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Thursday, October 29, 2009

Some Thoughts on Healthcare Reform

by economist Steve Landsburg, from his new blog Landsburg is known for his brilliant economic articles in

The American health care system desperately needs reform. But there are certain inescapable truths that would-be reformers would do well to heed; otherwise they risk making things worse for everyone, and particularly for the poor.

Here are a few of those truths.

1. Insurance is not part of the solution; it's part of the problem. Many people-and especially poor people- get too little health care in this country. That's largely because many other people-and especially rich people-are overinsured. People with insurance demand more health care, which drives up prices. More insurance coverage will make this problem worse, not better. There are good alternatives to insurance. For example, as David Goldhill points out in a magnificent Atlantic Monthly article called "How American Health Care ..., we could take, say, half of what's currently being spent on insurance and Medicare and use it to give each American family close to a million dollars to put in a health savings account. We'd probably want to couple that with insurance for catastrophic events that cost more than, say, $50,000.

Or, less radically (and therefore less effectively, but at least it's a start) we could restructure medical insurance to look more like car insurance-where nobody asks how you spend your claim check. If you're diagnosed with colon cancer, then instead of paying $X million to doctors and hospitals, the insurance company would pay $X million directly to you. That way, at least some of us would shop around for better prices and forgo treatments we don't think we need-lowering demand and making medical resources easier for everyone else to afford.
The last thing we need is more of the inefficient sort of coverage we've got now. The very last thing we need is to make that coverage universal.

2. Somebody has to say no. Nobody would want to live in a world where we all get unlimited health care, because in that world, health care would be all we could afford. That means we despearately need someone to say "no" from time to time. In a world of health savings accounts, we'd tell *ourselves* "no"; in the world we live in, our insurance companies do it for us.
We all know horror stories of claims delayed and claims denied, and many of those stories are true. They have to be, because no system is free of mistakes. Sometimes insurers say "yes" when they ought to say "no" and sometimes they say "no" when they ought to say "yes".

Now, we could always opt for insurers who err more on the side of "yes"-in exchange, of course, for higher premiums. But almost nobody wants that. I know this because I believe that insurers are consumed by greed, and would therefore happily offer any product as long as consumers were willing to cover the cost. Auto insurers compete on exactly this basis: Some companies hand out claims more easily than others, and their premiums reflect this. But when it comes to health insurance, it appears that the market is pretty satisfied with what we've got.

When your health insurer denies a claim, it's performing a valuable public service. If health care is going to stay affordable for anyone, somebody has to sometimes say no. And as much as we bitch and moan (sometimes rightfully, because some of those denials really are unwarranted), we really wouldn't prefer it any other way.

3. A public option can only make things worse. A government run insurance system can only do one of two things: Mimic the private insurers, or do something different. If it mimics the private insurers, it serves no purpose. If it does anything different, it can only be worse.

After all, what can it do different? Approve more claims? But where will the money come from? Higher premiums? But we've already agreed that if people wanted that kind of insurance it would already be offered. A more efficient bureaucracy? But if there were a way to save money by streamlining the bureacracy, why wouldn't all those greedy private insurers have adopted it already? Does anyone believe that the major insurance companies are too lackadaisical to make an easy extra buck?

You might say that the private insurers, unlike the government, won't always pass cost savings on to the consumer. But that too underestimates the greed of the insurers-and their willingness to undercut each others' prices in the endless competition for customers.

So if public insurance is going to provide anything that private insurance doesn't already provide, it will to have to do it by dipping into general tax revenues-maybe not at first, but surely soon. And that way lies madness.

Once those general revenues get tapped, all discipline goes out the window. With all that cash at hand, it becomes harder and harder to deny a claim. Nobody's saying no, and the cost of health care spirals out of control.

Eventually you're left with the health-care equivalent of Fanny Mae or Freddie Mac-an institution with dual mandates to earn a profit (or at least break even) and to serve the public-and therefore an excuse to fail on all fronts. When it loses money, well, that's because it was trying to serve the public. When it fails to serve the public, well, that's because it was trying to be financially responsible. Nothing counts as failure and nobody's responsible. It was Larry Summers who first (and most eloquently) made this observation about the inevitable fate of dual-purpose institutions; once upon a time, he was a very wise man.

I know, I know-the proponents of the public option insist that it will be self-financing. I don't believe them. What happens the first time a powerful congressman demands that his constituent's claims be treated more respectfully? And the second time, and the third? Where does the money come from? But even if you *could* somehow resist that kind of political pressure, what are you left with? A high-claim-approval high-premium option that nobody wants? What's the point of that?

4. It's always the poor who get screwed. Expanded insurance coverage means higher health care prices; universal coverage means higher prices still; universal coverage with a public option blows the roof off. That's bad for almost everyone, but it's hardest on the poor.
Now you might say that we could make up for that by spending lots and lots of public money to buy health care for poor people. The problem with that is that every dollar you spend on health care is a dollar that's unavailable to help poor people in other ways.

