-for-service) and Medicare Advantage (per-capita). Rating of care is good with a plus for lower cost compared to the higher layers. Unfortunately, Medicare does not negotiate drug prices according to laws supported by drug companies. Rating of care: good.

Next are decorations of socialized medicine. These include the Veterans Administration, Indian Health Service and various levels of military healthcare (Tricare). Rating of care: good.

Next is Medicaid. A State run and federally supported insurance for the poor. It is limited by budgets and willing providers. Rating of care: fair if you qualify, but many who need care don’t qualify for a variety of reasons.

Finally, the bottom layer. The layer for those with no insurance and no funds. All States require emergency rooms to provide care to “stabilize” a mental or physical illness. Anyone can obtain health care in the U.S. based on this nearly insane model where people wait until they are really sick to receive care in the most expensive setting. The bills, which none in this layer can pay, are astronomical and serve only to further bankrupt the unfortunate. Rating of care: poor with no connection to a primary care provider or mental health follow-up.

In conclusion, the recent superficial debate about healthcare seems to hinge on hot-button issues like rich insurance companies, greedy drug companies and desperate immigrants who become sick. Of course healthcare costs money — only a politician would say otherwise. The healthcare system we have or will have is exactly what we plan.

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Leadership and Narcissistic Personality Disorder

ilovemeThe label narcissist or description as narcissistic has appeared in the current presidential campaign rhetoric. defines narcissism:

Inordinate fascination with oneself; excessive self-love; vanity.  Synonyms: self-centeredness, smugness, egocentrism. 

Personality is the way a person views themselves and the way they emotionally interact with the world.  We all have a personality.  The first writings about personality were in the Renaissance.  In modern times psychologists have applied scientific methods to this difficult concept.

Psychologists have discovered some very important things about personality.

  1. Personality is persistent through adult life and is likely coded in our DNA.  Even animals have personality.
  2. The survival of a tribe may be enhanced by having members with different personalities.  Like members with confidence in themselves, members who are passive followers, or members who like consistency.
  3. People can have bits and pieces of different personalities which are called personality traits.
  4. Personality alone does not define a person psychologically.  Other things like intelligence, environment and interactions with other people have a huge impact.
  5. A little personality is very good.  But, a lot of a personality which is rigid and unyielding to social pressures is actually a disease.  The disease is called a “personality disorder” rather than a “personality trait”.
  6. Personality disorders cause problems for the person who has them.  They ruin relationships, cause financial harm, and may cause unfavorable interactions with the law.
  7. Finally, a person is generally blind to their own personality and can not change it.  People can learn coping mechanisms by appreciating how other people react to them — sometimes called mirroring.  An overbearing person might “tone it down” in order to make friends.

So, back to the narcissistic personality disorder.  The scientific definition can be found in the Diagnostic and Statistical Manual (DSM).  The DSM is a publication of the American Psychiatric Association that seeks to define mental disorders for the mental health professions.  Click here for a link to the part about personality disorders.

Key elements include:

  1. A high degree of self-esteem.  “I am great and only I can do things well.”
  2. Validating self worth through others.  “Everybody likes me and knows I am great.”  They tend to be surrounded by people who do think they are great or perhaps are unwilling to challenge that assumption.  Extreme dislike of people who don’t appreciate their self-perceived greatness.
  3. Setting high standards to gain approval of others.  “I follow tax rules so well it makes me a success.”
  4. Lack of empathy.  Actions they take are viewed on how they affect them rather than the harm, embarrassment, or financial ruin that others may experience from the interaction.  Divorce and bankruptcy are sometimes the result.
  5. Difficulty with intimacy.  Relationships are superficial — glad handshakes or kisses that have no underlying meaning.
  6. Shows arrogant, haughty behaviors or attitudes.  Such as denigrating minorities or the opposite sex.  And, strongly seeks the attention of others.

OK, this could describe many politicians!

But, is this the personality most modern people want in a leader?  Probably not.  We don’t need a leader to take us on a hunt for a woolly mammoth.  In primitive times people needed a grandiose leader to spur them on, but it’s likely when the mammoth stepped the leader the feeling was “better him than me.”  Now we want “servant leaders”.  People who have personality traits adapted to successfully improve our lives, not just theirs.

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Bitter Pill — redesign of health care

A fantastic article about US health care was published this week.

Time Magazine March 4, 2013 “Bitter Pill:  Why Medical Bills are Killing Us” by Steven Brill

There are two main lessons from Mr. Brill’s article.  First, as a business, US health care is doing quite well financially.  Second, the overwhelming drive for profit is bankrupting patients and the US economy.  He makes a damning case US healthcare has disconnected the actual cost of care from the high charges for care.  Mr. Brill has exposed the unethical side of US health care.

