Let the patient be damned! (Politics <==> Inertia)

This discussion point is part of a blog-series, "The Short Shrift of Healthcare." See "Reforming Healthcare & Managed Care" on HCPLive.com

There's a concept in healthcare insurance where all risks in a community of interest, a market, are pooled – community rating; and then there's experience rating where the healthy are advantaged in more ways then one and the sick are marginalized, paying disproportionately more into the pool just to have a seat at the table.  The latter is what we mean by 'a medical catastrophe is one step from personal bankruptcy.'  It also explains Paul Krugman's frustration with politics. 

In "Do the Right Thing," he speaks to the hit that healthcare reform took in Massachusetts: The "Republican victory in the Massachusetts special election means that Democrats can’t send a modified health care bill back to the Senate. That’s a shame because the bill that would have emerged from House-Senate negotiations would have been better than the bill the Senate has already passed. But the Senate bill is much, much better than nothing. And all that has to happen to make it law is for the House to pass the same bill, and send it to President Obama’s desk." Voltaire's "Perfect is the enemy of the good," rings true, part of the reason why politics often means inertia.

Universal Care or Nothin' 

From: Fredrick H (MD, PhD, Esq.):

Jessie McKinley in "California Democrats Revive Universal Health Plan" tells us that democrats just revived a bill that would create a single-payer, universal health care system in California.

I, nevertheless, feel this really can't be done right without incorporating Medicare, and it most certainly isn't going to be done right at the Federal level.  So, it's good that the states do what they can.

It's also good that it's not a hand-off to the Insurance companies, which is the plan that so alienated the Mass. voters.

On Jan 22, 2010, at 9:22 PM, Gilbert R. (An academic network's Exec. Dir.) adds a Krugman quote from the aforementioned op-ed piece, "Do the Right Thing":

"Suppose, for example, that Congress took the advice of those who want to ban insurance discrimination on the basis of medical history, and stopped there. What would happen next? The answer, as any health care economist will tell you, is that if Congress didn’t simultaneously require that healthy people buy insurance, there would be a 'death spiral': healthier Americans would choose not to buy insurance, leading to high premiums for those who remain, driving out more people, and so on."

"Where is your Moses Now?" [Edward G. Robinson]  [Referring to idol worship rather than doing the right thing.]

Jeff Kaplan writes: Personally, I'm getting sick and tired of the finger pointing, the special interests, the lack of insight, progress and the selling out.

Are you going to sit idly by as nothing is done?  That's a sellout and its sentinels are:

1. Sustaining the antitrust protections, i.e., the exemption enjoyed by the healthcare insurance industry.
2. Similarly, by not allowing insurance companies to provide policies across state lines, we squelch competition and support the high costs of care. (I.E., we need an 'exchange' program in the insurance marketplace).
3. By precluding the re-importation of pharmaceuticals and by allowing Big Pharma to pay-off the manufacturers of generic drugs, the high price of drugs is an exclusive U.S. business.
4. Who ever agreed that medical directors, "Utilization Review,' or  'Pharmacy & Therapeutics' committees would dictate how medicine is practice on the front line of medicine? Here's how they get you: multi-tiered pharmaceutical 'benefits,' the exclusion of integral 'supplies,' the denial of coverage of referrals to relatively unique or scarce specialty services or to vital transports to nearby hospitals.  And, I love how the managed care or insurance businesses obfuscate—'we don't deny care; we just won't pay for it.  It's not our problem that your husband was dying in a non-par (non-participating) ER and you wanted him transferred to a specialty hospital.  That possible tumor? What tumor?
5. By shortchanging primary care reimbursement and by allowing specialists to dominate the landscape, the first venue of care is often ridiculously fractionalized and it is certainly too expensive.  Don't you love it when an ENT refuses to evaluate the pneumonia?
6. Managing by exception, that is, not practicing continuous quality improvement is certainly a huge missed opportunity.  In a similar vein, so is paying for process, rather than outcome, and not aligning the incentives, for both doctors and patients.

The "Bang for the buck" issue, the Medical Loss Ratio, revisited. What are you getting for your health care dollar?
"Despite the valuable controls being put in place to prevent the insurance companies from denying and limiting needed care, the fact remains that Big Insurance and Big Pharma (the medical/industrial complex) are still in firm control of our health-care system and will still be able to spend 25-35% (or more) of your health-care dollars on management, marketing and huge administrative salaries."

"The insurance industry is attempting to develop loopholes in the badly worded new legislation mandating that they spend 80% of your premium dollar on providing health care... .They seek to include their insurance brokerage fees and a host of non-medical care expenses as part of that 80 percent mandate."*

The implication and why we felt let down when this legislation was watered down and passed is that eliminating multiple third-party payers might mean spending only 6-% of your health-care dollar on managing the delivery of care.

Indeed, "This legislation keeps us in thrall to the bottom lines of the insurance and drug industries and does not honestly address the broken elements in our current delivery system."

"My View: Despite health-care reform, system remains broken," < http://www.recordonline.com/apps/pbcs.dll/article?AID=/20100801/OPINION/... > (Pub. 8/1/10)

* This is the medical loss ratio (MLR) or the percent of medical spending to premium revenues collected.