When you're poor, it's hard to buy health care. It's also hard to buy schooling, housing, and groceries. It's a false compassion that tries to alleviate one hardship by exacerbating others. If we make it unnecessarily expensive to help poor people buy health care, we handicap our ability to help them buy milk and eggs.

Consider the disaster that is Medicare. It's easy to fool yourself into thinking that Medicare is working because it provides a lot of medical care. But it does so at a titanic cost that crowds out social programs large and small, some of which might have made a real difference in the lives of struggling people. Without drastic reform, the burden of Medicare will crush the next generation. Tack on a publicly run insurance system with its eyes on the Treasury, and you've made that burden all the harder to shed.

I do not know how much we should be collectively spending to help the poor. I do know that whatever we spend should be spent as helpfully as possible. I also know that the way to accomplish that is not to drive the cost of health care through the roof and then spend a fortune trying to help poor people afford it.

It's also worth remembering that political institutions are not notorious for their responsiveness to poor people. When Congressman Smith comes around demanding better service for his favored constituent, odds are that constituent is a person with the means to make considerable campaign contributions. When you move institutions from the private to the public sector, you skew their responsiveness more toward the politically powerful, which usually means the rich.

The answer is less insurance, not more, and private insurance, not public. In the long run, those health savings accounts are probably the best solution. In the interim, the single most effective way to cut health care costs in a hurry would be to eliminate the tax deduction for employer supplied health insurance. That deduction leads to immense overuse of health care resources, especially by rich people. That's one good reason to eliminate the deduction, and here's another: People would start shopping for insurance on their own instead of taking whatever their employers offer, which would make the insurance companies more responsive to consumer demands.

It saddens me that support for universal coverage and a public option has become, in many circles, a sort of litmus test for compassion and caring about the poor. It particularly saddens me to hear the president say that "What we face is a moral issue; at stake are not just the details of policy, but fundamental principles." It's the details of policy that change people's lives. The moral imperative is to get them right.

What an Honor It Is to Belong to the Family of Physicians

A wonderful post from a family doctor in California who despite the daily drudgery and abuse that he no doubt endures daily in a busy practice is able to eloquently share his thoughts and uplift the spirits of many of us who feel unappreciated in today's healthcare environment.

What an honor it is to belong to the family of Physicians.

It's Saturday afternoon and from the window of my office I see an Oncology practice where the physician comes in on Saturday to see patients. I see his head down as he goes from his office over to the hospital. I see his step grow a little shorter each day as he struggles to keep up with the work. He has shared with me how difficult it is to keep the practice going. With the new reimbursement for chemotherapy, many of the agents he gives in the office cost more than the reimbursement.

I see another office of cardiologists. They seem to come and go at all hours. I see them there late at night, going between their office and back to the hospital. I always feel apologetic when I call them with yet another case that I need their help with because of the complexity of the patient. How grateful I am for their dedication and professionalism. Never have they just said no. Even though I know they won't be making it home to their daughters performance tonight, I still call them with cases when I need help. Their sacrifice, like mine is personal.

Across the parking lot I see an office of surgeons. There are days that the parking lot is rather empty as they are in surgery most of those days. One of my good friends has worked with that group. The part of the story not reflected in the parking lot, is the many hours they spend in the middle of the night, caring for yet another patient needing their skill. Many of these late night cases do not have insurance and many of them require long hours of dedication. What dedicated men and women these surgeons are to come in and work three or four hours through the night, trying to get someone through surgery. When morning finally arrives they have a full day awaiting their attention, compassion and skill. Some of them drive nice cars but somehow I don't think it really helps at the end of the day when they return home to find their family sleeping at a late hour.

There's a group of obstetricians and gynecologists at the end of the parking lot. Never have I felt that their lifestyle was something I would desire. I remember assisting them at C-sections and found that we would do one or two almost every night when I was on call. The funny thing with those late-night surgeries is that when morning arrives, you don't get to go home and take a nap. Somehow the rest of the world expects them to work through the next day as if nothing happened. I have five wonderful children and I can thank them for their dedication and professionalism in doing their job.

We are a very special community. No one in our society really understands what we do, nor do they understand the sacrifices we make as we obtain our training and practice our profession. Only another physician really understands the lengths to which this profession reaches into our personal lives and removes little pieces of us each and every day as we give of our time, intellect, compassion and dedication.

I for one, am proud to be a member of such a community. I feel a tremendous sense of brotherhood with other physicians, be they radiologists, pathologists, cardiologist or oncologists. All of us have made similar sacrifices. Some of us have continued training another three, four or five years longer than others who share the same title of Doctor. Ultimately, we all belong to the same organization of healers, dedicating our lives, our talents, and our abilities in caring for others.

I've not met a physicians who was in this for the money. What an amazing group of individuals we are.I reject the concept that there is a limited pool of resources that must be divided up among the different specialties. Each one of us provides a valuable service to complement what the other does. None of us could work very long in this arena by ourselves. We need each other and we complement each other. We actually work well together in providing care and sustaining life.

