By Evan Falchuk
EXCITEMENT, that’s what.
Archive for the ‘Reform’ Category
What is Nancy Pelosi Talking About?
Wednesday, March 10th, 2010
On Health Care Reconciliation
Thursday, March 4th, 2010By Evan Falchuk
So the President gave a speech yesterday in which he said he would push, with Democrats in Congress, to pass a major health care bill through a process called “reconciliation.”
I don’t think most of us know what that is, exactly. The meaning of it is simple, though: they can pass a bill with a simple majority vote. They can eliminate a Republican filibuster in the Senate. It’s been called the “nuclear” option, well, at least since Republican Trent Lott dubbed it that some years ago.
Some people are appalled that this could happen. Should they be?
I don’t think so.
Never Get Involved in a Land War in Asia
Tuesday, March 2nd, 2010By Evan Falchuk
Warren Buffet is talking and reform opponents love what the unofficial Obama adviser has to say. He says the President should scrap the whole thing and start over.
He says health care costs are a “tape worm” eating at American competitiveness. His prescription: a “united effort,” a “national emergency” that will allow us, finally, to focus on “costs costs costs” above all else.
Buffet is a brilliant man, and he makes a very good point about how botched the sales job on reform has been. But he’s missing something very important:
We have been focused on health care costs in America. For decades.
Look Out, More Charts
Monday, March 1st, 2010By Evan Falchuk
Today the Commonwealth Fund came out with a chart that it says is a “grim reminder” of what happens when health care doesn’t get reformed.
If only we had listened to Richard Nixon or Jimmy Carter. We would have saved tens of trillions of dollars in health care spending.
Click to enlarge
My Quick 5 Reactions to the Health Care Summit
Thursday, February 25th, 2010By Evan Falchuk
So the big, long health care summit in DC is over- here are my quick five quick reactions to it:
1. It should have happened a long time ago, but it couldn’t have. It was a substantive conversation. David Gergen said that, intellectually, “the Republicans had their best day in years” (he meant it as a compliment). The bills that came out of Congress probably would have been a lot better if they had been discussed like this before they were drafted. The trouble is, representatives on both sides weren’t at all up to speed on health care back then, so they couldn’t have had a conversation like this. So we end up with bills first, smart talk later. I think there’s a movie coming out about that kind of thing next week.
2. It was still riddled with silliness. Nancy Pelosi said the plans would create 400,000 jobs “almost immediately,” and would overall create millions of new jobs. Meanwhile, John Boehner kept insisting that the plans were a “government takeover” of health care. It wasn’t clear if Pelosi or Boehner were talking about the House bill, the Senate bill or the President’s new plan. Actually, it wasn’t clear what they were talking about at all. What always surprises me is the extent to which many politicians just say stuff that they can’t possibly believe to be true. It’s one reason why a lot of people don’t want to trust them with important things that directly affect their lives…like health care.
3. You can’t put reform in a box and say you’re for it or against it. Well, I guess you could do it literally with the 2,000+ page bills, but I mean it figuratively. They talked about a huge number of topics. The uninsured, medical malpractice, rising health care costs, Medicare, Medicaid, comparative effectiveness, health insurance premiums, insurance mandates, state versus federal insurance regulation, interstate sales of insurance, pre-existing condition exclusions, uncompensated care, over-use of the ER, and on and on and on. It’s the trouble with the so-called “comprehensive” plans- there’s no “system” to comprehensively reform. So the bills aren’t “comprehensive,” they’re just long – a giant collection of stuff that will impact the health care system, some for the good some for the bad.
4. It’s another cog in the anxiety machine. The fact that all of America’s top leaders, in the midst of a terrible economy and two wars, would meet for an entire day about health care sends a message that this is a hugely important issue. And it is an important issue. But the trouble with reform from the beginning has been that voters don’t understand what’s happening and are worried about it. Today, as a friend suggested to me, was like porn for policy wonks. But I think to regular people it just sounds like trouble. Something big is happening which I don’t understand but which I know will affect me in ways I’m not going to like. I’m sure representatives from vulnerable districts didn’t like it when the President said near the end that if the voters don’t like it they can vote in November.
5. Republicans shouldn’t misread what’s happening. Republicans clearly have read the polls showing opposition to the reform plans. But like in Massachusetts, rising support for Republicans isn’t because Americans are suddenly turning to their ideas. I think voters just want this long, long, long health care saga to end. As James Carville might have said, it’s the health care, stupid.
Price Controls, Again?
