Map of life expectancy at birth from Global Education Project.

Thursday, March 05, 2009

¿Tienes preguntas? ¡Tenemos respuestas!

Yes, I certainly think that the average person is capable of understanding the basic issues underlying the need to reform our health care system. Where the dollars come from and where they go is certainly a good place to start -- one problem that Victor Fuchs mentioned which I didn't note yesterday is that people tend to think of employer provided insurance as a free lunch, without realizing that it actually reduces their wages.

But a lot of the key information does get repeated in public, constantly, by reform advocates, and it doesn't sink in. One obvious and compelling point that doesn't seem to get much traction in the public consciousness is the enormous administrative waste created by the patchwork system of private insurance. Medicare spends only 1/10th as much on adminstration. But people are so conditioned to think of government as inefficient and wasteful that this incontrovertible fact just doesn't compute -- it doesn't fit into the pre-existing frame.

The people have had sand thrown into their cognitive gears by Republican politicians and the hairhats on TV who support and enable them. While average people can certainly understand the issues, the clowns on CNN and ABC evidently cannot, and of course Fox News lies on purpose. (ABC also employed John Stoessel, who I would actually classify as the biggest liar of all.) The right has succeeded in infesting our discourse with meaningless rhetorical tropes that effectively substitute for facts and arguments. Free markets™, Big Government™, Rationing™, Socialism™, Free Choice™, and so forth, don't actually mean anything. But all you have to do is say them and people think you've successfully categorized a proposal as good or evil.

Now, as for Electronic Medical Records. There is what I will call the radical proposal, and there is the moderate proposal.

The radical proposal actually has a lot of advantages and on purely technological grounds it would provide the best infrastructure for a true health care, as opposed to disease care system. This proposal is that your medical records are not located in your doctor's office, and the hospitals and other places where you are treated. They are located on a web server in Palo Alto with backups in Tuvalu and on your own thumb drive if you wish. They belong to you. You control access. You can give the passwords to your primary care doc -- and presumably you would need to -- but you could if you wished make some parts off limits even to him or her, though I would not recommend it. You authorize your PCP to provide access as needed to other providers, to the portions of the record which are relevant for them. The payer -- probably an insurance company for now, but we can hope some day it will be otherwise -- automatically gets sent billing information, including whatever diagnostic info they require, but that's all they get. The doctor doesn't even need to send them a bill.

So, if you're on a trip to Las Vegas and a slot machine falls on you, the docs there can get access to your records and find out all about your drug allergies, medication needs, and history of pulling over slot machines onto yourself in order to generate lawsuits. Small physician practices don't need to buy any software or systems because the software resides on the server in Palo Alto. All they need is a web browser. (I recommend Firefox, and it's free.)

Nobody can write anything in the record that you don't know about, and you can write your own comments disputing anything you don't like, and/or petition to get things changed. Nobody without the passwords that you control can get access to the records, except perhaps in carefully defined emergency situations.

Sounds utopian, right? Not going to happen, at least not any time soon. And I don't have to spell out for you the huge privacy and security concerns this would raise. Perhaps they are insurmountable, perhaps not.

So what we will get instead is every institution having its own, stand-alone system. There will be various competing off-the-shelf systems, and some big academic medical centers will have proprietary systems built just for them. They may or may not be able to talk to each other and exchange information easily. That's very difficult because they won't all use the same information architecture so there will have to be all sorts of software written to convert info and move it around. And small practices will still not be able to afford it or use it efficiently if somebody else buys it for them.

So we'll see.

As for preventive medicine, yes there are some procedures, notably some immunizations, which are or can be cost saving. Having doctors counsel people about smoking cessation isn't very effective, but it doesn't cost much either so it may have a net saving. But screening procedures, prophylactic statins, stuff like that, may be cost effective, meaning that the money spent is worth it, but that's not the same as cost saving, meaning the net cost is actually less. And right now, except for the autism nuts, we have near universal immunization, so there isn't much potential left there. We'll have to look elsewhere for savings.


kathy a. said...

when we talk about costs, i don't know why the only measure should be dollars spent at the moment. "cost-effective" is worthwhile. and the human costs and increased medical costs down the road of NOT providing early access and care seem absolutely relevant.

one of the twisted things about the patchwork insurance system in place is that the companies look for maximum cost savings and maximum profits in this year or quarter. the companies do not have much incentive to assume a long-term sense of responsibility -- they know that many/most people change insurance regularly, when they change jobs or when the old policy doubles in cost and a new one is lined up. newcomers are frequently denied coverage for "pre-existing conditions." so, even if saving a dollar today is likely to cost $100 down the road, there is a decent chance that later cost will not be their problem.

a health care system that operates like a giant game of musical chairs is not a sensible system.

Cervantes said...

Absolutely! That's really key -- the insurance company has no incentive to invest in keeping you healthy because by the time you get cancer or heart disease, you probably won't be on their plan any more. If we could just get people to understand this -- it's one of the strongest arguments for a single payer system.

kathy a. said...

is anyone looking at "costs" this way? i really don't know, but think probably not.

nobody has the incentive [or maybe, the ability] to look at how changes in coverage or denials of coverage are affecting the millions and millions of people who have or had health insurance. while we have rough [huge] numbers of people who are uninsured, the first priority for them is getting them to some care.

but it seems to me, those are stories that need to be researched and told.

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