I salute my colleagues who answer my calls when I need a specialist to help me with a complicated case. I give you only the hardest cases as the ones that I can figure out, I keep myself. How grateful I am to have learned colleagues so willing to assume the responsibility for cases that I have not been able to either figure out or provide what they need due to my limited training.As a profession, we need to remind ourselves that we all share in the healing arts.

We must all reject the concept that for primary care reimbursements to go up, there must be a balanced reduction in the reimbursement to specialists. Only a politician would subscribe to this concept. Clearly, we can do more to ensure cost effectiveness in the system. We've never really been asked to contribute to that by providing peer review of interventions that perhaps may not warrant the expenses. Those decisions are now being made by insurance companies, with executives who care little for the health of their clients.

If the system is going to be overhauled at all, and if we are ever to successfully reform the way medicine is delivered, now is the time. For those of you who think that we should sit back and wait and see what happens, I would say that it is unlikely there will come a time where there is more interest in healthcare than that which we find right now.

Over the next few years, this reform will spell perhaps disaster and perhaps opportunity. Now is the time for us as physicians to link arms and band together as a profession to support one another. No more infighting which serves only to strengthen the arms of those who provide no health care at all yet bleed the system dry.

I for one, will be sending out thank you cards to the specialists I work with this next week, letting them know how grateful I am for their support and their care. I invite all of us to do the same. Reach out and connect as we reestablish the bond that we all share. All of us love the practice of medicine. We enjoy the challenge and the intellectual reward that we receive by the practice of our art. We truly do enjoy helping those around us in ways that few people would understand. What a great profession we have and what dedicated men and women we serve with.

Let's close ranks and support one another and provide a beacon of hope for America over the next year as we speak out and address the issues. True form will come from our experience and our leadership. Before we step into those leadership positions though, let's make sure that we as a profession maintain the respect for one another that we all deserve.What an honor it is to be part of this community who practice the healing arts.

Tuesday, October 27, 2009

Public Option a False Start Without Cost Control

By Fred Hiatt The Washington Post

The “public option” is dangerous not for what it might do but for what it allows the politicians not to do. From the start, the Obama administration has said that health-care reform has to make health care both more accessible and less costly . If Congress does the first without the second — guarantees a new entitlement without controlling costs — it will bankrupt us, because health-care costs are rising faster than the overall economy is growing. So far, though, that seems to be where Congress is headed, for two reasons: First, no one knows for sure how to control costs; and, second, the reforms that are likeliest to work are politically unpalatable.

What are those reforms? The most logical big thing Congress could do would be to tax, as income, the value of the health-care benefits Americans receive from their employers. By not doing so, the government forgoes $250 billion in revenue every year — effectively, its second-biggest health expense after Medicare. It discriminates against people who have to buy insurance on their own. And it encourages overuse of health care, which drives up costs. If employees had to pay taxes on their plan, they might opt for one that cost, say, $12,000 per year rather than $16,000, and push to receive the difference in wages. The government could use the revenue to subsidize health insurance for those who need help. But many unions oppose this change, because they fear it would jeopardize their members’ hard-won benefits, and so Democrats won’t go for it. Sen. John McCain, R-Ariz., embraced the idea as presidential nominee and was irresponsibly attacked for it by his opponent. Now Republicans oppose it so that, were President Obama to embrace it even in part, they could beat him up for retreating from his foolish campaign promise to reform health care without raising taxes on anyone but the rich.

The second big thing Congress could do would be to cede its power to regulate the minutiae of Medicare coverage. Cost control will come from a series of changes, adjusted and readjusted over time, in how physicians and other providers are reimbursed and what they are reimbursed for. Such decisions should be made based on evidence of what works and what doesn’t. But all such changes make one interest group or another — urologists, MRI operators, oxygen tank manufacturers — unhappy. They go to Congress, and Congress blocks the changes. Now Congress is being asked to cede both power and a reliable fund-raising source. And — surprise! — it doesn’t much like that idea.

Which brings us back to the idea of a government-run insurance plan. It allows Democrats to make their base happy, to bash the unlovable insurance companies — and to claim to be taking care of cost control, too, by ensuring competition in the marketplace. The claim merits skepticism. If, as advocates sometimes argue, a public plan operates without favoritism, it will be simply one more entrant in the marketplace. Like other companies, it will have marketing and administrative costs. In some markets served by few private plans, it could offer a useful alternative. But it won’t radically reduce costs. If, as advocates argue at other times, the point is to insure sick people whom private companies, despite all regulatory efforts, find ways to shun, the public plan could offer a valuable safety net. But that wouldn’t save money.

And if, as seems likeliest — and as House legislation mandates — the plan uses government power to demand lower prices from hospitals and drug companies, those providers may lower quality or seek to make up the difference from private payers. Private companies would have to raise their rates, so more people would choose the public plan, so private rates would rise further — and we could end up with only the public option and no competition at all. Single-payer national health insurance may be the best outcome, but we should get there after an honest debate, not through the back door.

So all the attention on whether Obama will get a public plan, as he says he hopes, misses the bigger point. The question is whether he will allow Congress to use the public option as an excuse to dodge the harder reforms, or whether he will insist on true cost control.