If  Mr. Brill’s article has a weakness it would be the suggestions for correcting what he has found.  He proposes a few solutions but he acknowledges, as a journalist, he was not looking for solutions.  However, he is on the right track — the US clearly needs to redesign the health care system and, he makes a very good case for Medicare as central to any effort at cost containment.

The following suggestions for redesigning our health care system spring from the collision of high cost, poor quality and the belief an expansion of Medicare will help to solve the crisis.

1. Allow all citizens to buy into Medicare at any age (some would pay more than others according to risk and ability to pay)
2. Mandate that all health care subsidized by the US government (Medicare, Medicaid, postal workers, veterans administration, indian health care etc) is covered by Medicare (consolidate the vast array of  plans to just one — make it simple and manageable).
3. Allow the States to purchase Medicare for their workers — a big cost savings for the States.
4. Mandate employers to provide healthcare for all workers — Medicare would be an option  — but  the health care benefit must be at least as good as Medicare.
5. Allow the FDA to evaluate drugs, devices and equipment for cost effectiveness and to make a Medicare listing of those items that are covered (those that are not listed can be purchased by individuals outside of Medicare).  The FDA would be required to make the cost of the list stay within a maximum stipulated by Congress).
6. Allow Medicare to negotiate the purchase price of drugs, devices and equipment nationally.
7. Force the creation of Accountable Care Organizations immediately.  All Medicare benefits must flow through ACOs.  This solves the payment for volume of services problem.  There has been a delay to “see if ACOs work”.  Similar systems are well proven in other countries, we just need to act.
8. Physicians and hospitals who provide Medicare should be employed by, or under contract to, an ACO.
9. All physicians who work full time under Medicare will be salaried at $200,000/year with an additional $100,000/year  awarded (or not) if established quality and service targets are met.  For example, there is no pay differential for primary care and neurosurgery.  (this payment system works wonderfully in the UK).
10. Establish a copay for primary care, specialty care, ER care, hospital care, SNF etc to incentivize a primary care home, and to put a clamp on overutilization.  (the poor may get coupons, like food stamps, for the copay)
11. Increase the nurse practitioner and physician assistant workforce as quickly as possible.  It only takes 3 years after college for them to be care providers whereas it takes 7-10 years for physicians and surgeons.  Offer to pay for physician training if they will be Medicare doctors for at least 10 years in locations where Medicare finds a need.
12. Mandate a national medical record for Medicare
13. Mandate a national health card — show the card at the point of care, pay the copay and get the service — no paperwork!
14. The US needs to think of health care as a right — a right to reasonably priced health care!
15. Monitor quality for Medicare and push the quality agenda so the US can again have the best quality health care.

Those are my thoughts for a big-picture redesign.  What are yours?


A few links of interest:

Diane Archer (Board of Directors, Consumer Reports)
Bitter Pill:  5 part series (a blog)
Naomi Freundlick (Reforming Healthcare Blog)
Bob Haiducek  (Medicare for All)
James Kahn (Physicians for a National Health Program)

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Analysis of the Affordable Care Act

The New England Journal of Medicine published an editorial about the Affordable Care Act (ACA) by former Health and Human Services Secretary Gail R. Wilensky, Ph.D. on October 18, 2012.  Dr. Wilensky is a knowledgeable source for comments but she is clearly a political player.  Her description of problems for the ACA is reasonable although her conclusion a voucher system solves the problems does not follow logically (fully understandable in this political season).  But it is worth summarizing her findings and adding a less political conclusion.

She states that US health care suffers from

  1. Millions of people go without insurance.
  2. Health care costs are rising at unaffordable rates.
  3. Quality of care is not what it should be.

Her criticism of the ACA (in summary form by this blogs author):

  1. The penalty for not purchasing insurance is too small
    (she suggests a penalty like medicare that builds up every year if a person does not comply)
  2. A lack of organization to ensure effective, high quality and affordable care.
  3. No attack on the system of reimbursement of providers, based on number of services, rather than quality and cohesive delivery.
  4. Not enough resources are put into value-based purchasing and accountable care organizations (ACO).  And, too little money is at risk for providers who fail to meet quality targets.
  5. Not enough regulatory framework to force physicians into large multispecialty groups and patients into primary care systems.
  6. No sense of urgency to make meaningful reforms take effect.
  7. Lack of clarity  on how market forces will be harnessed.
  8. Allow a 2-tier system so those who can afford more health care coverage can purchase it.
  9. Reduce the cost of health care by government action (presumably health care vouchers as proposed by congressman Ryan)

Vouchers are one way to put a maximum on how much government will pay.  But, without simultaneously attacking the other problems we just end up with low cost awful health care — not a happy outcome.



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