Monday, February 22nd, 2010By Evan Falchuk
Barely a week after Massachusetts Governor Deval Patrick said he wants state controls on the price of health insurance, President Obama apparently wants to do the same at the federal level. Both men must believe it’s good politics, because there are about 4,000 years of evidence that it’s not good policy.
But the trouble for reformers has never really been about policy. It’s been about a fundamental misunderstanding of how people view health care and the very bad things that happen when you give people the impression you’re going to mess with what they have.
In this sense, the reform bills are like perpetual anxiety machines. Contraptions that continually produce more public anxiety than they consume.
But why is this?
US Employers: Not Crazy to Pay for Health Care
Saturday, February 6th, 2010By Evan Falchuk
“I’m from Massachusetts,” I told the audience. “So depending on how you feel about reform, I will say either ’sorry,’ or ‘you’re welcome.”
The audience, made up of large employers and benefits professionals seemed to like this. But it was clear that they were pleased that the health care reform legislation is Congress is pretty well dead now.
Now, if it’s true that health care costs are rising (they are) and this heavily impacts employers (it does) why would the death of a bill meant to address this problem make those people happy?
There is no Voom
Saturday, January 16th, 2010By Evan Falchuk
Did you ever read The Cat in the Hat Comes Back?
It’s the sequel to The Cat in The Hat and it’s better than the original. Kind of like how Empire Strikes Back is better than Star Wars.
In the Cat in the Hat Comes Back, the Cat returns to the scene of his first adventure, and accidentally creates what seems to be a manageable problem – a ring of pink goo in the bathtub. He tells the children he can clean it up. But every solution he tries creates a new problem. Great pink spots of goo keep getting spread all over the place.
The cat brings in more cats to help clean up the spots. These cats – 25 in all, bring increasingly intricate solutions. But they only spread the spots around more and more, making the problem much bigger, and much worse.
The spots finally get cleaned up, but only when one final cat – so small that you can’t see him – uses a magical power called “VOOM.” Unleashing VOOM suddenly puts everything back exactly as it was supposed to be.
Dr. Seuss understood people. When faced with a problem, people tend to want to do something. But when this happens, people often seriously undervalue the unintended consequences of whatever it is they’re trying.
It happens in business all the time. You face a problem and decide some new software will fix it. You rush to build it. Then, along the way somewhere, maybe millions of dollars later, you realize the software isn’t helping. In fact, it’s created a whole host of new issues. You realize, too late, that your real problem had to do with the way your business was organized in the first place.
Politicians are very susceptible to this, especially when dealing with big, important issues. Who among them wouldn’t want to champion some giant, historic solution to a giant, historic problem?
So, here are three ways the what’s gone on in health reform in Washington DC is the return of the Cat in the Hat – but without the Voom.
1. “To take spots off THIS bed will be hard,” said the cat. “I can’t do it alone,” said the Cat in the Hat.
The reform bills have never been based on a vision of changing American health care into some new, coherently different state. Instead, they are a collection of big and small deals meant to satisfy the needs of one or another Congressman or constituency. The most recent of these – the deal to exempt union plans from the “Cadillac” tax underscores the point. Rising health care costs are the most important fiscal issue we face as a country – well, unless those costs are covered by a union benefit plan.
I don’t know that the Cadillac tax was ever a good idea. But if you’re going to have it, shouldn’t it apply to everyone equally? If the reason to have it is to get rid of high-cost insurance plans, how does exempting a huge portion of the high cost marketplace further that goal? It doesn’t, of course.
2. Oh the things that they did! And they did them so hard. It was all one big spot now all over the yard!
One of the major reasons why health insurance is so expensive is how it’s regulated. Today, 50 state agencies dictate what companies can sell in their states, what they have to cover, the terms on which they must accept business, and many other important activities. It adds a significant amount of cost to all policies. Worse, it makes the market for health insurance deeply uncompetitive and stagnant. In short, it’s a terrible deal for consumers, and a great one for insurance companies. The bills in Congress address this issue….by replicating a federal version of this state system.
Now, instead of dealing with 50 regulators, insurers can work closely with just one regulator, if you know what I mean. This isn’t progress. It is a failure of imagination.
3. “Why, Voom cleans up anything clean as can be!”
As a plot device, using Voom is a sort of cheap way to end the chaos unleashed by the Cat in the Hat in a page or so. But that was the point. There’s no such thing as “Voom,” even though we all wish there were. The lesson is this- cleaning up messes is hard, so be careful not to make them in the first place. Don’t act without thinking. Realize that once you have a mess, the only way to fix it is not through dramatic short-cuts, but through the hard, daily work of chipping away, one bit at a time.
“And so, if you ever have spots, now and then, I will be very happy to come here again.”