Hiatt is The Washington Post’s editorial page editor.

Monday, October 26, 2009

Canadian Patients Feel Wait Of The World

Canadian Patients Feel Wait Of The World

Posted 10/22/2009 07:27 PM ET
From: Investors.Com

Socialized Medicine: A group in British Columbia has offered medical waiting-list insurance to members whose government treatment is on hold — another example of why state-run health care must be avoided.

Canadians have a health care system that should be the envy of no one. It's not free, it's funded by taxpayers, and it isn't truly universal. Two Canadian Supreme Court justices made this clear three years ago when they concluded that "access to a waiting list is not access to health care."
Delayed treatment in an overused system has been the root of much unnecessary suffering. To prevent premature deaths and the needless misery that are hallmarks of Canadian care, the British Columbia Automobile Association began offering waiting-list insurance to some of its members in August as part of a pilot program.

Those who bought the coverage would receive treatment in a private clinic in British Columbia or the U.S. if they were placed on a government care waiting list longer than 45 days.
The program, which took two years to develop, never got beyond the pilot phase, however. The association shut it down when critics howled and government officials checked to see if such a program was actually legal in Canada.

"This is an example of a company that's actively soliciting for clients that have the ability to pay for the privilege of queue-jumping," said Adrian Dix, a member of B.C.'s Legislative Assembly. "In my view, and in the view of the legal opinion that we obtained, it is illegal, and it violated both provincial and national health legislation."

It's hard to understand why an elected official, or anyone else, would knowingly trap people in a system that can't take care of the public it is expected to serve. Yet there are many Canadians who would, in the name of "fairness" and "equality," deny others' right to take care of themselves outside of the collective. They are outraged that some of their countrymen could escape the agony of the waiting lists while others languish in the bureaucratic wreckage.

But the real outrage, to quote Brian Day, former director of the Canadian Medical Association, should be that a government would actually force "a citizen in a free and democratic society to simply wait for health care, and outlaw their ability to extricate themselves from a wait list."
That, however, is the system Canadians have been living and dying with for decades. Only in recent years does it seem that they've had enough of it. First in Quebec and now in B.C., private clinics have been opening to treat those who either don't want to wait or are too sick to endure the system's waiting list. Whether they will remain legal and open will be decided this fall by the courts.

Meanwhile, Canadians keep waiting — and waiting. The Fraser Institute in Canada reports that the median wait time from a general practitioner's referral to actual treatment by a specialist was 17.3 weeks in 2008 (see chart). That's a full week better than the previous year, but far worse than a decade and a half earlier when the wait time was 9.3 weeks.
Despite the decline from 2007 to 2008, the long-term trend indicates that wait times will continue to grow. It's a discouraging pattern that the U.S. will follow if Washington forces any kind of government care on this country.

Health care: How the U.S. system is designed to waste your money

This is a great article. It's what I have been arguing for years (See "What's Wrong With Healthcare Today").

Health care: How the U.S. system is designed to waste your money

Bruce Watson Oct 26th 2009 at 5:10PM

Filed under: Technology, Economy, Healthcare

From: Daily Finance

On Monday, Thomson Reuters released "Where Can $700 Billion in Waste Be Cut Annually from the U.S. Healthcare System," a white paper exploring American health-care costs. The report identified six factors -- administrative inefficiency, provider inefficiency, lack of care coordination, unwarranted use, preventable conditions, and fraud -- that cost the U.S. health-care system roughly $700 billion a year.

That's a shocking figure, but $700 billion is a conservative estimate. The price of waste may be as much as $850 billion annually, the report concluded, and other studies suggest the figure may be closer to $1.2 trillion. Given that the most expensive health-care proposal on the table in Congress would cost about $1 trillion, it's clear that significant industry reform could fund most of the cost of universal health insurance.

Where do these costs come from? As much as $150 billion can be chalked up to inefficient hospital administration. Our hospitals spend 25 percent of health-care revenues on administration -- twice as much as Canada's. Better scheduling and more attention to avoidable errors could save up to $100 billion per year, Reuters says. "If all hospitals reduced their average cost to the average cost of the most efficient 10 percent of hospitals," the white paper says, "operating expenses would [drop] by $73 million per year.

"Another big potential money saver: coordination between caregivers. Duplicated tests and overuse of emergency rooms result in as much as $50 billion of unnecessary expenditures annually. Preventive medicine could save as much as $50 billion. It would be reassuring to pretend that such waste is accidental, but it seems to be part of a larger business plan. Every time a patient has blood taken, the hospital gets to bill for administering the test, analyzing it, and storing additional materials, and the insurer subsequently often challenges the patient over the necessity of the test. By the time the transaction is complete, a few vials of blood have supported doctors, nurses, lab technicians, billing agents, test manufacturers, insurance adjusters, and other health-care professionals; the question of whether the test was necessary in the first place is moot.

