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March 2006 archives
Not so long ago when I was a smart young health care consultant, I spent a great deal of time poking around the innards of health plans. Health insurers were going to be the vehicles of care management. Once the principles of how to manage population health were figured out, health plans were going to be run by wise medical directors who were going to explain the correct way to manage care.
The ideas was to put all the information about a patient together from the many doctors and providers they see, and make sure that their treatment followed best practices. Everyone in health care knows that no doctor knows what the others treating the same patient are doing — that’s why there’s a huge push to get physicians to use electronic medical records. So the thought was that a central “sponsor” would oversee the process. This thinking went quite far.
If, say, patients needed care that wasn’t strictly medical, but would reduce problems and costs later, the health plans (or the medical groups they contracted with) would provide it. For example in the mid-1990s in Southern California some medical groups really sent handymen out to the homes of their elderly patients to check that the rugs were fixed down, and that hand rails were in the toilets. Consequently they reduced the number of broken hips caused by falls. Good for patients, good for the insurer. There was also an incipient industry called “disease management” in which call centers full of nurses contacted patients to make sure that they were doing OK and taking their meds, and hopefully had fewer of them show up in the emergency room because of something bad that happened because they didn’t take their pills.
Believe it or not, there are still many people working away within health insurers, or subcontracting to them, doing just this type of thing today. Hospitals and doctors make their living off sick people—which is a problem in and of itself. Insurers ought to make their living off keeping them healthy.
But a funny thing happened on the way to the Forum. The headline in the LA Times this morning is about insurers cancelling insurance of sick people based on the most tenuous of excuses. And we’re not talking podunk little fraudulent insurers. The villain in question is Blue Cross of California, which these days is part of Wellpoint, the second biggest health insurer in the nation. Now of course it’s possible that the policies they’ve been cancelling were fraudulently acquired by people lying about their health conditions, but it certainly looks as though the insurers went trawling for any flimsy excuse to kick them off the policy once they became sick.
Continue reading "Yin and Yang - The wonderful world of health insurers" »
So Ben Domenech’s tenure as the token conservative blogger at the Washington Post is over. The real journalists are all in a huff about plagiarism. And the more aggressive of my fellow travelers on the left are enjoying the moment. But I have to ask, is what he did wrong that big a deal?
I don’t know Ben — obviously my fellow Spot-oner Josh Trevino does, having co-founded RedState.com with him —and equally obviously I don’t agree with 99% of his political views. In addition, what happens to one young conservative punk don't amount to a hill of beans in this crazy world. There’s plenty more opportunist cannon fodder to take his place.
Continue reading "Breaking a Caterpillar Upon A Wheel?" »
Last week leading “liberal” magazine The New Republic (TNR) came out with a battle cry to restore health care to the center of American liberalism. In an editorial called Universal Health Care--Now TNR argued that
Since President Clinton's health care plan unraveled in 1994--a debacle that this magazine, regrettably, abetted--liberals have grown chastened and confused, afraid to think big ideas. Such reticence had its proper time and place; large-scale political and substantive failures demand introspection, not to mention humility. But it is time to be ambitious again. And the place to begin is the very spot where liberalism left off a decade ago: Guaranteeing every American citizen access to affordable, high-quality medical care.
TNR overstates the role of the dreadful No Exit article in taking down the Clinton plan. No Exit was published in the days when TNR was edited by latter-day gay conservative but now Bush-hating flip-flopper and Time blogger Andrew Sullivan. It was written by a pundit called Betsy McCaughey. She later went on to be Lt-Governor of New York before quickly thereafter divorcing herself from Pataki, her billionaire husband, and reality.
But overall you might think that an analyst like me who’s a pinko-commie on social issues because I believe in a single health insurance pool would welcome TNR coming to the fold. Especially as I’m a big fan of their lead health care editor Jonathan Cohn. And there’s no question that the current state of healthcare is a disaster precisely because we do not have universal health care. No one is responsible for overall costs, and the existence of the “uninsured category” allows the system to keep raising its prices knowing that, because of the dire consequences of having no health insurance, anyone who can afford to will keep paying or desperately try to find an employer or taxpayer to do it for them. It’s even got to the stage that the WSJ reports that having health insurance is becoming the desirable commodity in the online dating world. And I’m on record on Spot-on as saying that health care will be the defining issue of the next decade.
But there’s one thing wrong with TNR’s clarion call: It’s too soon.
Continue reading "Politics, Religion, The New Republic and Health Care" »
In an article misleadingly called “Is Socialized Medicine the Answer?” Arnold Kling lays into Krugman and Wells’ rather good article in The New York Review of Books on how we need a single payer system to ration health care equitably. Kling, who appears to be a bright enough guy, is yet another libertarian who made a fortune in the technology business and has plenty of time to mouth off about new subjects.
Sadly despite all his wealth and education apparently he cannot tell the difference between socialized medicine (where all the providers work for the government) and socialized insurance, where all the people are in one or multiple insurance pools and the government sets prices for private contractors. It’s scarcely worth the bother of correcting him, but let’s just remember that Canada, the UK and Scandinavia basically fall into the first category, and everyone else in Europe and Japan (and Medicare here) fits into the second. (See Ezra Klein’s great synopses on different health care systems if you want to know more). Hint: private medicine is predominant in those systems and even exists in the UK. So no one is going to make a rich kid like Kling wait for his care. He can just by-pass the queue,
Continue reading "Rationing's opponents: Happy in their fantasy world" »
I’ve always been what’s now called a social libertarian — it’s a fine English tradition dating from the days of Bentham and John Stewart Mill, and if you can fuzz it a bit, you can trace it back to the English supporters of Henry II — the Knights of the Grand Assizes. (Henry II was a Norse Froggy, don’t forget). And the philosophy remains: You should be able to do whatever you like so long as it doesn’t hurt someone else. But sadly, another European tradition coming out of the same Reformation period has been predominant in the U.S. The notion of intolerance of other people’s behavior has played a strong part in the U.S. due to its Calvinistic heritage. That intolerance comes out in much of the current conservative domination of our politics, but none so much as in what I call the “war on (some) drugs”. Sadly that war - or should we say massacre, as there’s no army to protect those who disagree with the intolerance of the government - has moved front and center into medical care.
This comes out in several areas, in which patients and their representatives have been fighting a rearguard action to be allowed to deal with their medical conditions in the way that they want. The most obvious is the medical marijuana (MM) movement, which has developed into a twilight world in several American cities, where the states and local jurisdictions support the rights of patients to use MM, but the Federal government using some incredible twisted manipulation by the Supreme Court — the same ones who brought you the Bush Administration — has effectively outlawed it.
But marijuana was never in the medical mainstream, and never likely will be. Opiates are a different matter. It may surprise you to know that the biggest opium crop in the world comes not from Afghanistan, but from the Australian state of Tasmania. And there have actually been serious calls to allow the Afghans to grow opium for the same purpose — to be used as the basis for medical grade morphine.
Why do opiates matter? Because they are essential medication for one of the most under-treated medical conditions: chronic pain. How bad is this under-treatment? A report out this week shows that:
According to the American Geriatrics Society Panel on Persistent Pain in Older Persons, 45 to 80 percent of nursing home residents have substantial pain. The consequences of poor pain management include sleep deprivation, poor nutrition, depression, anxiety, agitation, decreased activity, delayed healing and lower overall quality of life. Fewer than half of nursing homes residents with predictably recurrent pain were prescribed scheduled pain medications
Continue reading "Calvinists in the Medicine Cabinet" »
