Map of life expectancy at birth from Global Education Project.

Wednesday, March 04, 2009

Victor Fuchs pretty much nails it

Victor Fuchs is a health care economist who among other distinctions wrote a famous book called Who Shall Live, which Prof. Fuchs discusses here. This week in JAMA (subscription only, but here's the opening paragraph. A big razzie to JAMA for making this closed access.) he discusses the prospects for health care reform. Since everything he says is the pretty much the same as what I have already said here in recent weeks, he must be right.

Fuchs says, first of all, that the Clinton effort failed because, while a majority supported reform of some kind, proponents never got behind a single plan but rather divided their energies, while opponents were united; and that the public never properly understood the issues. Both true. Alas, the situation is really no different today. Also true.

Given that we are in a period of economic decline, Fuchs argues that controlling costs has to be a salient goal of reform. Hey, I just said that a few days ago. Fuchs makes the following points about cost containment:

  • The best shot for a quick knock down of costs is reducing administrative expenses. These are what insurance companies provide, and also come along with means tested programs. Universal coverage will pretty much pay for itself if it eliminates this waste. (However, as the wise professor is surely aware, the insurance companies aren't going to sit still for that. We will without a doubt see an encore by Harry and Louise or their modern descdendants.)

  • Long term, we need an equivalent of the UK's NICE. How often have I said that? As I also noted a couple of days ago, conservatives -- pretending to stand for freedom but in fact standing for drug and medical device manufacturers who fatten their campaign coffers -- call efficient and effective medicine tyranny. This is utter nonsense, but will the people listen to Victor Fuchs, or the idiot talking heads on teevee?

  • Ultimately, cost containment requires establishing global budgets (as the UK does for all health services and Canada does for hospitals, although Fuchs doesn't mention it). Yes, but just wait for the screaming and yelling about rationing. Again, will the people get this, or will the hair-hatted phonies on teevee scare them with images of sending Grandma off on an ice floe?

  • More emphasis on preventive medicine may be good for our health, but it won't save money. Hey, didn't a blogger we all know just talk about that?

  • Electronic Medical Records aren't cost effective for small physician practices, although they may have a payoff in large systems. See above bullet.

Fuchs also draws attention to the likelihood of adverse selection torpedoing a proposal to offer a Medicare buy-in to people age 55-64. Maybe a good point, on the other hand that would not be a problem if we had mandated coverage, because the Medicare buy-in would likely be the best deal for everyone. Of course, it would also set the insurance companies on the slippery slope to oblivion -- a good thing, but here come Harry and Louise.

So, the bottom line is, good public policy will be very tough politics. Let's not waste time in yacking about it, however. Organize!


kathy a. said...

don't you think the public is educable, and at a point in time when it wants to be educated?

the health care disaster arguably touches nearly everyone, or someone in their lives. it is not just the staggering numbers of uninsured folks, either; the costs keep shooting up, and coverage by insurance companies keeps becoming more and more restricted. who doesn't know a horror story about an arbitrary or unreasonable denial of coverage?

i think basic charts showing where insurance dollars go could be very useful in showing the waste of the system. why would i want to pay herds of clerks who arbitrarily deny claims in the hope that the insured won't fight it, or to line the pockets of shareholders who are not contributing value to consumers at all?

since the scare tactics about rationing are clearly in the aresenal, can't they be defused in advance? there is already rationing; all plans come with limits. but many times the allocation of resources doesn't make sense -- designer drugs that work no better, scads of tests that really aren't justified -- while others are wrongly denied benefits when the necessary procedure is expensive or unusual. people will always be able to buy extra services, just as they do now.

one thing i want to ask is, how are you defining preventive medicine? surely you can't be counting immunizations, which are extremely cost-effective and prevent untold misery. are you including regular physicals? standard screenings such as pap smears and mammograms?

i also don't know if you are including early access to medical care when something goes wrong as preventive -- symptoms of infection, for example, or cancer, etc. it seems to me that early access to care must be more cost-effective than waiting until the medical problem becomes a medical emergency. the doctor's office is far less expensive than the ER; a round of antibiotics or limited surgical intervention is less expensive than trying to deal with a problem that has escalated out of control.

kathy a. said...

i also have a question/observation about electronic medical records. does it make sense to just look at costs to a small practice? because a patient's medical care may often wander outside the confines of that small office, and the records could be extremely important to other caregivers. ordering a photocopy of the file isn't a good solution in many instances, because that can take quite a while, but decisions may need to be made very soon.

i'm not sure how they plan to put records in electronic form, but it may not be as onerous as it sounds. an organization that i work with started going digital about 10 years ago, and has scanned millions of pages of documents into a pdf format. my understanding, which is admittedly limited, is that it's not much more complicated these days than running a photocopy machine. time-consuming at startup, for sure. but then there is all this searchable data, which is rather amazing and useful.

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