One of the central points of today's battle over health-care reform has been the issue of a public option: a government-administered insurance plan designed to encourage competition in the marketplace. Reform's most extreme opponents criticize the public option as a step in an inexorable death march to Soviet-style communism and conjure Kafkaesque fantasies of "death panels" and rationed care in an apocalyptic prophesy of American health care. Reform's most ardent supporters, on the other hand, view the public option as an all-purpose solution to a system with no checks and balances: a government-administered price-setter that automatically injects price cuts, improves service, and increases efficiency.

But the Reuters white paper suggests that the public option is a red herring. The real heart of the debate, it says, lies in wonkier issues like efficiency and oversight. The system is now designed to maximize profits by minimizing efficiency: The longer a patient languishes in the hospital enduring tests and procedures, the more money goes to hospitals, drug companies and the medical industry. As health-care becomes more complex and expensive, insurers reap the harvest. For the health-care industry, making money is the primary goal. Healing the sick is a mere side effect.

While a public option might encourage industry players to strive for efficiency and lower prices, it doesn't directly confront the central issue of waste; nor do the health care proposals on Capitol Hill. The focus on universal health coverage is overshadowing the issue of health-care waste, inefficiency and fraud. In a recent New York Times op-ed, former Treasury Secretary Paul O'Neill warned, "Any health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate."

Stealth Socialism

Stealth Socialism

Posted 10/23/2009 07:30 PM ET

Health Reform: Congress' planned health care revolution will be bad enough without a government-run option. With it, Euro-style socialism becomes inevitable. It's time for a bipartisan way out of this disaster.

Last week proved Democrats want as much big government control as possible in the huge medical sector of the economy. The president's advisers said he's still committed to a government-run public option, House Speaker Nancy Pelosi lined up three versions of such a plan and the Senate majority leader announced a public plan with a state opt-out.
Why is the public option back at all? It seemed dead after a study earlier this year indicated such a plan would mean private health insurers could lose nearly 120 million customers.
Described as being "prized by liberals as a fundamental pillar of reform," the public option is really a way to put capitalistic America on a path toward socialized medicine.

Senate Banking Committee Chairman Barney Frank, a longtime co-sponsor of single-payer legislation, said in July, "I think the best way we're gonna get single-payer, the only way, is to have a public option and demonstrate its strength and its power." Why not just enact single-payer? "We don't have the votes for it," Frank replied.

The public option was conceived by leftist organizations such as the Campaign for America's Future years ago because polls showed the American people liked private health insurance and would never go for a direct government takeover. Ex-Sen. John Edwards' presidential campaign embraced it as "stealth single-payer," and the campaigns of Hillary Clinton and Barack Obama followed suit.

Renegade Republican Sen. Olympia Snowe of Maine may be the one to thank if this new medical entitlement becomes reality, at a time when government accountants warn that Washington is spending the country toward a fiscal doomsday.

The president is reportedly smitten with Snowe's public option "trigger" — an idea that comes down to this: If private insurers charge customers more than Uncle Sam dictates as they deal with all the new costs Washington imposes, the federal government will become their unfair competitor and wreck the private health insurance industry.

With or without a government-run option, the Democrats' radical transformation of the greatest health care system in the world still means reams of new regulations on private insurers, including the likely end of anti-trust protection.

It means fines for those — especially the young — who won't buy what will become high-priced insurance. It may slap uncooperative employers with an 8% payroll tax. And it may impose a $460 billion, 5.4% income tax surcharge sure to kill private sector jobs.

It's time for new ideas, like the expanded private coverage options of the Patients' Choice Act, backed by Rep. Paul Ryan, R-Wis., and Sens. Tom Coburn, R-Okla., and Richard Burr, R-N.C.
As Ryan warns, the federal government would run health care "with the compassion of the IRS, the efficiency of the Post Office and the incompetence of Katrina."

Does the AMA represent us?

Esteemed Colleagues,

I recently had a non-physician tell me that a recent survey by the AMA showed that "physicians in the US overwhelmingly supported universal health care". I explained to him that the AMA members only represented about 15% of all US physicians--at which time he explained to me that it was a random survey of all licensed physicians, including non-AMA members.

Is this true--or have I been locked in a time-warp?

(I actually looked at the numbers and found out that approximately 57% of those responding (of 2000 surveyed), actually supported a "public option", but for the sake of argument, I calculated the numbers and pointed out to him that 1200 respondants that supported the "public option" was hardly an overwhelming mandate and that that number actually represented less than 00.0015% of all US licensed physicians. He then proceeded to educate me on "using random sampling" whereby I had to educate him on "sampling error" and the danger of extrapolating any meaningful data from such an infinitesimally small sample to such a large and heterogenous population.)

What are your thoughts?

dximgr Radiology
Posted Oct 25, 2009 at 4:18 PM
From the first lines of the Wikipedia article on the AMA: "The American Medical Association (AMA), founded in 1847 and incorporated 1897,[1] is the largest association of physicians and medical students in the United States. While its membership has declined in recent years, it claims approximately 20% of practicing physicians as members."The number of physicians in the US is guesstimated at 800K by several sources (but 1.5M by WHO). Assuming the smaller #, the AMA would have 160K members. Sermo advertises about 115K members. But the latter # is growing while the former # is shrinking.These are back-of-the-envelope calculations. Use them at your own risk.

lasermed1 OBGYN
Posted Oct 25, 2009 at 4:47 PM
The AMA does not represent me, nor many of the other physicians on Sermo. And I do not support the current version of "Universal Health Care".

