Tuesday, August 11, 2009

Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 2)

In a prior post, I examined the how empathy (i.e., the ability to put oneself in the shoes of another), which is often lacking from the healthcare reform debate, ought to be an essential ingredient in the decisions our country makes. My discussion about the need for greater empathy triggered a contentious debate between a man working in the insurance industry and myself. The first part of this hot debate is at this link. Following is the second part. Please feel free to join in.

He wrote:

I own three TPAs…Both sides of my business entail helping employers offer insurance more efficiently. This is usually at the expense of insurance companies. We attack the fat. We have also been carving out a lot of drug plans because employers can self fund the risk cheaper then paying premium to a carrier.

And, in response to a discussion we've been having about Wendell Potter— insurance exec turned whistleblower, who spoke out against the underhanded tactics of the health insurance industry—he continued to discredit Mr. Potter by saying:

I do know the left is quick to point out he was an ex "insurance industry" executive but fails to mention he is now on the payroll of a pro-reform, anti insurance company advocacy group. On THCB [The Health Care Blog] previously I posted a very long and detailed explanation of what terms he doesn't appear to understand and where he was lying. When time permits I'll try to find it. I think there are all sorts of abuses that could turn someone off of insurance companies and even lead someone to campaign against them…Mr. Potter is by no means a whistle blower, he hasn't disclosed any abuse or actions that are not common knowledge. He's a paid shill at best.

I responded:

I would like to see your post. And I'm glad you are not defending the abuses of insurance companies, even though the ones Mr. Potter pointed may be common knowledge to certain people. What would be great is if you would share your knowledge of all the abuses and underhanded actions you've observed.

In response to my question—"Are you are insinuating that the right kind of capitalism is the pathologically mutated form of free market capitalism we've been living with for many years, with its weak gov regulations" – He responded:

You don't know what the term free market means. Nothing about our current system is free market or weakly regulated.

To which I replied:

As I understand it, many legislators have a free market ideology that focuses on weakening or eliminating certain governmental regulations that were originally created to protect the public. For example, Federal Reserve Board Chairman Ben Bernanke said we need to strengthen regulation of financial markets to stem excessive risk taking (see this link). And my reason for saying we have had a pathological mutation of capitalism comes from an interview of John Bogle, who has been named by FORTUNE magazine as one of the four giants of the 20th century in the investment industry, and by TIME magazine as one of the world's 100 most powerful and influential people (see this link). Anyway, call our current system whatever you want. The point is that those with free market cravings have been conspiring to kill regulations that were preventing our financial meltdown and, no doubt, important regulations in other areas have been on the chopping block.

In response to my statement—These sub-systems share various business models, operational processes, and metrics." – He replied:

I wouldn't call Medicare and private employer plans sub systems they are to distinct. And this whole point matters because the failures of Medicare and Medicaid are a terrible reason to destroy our successful private insurance system. None of the reform being discussed will improve the private systems, it will reallocate resources to the failed public plans so they can last a few years longer. Far from being semantics it is the underlying reason why all government reform fails to deliver what they promise the public it will.

To which I replied:

Still semantics. Sure, sub-systems can be distinct. For example, like the healthcare system, Nature is a complex system composed of interconnected parts (sub-systems) that as a whole exhibit one or more properties not obvious from the properties of the individual parts; that is, it is a system of distinct interacting sub-systems. Same goes for the human body; the digestive and respiratory systems are distinct interacting sub-system of the human biological system.

As far as Medicare and Medicaid being failed systems and private insurance being successful system, I guess we have to define what is meant by "success." There are those who say these programs are successful because, with Medicare for example:

  • Its universal coverage nature creates the ability to redistribute benefits to those who are neediest.
  • It pools risk in order to share the burdens of health care among the healthy and the sick.
  • Through Medicare, the government protects the rights of all beneficiaries to essential health care (Reference).
  • Medicare is more efficient because, in contrast to private insurers, Medicare doesn't have to spend millions on marketing, advertising, and Washington lobbyists. On top of that, private insurers must generate profits for their shareholders. (Reference)

And in an interesting interview, John Stewart summed up his conversation about healthcare reform with conservative pundit Bill Kristol (editor of Weekly Standard): "So what you are suggesting is that the government could run the best health care system for Americans, but it's a little too costly, so we should have the shitty insurance company health care" (See this link for the interview).

Nevertheless, others say the Medicare's efficiency is over-hyped (e.g., see this link).

In any case, private insurance has never been designed to cover everyone, unlike proposals such as "Medicare for All." While I'm not opposed to any coverage/payment strategy—be it single payer, public together with private insurance plus subsidies, or any other method—just as long that gives everyone access to good care.