Doctors are People, Too, Ctd.
Wednesday, January 13th, 2010By Evan Falchuk
A new study out of Israel (h/t Robin Grantham via twitter) says that the kind of mood your doctor is in may significantly impact the quality of care you get.
On days the doctors felt positive moods, they spoke more to patients, wrote fewer prescriptions, ordered fewer tests and issued fewer referrals. However, when doctors were in a bad mood, they did the opposite.
Now, I bet this is true in any line of work. If you’re in a bad mood one day you probably aren’t as good at your job as on days you are in a good mood. Ok, well maybe not every line of work.
Still, if being in a bad mood leads to lower quality, higher cost medicine, let’s think about what the work life of a doctor typically looks like.
For starters, they often have to see 30 or 40 patients a day, and spend maybe 20 minutes with each. Private insurers and the government impose on them an increasing amount of administrative work. They’re also increasingly involved in the medical decisions the doctor works so hard to make. Doctors’ incomes aren’t going up, but the cost of their malpractice coverage is. Meanwhile, patients are increasingly demanding and sophisticated, the pace of change in diagnosis and treatment is accelerating.
It’s a set-up that seems exquisitely designed to create high levels of stress, anxiety, fatigue and burn-out, doesn’t it?
Of course, these were precisely the things the Israeli researchers said led to lower quality, higher-cost medicine.
The stress, anxiety, fatigue and burn-out we see, though, are just symptoms of a larger problem. Our system too often deprives doctors of the time and space they need to get to know a patient, think about their problem, consult with colleagues, and offer sound advice. These are the things patients want from their doctors. What’s more, doing these things are a big part of why people become doctors in the first place. Unfortunately, there isn’t much of anything in the health care reform proposals that addresses this deeply fundamental problem, and so it will continue, or get worse.
Which ought to create bit more stress and anxiety for the rest of us.
http://twitter.com/RobinGrantham
Wait, What?
Monday, January 11th, 2010By Evan Falchuk
“We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.” – Peter Orszag
Could anyone disagree? Not really. Which ought to be the first clue that it’s a meaningless truism. I mean, of course more isn’t always better.
But this hasn’t stopped this truism from becoming one of the most popular refrains in health care reform. Most of the time this is directed at one area: end-of-life care.
The idea is this: Americans spend too much money on heroic, but ultimately futile care at the end of people’s lives. Well-known research out of Dartmouth shows that that huge percentages of health care dollars are spent on end of life care. What’s more, it shows that this kind spending varies by big amounts, depending on which hospital you go to. For example, the federal government spends an average of $85,000 at Johns Hopkins, while spending less than $30,000 at Mayo Clinic. Reformers see the chance to save huge amounts of money by getting rid of these variations. Some say this could save the government a half a trillion dollars over 10 years.
It sounds good.
But here’s something you probably didn’t know: the Dartmouth study only measured spending on patients who died. If the spending saved your life, the researchers didn’t count it.
What the hell?
The New York Times (h/t Kausfiles) reports that some people are trying to take a clearer look at this problem, and conducting research that looks at the living, not just the dead. Those studies show that when you count patients who live, the difference between the most and least expensive hospitals narrows by as much as 44%. Government research that accounts for the fact that sicker patients often end up at more highly skilled hospitals further narrows the gap. Seen in this light, that potential half-trillion dollars evaporates pretty quickly.
This isn’t to suggest that variation doesn’t exist, or that some patients or their families demand care beyond the point where it’s beneficial. But it does show — again — how easy it is to get lured into oversimplifications of the problems in health care.
There are many people in health care who pore over the enormous amounts of data our multi-trillion dollar health care economy generates. They’re looking for patterns, big, systematic problems for which they can devise systematic solutions. But for all their looking, they keep missing the most important lesson of all. Which is that health care is not an assembly line process amenable to one-size fits all solutions. They miss that the answer to the most important question – what is the right way to treat this patient? – is a very unsatisfying: “it depends.” As one of the lead researchers of the Dartmouth study framed it: “Sometimes more medical care is better, but the question is when.”
Getting the right answer to that question isn’t a matter of protocols and financial incentives. Doctors want to get these answers right, regardless of the financial incentives, and so do patients. What is required to do this is a commitment to making sure each and every patient has the time, insight and judgment of their doctor. Yet our system fundamentally undervalues these things, and the reform efforts continue this mindset. If we continue to focus on how much money is spent, rather than whether that money is spent correctly, we will keep making it harder for doctors to get these answers right.
And people will continue to look at data, see puzzling results, and wonder how things ever got that way.
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