Phillip Surgery, General
Posted Oct 25, 2009 at 5:39 PM
Asking whether physicians support universal health care is rather like asking all Americans, "Are you in favor of automobiles?" Well, . . . .sure. But what make of automobile? And what FORM of universal health care? There's the rub. Devil is in the details.

drjrvigil Surgery, General
Posted Oct 25, 2009 at 6:13 PM
Thanks for the feedback. Hell, if we can't come to a consensus on what "universal health care" is, imagine what the public is faced with when asked the same question. Unfortunately, they are played to by the pied piper Obama...

rarmstrong Surgery, General
Edited Oct 25, 2009 at 7:18 PM
drjrvigil, Even in the current debate about HR3200, the AMA came out in support of it within 48 hours. Now, they didn't run this by their house of delegates first and their was no poll of the AMA members. Word on the street is that someone in the corporate side of the AMA threw their support behind HR3200. There is a lot of history here on Sermo about this topic. For me, the AMA does NOT represent my views, and any claim that they represent American physicians is completely false. Does that help?

drjrvigil Surgery, General
Posted Oct 25, 2009 at 7:47 PM
rarmstrong, yes it does...thanks for all your comments. For anyone interested, I have posted a blog on this subject on my I would love any editorial, articles, or comments from all of you on this contentious subject

rarmstrong Surgery, General
Posted Oct 25, 2009 at 8:13 PM
So, if you are interested, those of us who went to Washington on October 1st to protest what is occurring, at the Million Med March were interviewed by Fox News. Part of those interviews will be on Sean Hannity's show at 9:00 pm EST tonight.

wbarrettmd Family Medicine
Posted Oct 25, 2009 at 8:47 PM
Do youthink your going to get a different response, from the other 62 times this ? has been asked over the last 2 weeks

docrww Rheumatology
Posted Oct 25, 2009 at 9:53 PM
JR, I believe that your classmate was probably citing a recent 'survey' published in mid-Sept in NEJM online, based on subjects in the AMA database of physicians (and it did break-out responses of AMA respondents.).The survey reported 'wide support' or overwhelming support' (depending on which politician was describing it) for "The Public Option" - but not "universal health care."The survey was discussed on Sermo. The 2 authors (who designed and executed the survey, and even described placing phone calls to subjects who didn't respond promptly - something smell funny about that?) belong to 'Physicians for America' - a group that was known as "Physicians for Obama" until May, and the first author, Dr. Salomeh Keyhani, now serves as Chairman of their Foundation ('foundation' - you know, the fund-raising arm) - potential conflicts of interest not disclosed to/by the NEJM or in any of the TNTC press releases. It's the sort of baloney that would have been shredded in our 1st-year medical school journal club exercises as hopelessly conflicted and methodologically corrupt - but of course the lay press and your MBA classmates don't understand the need to read things critically... But so goes health care reform.