In response to my statement—"Are you implying that we should eliminate Medicare because it has inefficiencies, or are you saying we should work to make it more efficient?" – He responded:

I'm saying we should eliminate Medicare because it is a complete failure. It never delivered what the public was promised when it was passed. It's poorly ran and destroying our entire healthcare system. Medicare is a cancer on American Society.

To which I replied:

Just as private insurance has very serious problems (including cold-hearted abusive tactics, which I hope you can elaborate upon), Medicare and Medicaid certainly have their share of problems. Radical reform is the only way to solve these problems. But failure to cover everyone is a deal-breaker as far as most Americans are concerned (e.g., see this link).

In response to my statement that we must focus on—"making our entire healthcare system (including all sub-systems) much more efficient by cutting out waste, fraud, abuse, and inefficient operational processes." – He replied:

This is not accomplished by expanding governments role. If you really wanted to accomplish any of this you would eliminate government from healthcare as it is the main driver of waste, fraud, and abuse.

To which I replied:

Few would argue that we need government reform, just as we need healthcare reform. But I'm hard pressed to conclude that there is less waste, fraud, and abuse by the private insurance industry compared to government. In fact, it seems to me that government and the private insurance industry have been in cahoots since, as reported recently in the Chicago Times: "Health insurers have lavished $41 million in campaign contributions on current members of Congress since 1989, with more than half going to lawmakers on the five House and Senate panels writing this year's health bills, according to the nonpartisan Center for Responsive Politics. Since the beginning of 2008 alone, they have spent $145 million on lobbying, led by Blue Cross-Blue Shield organizations and the AHIP trade group."

This tells me that no matter what is done, we must have independent oversight and strong regulations to minimize waste, fraud, and abuse, as well as the knowledge to know what constitutes cost-effect care.

In response to my question—"Do you want private insurance to become more efficient and affordable as well?" – He replied:

Yes I do and this is achieved by eliminating wasteful and inefficient regulation like COBRA, HIPAA, ADA, and the limiting of self funding. This is not accomplished by a public plan, 1000 page bills no one has read, or insurance exchanges.

To which I replied:

What's required is a rational plan that is well-read and understood (although I don't know how many pages it should have), which gives everyone access to good care, and equally important, the plan should:

  • Enable all clinicians to continually learn how to make (and keep) their patients healthiest and happiest for longest, using the most cost-effective methods of treatment and prevention, and encourage/reward them for doing so.
  • Enable all consumers/patients to continually learn how to make (and keep) themselves healthiest and happiest for longest, using the most cost-effective methods of self-care and self-maintenance, and encourage/reward them for doing so.

These two bullets, sadly, have not been adequately discussed since we're so consumed with how to pay for care that we aren't discussing how to make that care much more cost-effective. A sustainable solution MUST fully address both these issues.

He wrote:

I didn't ask how to measure value I said who? It is VERY easy to come up with legitimate methods to measure something. Depending who's hand you put that in though is what matters. In the absence of a fair, honest, and efficient god to do this judging it needs to reside with the consumer. Government and corporations have both been given this chance and failed completely, neither can be trusted to measure value.

How does some disinterested third party appointed to this job make those decisions better?

Self funded Employer plans deliver the highest percent of dollars to legitimate benefits. All employer plans have lower administrative cost, when you include loss due to fraud, then public plans.

And I replied:

Actually, the necessary measures and related research are FAR FROM EASY; anyone believing otherwise is likely unfamiliar with what's necessary. Anyway, asking who would do the judging is certainly a reasonable question.

I absolutely DISAGREE with your assertion that consumers should be the judge of whether they received the best possible (i.e., most cost-effective) care. That's because the typical consumer doesn't and can't have a clue as to what generally constitutes cost-effective care; in fact, rarely do clinicians, administrator, or anyone else! Why? Because that knowledge doesn't exist! Why? Because we've been overly focused on issues related to insurance/payment and not enough on (a) discovering what works best for each patient and how to provide that care efficiently and (b) how to incentivize the delivery of such cost-effective care.

In any case, what we need are three basic things:

  • Independent researchers and other healthcare experts focused on collaborating world-wide to establish ever-evolving, personalized, evidence-based guidelines.
  • A new generation of computerized decision support tools that help clinicians and patients select the most cost-effective guideline to follow for promoting competent self-care and efficient prevention and treatment.
  • A cost and payment system that rewards good self-maintenance and effective care that results in good clinical outcomes, as well as penalizing inefficiency and ineffectiveness.

That's where the debate stands now.

Let me add this: I'm thoroughly convinces that any sustainable healthcare reform strategy must focus on transforming our current low-value healthcare system into one that brings high-value to the consumer/patient. I discuss this in a post at this link.

Related links:

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