drnopain Pain Medicine
Posted Oct 26, 2009 at 9:13 AM

docvicolo Surgery, General
Posted Oct 26, 2009 at 10:56 AM
Universal healthcare should not be synonymous with Free Universal health care but it seems this is what most people think it is............ On the contrary, I hope people will have affordable healthcare that is by all means NOT FREE. People do not appreciate what they perceive as free and tend to abuse the privilege.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:14 AM
One thing universal health care will do is provide a massive shift of health care from the private sector to the public (your tax increase) sector. At present, your family plan costing $12,000/yr will rise to about $26,000 by 2019 because of the additional 40% tax. Most employers cannot afford this increase and will drop coverage forcing you into the publlic option. And this option will pay like medicare and medicaid. Remember the 21.5% pay cut coming up in medicare? This means most of us will not participate with the public plan and many will have insurance, none will have doctors. The common misunderstanding is between having insurance and having a doctor. It is not one of the same. Other stats...the government ALWAYS underestimates cost of programs. In 1965, actuaries estimated medicare costs for 1990 to be $10 billion....infact it was $107 billion. Now the program is spending more than its taking in. Washington has 2 options, ration medicare or raise taxes. Best place for data and statistics is and hit the health care in the search bar then hit ibdeditorials. Wealth of information to argue our side of health care.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:17 AM
Most of us that sign pay checks on the front are horrified about the socialization of medicine. Those of us that sign paychecks in the back are often clueless.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:21 AM
To: AMA Members An overwhelming majority of U.S. senators, Democrats and Republicans alike, are on record stating that the so-called Medicare sustainable growth rate (SGR) is flawed and should be replaced. S. 1776, the Medicare Physician Fair Payment Act, introduced last week by Sen. Debbie Stabenow, D-Mich., would have repealed the SGR, erasing the existing debt and freezing physician payments at current rates for 10 years. Yesterday's Senate vote (PDF) on S. 1776 was an opportunity for every senator to deliver on their pledge of support for repealing the SGR. Instead the Senate voted 53-47 to block consideration of S. 1776. The blame game being spun by some politicians over the outcome of that vote should be seen for what it is—pure political gamesmanship. Notwithstanding all of the hard work conducted by physicians who reached out to senators of both parties, this bill was blocked for these basic reasons: There is growing concern on the part of legislators and the public over expanding federal deficits. Therefore, a number of moderate Democrats and Republicans, although concerned about the SGR problem, simply would not vote for a bill they viewed as having negative deficit implications. The Senate Republican leadership cast this as a test vote on Democrats' health reform legislation. The problem is that another temporary fix of the SGR formula will merely exacerbate the very deficit problem that so concerns many senators. In 2005, the cost of repealing the SGR was $48 billion over ten years and physicians were facing cuts of 3.3 percent. Today, the price tag to permanently repeal the SGR is $245 billion and next year's scheduled cut is 21.5 percent.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:21 AM
The AMA shares concerns about federal deficits but we believe the responsible thing to do is to finally stop the Ponzi-like scheme to manage the SGR. Instead, Congress must once-and-for-all fulfill its obligation to senior citizens and the physicians who treat them. They can do this by wiping the slate clean and adopting a realistic baseline not predicated on physician payment cuts of 40 percent over the next several years. This effort to permanently fix the SGR isn't over, but we should acknowledge a few positive developments associated with S.1776 including continuing strong support and leadership by Sen. Stabenow and active support from the AARP and the Military Officers Association of America. We also need to thank the 47 Democratic senators who voted for cloture. We need to take a moment to clear up erroneous trade press reports over an Oct. 13 meeting with Sens. Reid, Baucus and Dodd and senior White House staff. At that meeting, the AMA did not agree to support a Senate bill still being drafted. While expressing our ongoing commitment to achieving meaningful health system reform goals this year, we reiterated clearly the AMA's continuing concerns with a number of provisions of the Senate Finance Committee's recommendations. These concerns have yet to be fully addressed.

wsugaimd Pediatrics
Posted Oct 26, 2009 at 11:23 AM
In other words, the AMA tried to kiss Obama's arse. Instead, it got bullwhipped.

Physician Responses to Apples are Apples Post

I posted my "Apples are Apples and Oranges are Oranges..." post on Sermo for commentary from real doctors in the trenches--not from the AMA.

dximgr Radiology
Edited Oct 25, 2009 at 8:11 PM
Dr. Virgil: There are several reasons to cast doubt on the WHO rankings. But this is not one of them: "I then pointed out to them that the average population of the European nations they had compared us to was about 50 million (ranging from 9 to 87 million) compared to 350 million in the US and that it was rather disingenuous to compare economies of scale in delivering and administering health care between countries with 9 to 87 million people (Sweden, Spain, France, England, and Germany) and ours with 350 million."Economies of scale allow one to SAVE money as the number of units increases. So if economies of scale played a role (and as I've expressed elsewhere on Sermo I don't think they do), it would lead one to assume the US, with its larger population, would have a lower cost per capita, not a higher one.So unless I'm completely misunderstanding your point, I don't think your reasoning works.

bpoterjoy Pediatrics
Posted Oct 25, 2009 at 8:18 PM
DrJ Your post here is a much longer version of a discussion I have had in non-professional forums. I have grown tired of continually hammering stat-quoters who really have no background in statistics, or who have had no formal instruction in critiquing data. So as to not rehash your well written post, I will simply say I fully agree with your comments. The one thing you left out is this- any meaningful comparison of the US v anyone is difficult not simply on population size, but on demographics- economics, race, social environment, etc. How does one compare the US, with a landmass the size of Europe and a more diverse population to, let's say Norway? I just don't think any comparison is valid. The dilemma is that the average person most likely does not have any exposure to an academic approach to data analysis, and is left with whatever he/she reads online or in the paper, or hears on television, and then quotes the data as if it is gospel.....sort of like the college student writing a term paper....or a med student doing journal club. Speaking for myself, it has taken a decade in medicine to get to reading the hypothesis, methods, and results...

rarmstrong Surgery, General
Posted Oct 25, 2009 at 8:43 PM
John, this subject has, of course been recognized and thoughtfully debated by many here on Sermo. To expect the media, politicians, pundits and others to be educated and honest about these numbers is kind of refreshing but as you have presented, is naive. So, how do you win a debate about health care in America with an uneducated, uninformed and easily inflamed public? You use statistics to lie, dramatize and support your opinion. This is operative, everywhere you look. If you are trying to sort it out...excellent! More of us should work to sort it out. Then, maybe we could form a rational informed opinion on how to proceed. You will not find this type of analysis in abundance inside of the beltway.

lawdoc Psychiatry
Posted Oct 25, 2009 at 9:49 PM
I would like a link to the reference that the editor was concerned about the methodology of the UN. I have often found the statistics problematic, but I have not seen the criticism you reference.Thanks.

theesist Anesthesiology
Posted Oct 25, 2009 at 9:53 PM
I don't know if you ran across these articles when researching for your blog, but here are a couple more that dispute our

slatosky Family Medicine
Posted Oct 26, 2009 at 9:09 AM
it is about expenditure not outcomes. if you take a country that has no medical care and everyone with breast cancer dies from it quickly and compare them to a country with great cancer survival rates you can then conclude that the country with no medical care has a lower percentage of people with breast cancer with a much lower expenditure. this is what was done in this study. If you were a patient with breast cancer where would you want to be.

rosevoran Internal Medicine
Posted Oct 26, 2009 at 9:36 AM
Power & Idealogy, this is what "Health Care Reform" is all about. Rarmstrong is right, statistics are used to lie.... This administration's goal is a socialist makeover of America. Controlling medical care is pivotal in this quest. There is no debating with them. Have you ever wondered why every one concerned (patients, physicians, pharmaceutical companies, DME companies, etc) will take a huge hit with the Obama plan...all except lawyers. There is no debate, this is a power grab.

Isledoc34 Pathology
Posted Oct 26, 2009 at 10:27 AM
One of my college texts was "How to Lie with Statistics". It seems to be the most popular texts in the WH today. Any good Socialist Govt. needs control, power, and money and will obtain their ends by whatever means available...lying being one of the best,

docvicolo Surgery, General
Posted Oct 26, 2009 at 10:34 AM
Nice Post and Comments. But can we really have any serious discussion about healthcare reform without showing our individual personal bias?.......... Not on Sermo. " Statistics is the art of drawing a crooked line from an unproved assumption to a foregone conclusion." (~ Emil Frankel )

jabmd1 Surgery, General
Posted Oct 26, 2009 at 11:00 AM
I think the key to the statistics is to compare the apples. When you compare surivial rates from many diseases the US is tops (especially cancers) To get high survivial you need to SPEND money. You spend the money on the screening, you spend the money on the treatment and you spend the money to find better treatments. I am in agreement with those that posted before me. This healthcare reform debate is all about power and trying to get a 50% majority vote for all time. Once a group of people have an entitlement program in place do you think any politician that wants to revoke it will garner any votes from the group that gets the entitlement.

lawdoc Psychiatry
Posted Oct 26, 2009 at 11:47 AM
Most of the time, it is not the statistics, it is the liars. There is rampant scientific illiteracy in this country, so the statistics are simply misused.Again, I would like to see the the actual comments of the editor. It should always be evident that we, in the USA, have social problems that pass as medical. When Farrakhan recently was encouraging black people to avoid the H1N1 vaccine, the outcomes will be reported as a failure of the medical "system." Why is it, that the failure to teach health as a meaningful course in the schools never gets mentioned as the main reason people don't know how to take care of themselves or know when it is appropriate to go see a doctor? Parents who don't know anything will only teach mis information to their kids.

Isledoc34 Pathology
Posted Oct 26, 2009 at 12:30 PM
Lawdoc, Re: "Why is it, that the failure to teach health as a meaningful course in the school never gets mentioned"... The schools all give sex education and hand out condums "to prevent disease" which is great Health Care. The kids also sing songs to BO which encompasses all of Health Care, doesn't it? It's disgusting, really.

drjrvigil Surgery, General
Edited Oct 26, 2009 at 1:04 PM are absolutely correct that economy of scale allows the ability of producing or supplying a commodity at a decreased price..but this hold true only to a point until discoordination occurs in management, inefficicney rises and average total cost of production increases again forming a U-shaped curve (this is called diseconomy of scale). E.g. General Motors. Hence it is ok to compare economies of scale between 9 million and 50 million, but somewhat of a stretch to go from 50 million to 350 million.

dximgr Radiology
Posted Oct 26, 2009 at 1:06 PM
That's exactly why, Dr. Vigil, I said above (and elaborated in prior Sermo comments) that I don't think "economies of scale" explains much in healthcare comparisons among nations. Economies of scale explain things at the level of the factory. When we talk about larger entities, another economic principle swamps it: Diminishing marginal returns.My point was merely theoretical. IF you believe economies of scale plays a role among national healthcare programs, THEN you'd expect the larger ones to be more economically efficient. But if I read you correctly, you were arguing the opposite: that the US, larger, doing worse than European countries, smaller, was explained by "economies of scale." My apologies if this was not your original claim.(If you wish to make some complicated "U-shaped" curve argument, than it's all an empirical question, and you'd need to provide numbers rather than just say it's all explainable by 'economies of scale'.)

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:06 PM
bpoterjoy, You hit the nail right on the fact that was one of the main reason that the WHO stopped the rankings because of the difficulties in comparing demographics, race, socioeconomic variables, and etc.

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:20 PM
lawdoc, here is the link and a summary. Judging health systems: reflections on WHO's methods Philip Musgrove PhD a Summary The attainment values in WHO's World Health Report 20001 are spurious: only 39% are country-level observations. The responsiveness indicators are not comparable across countries; and three values obtained from expert informants were discarded in favour of imputed values. Indices of composite attainment and performance are based on imputations and thus are also meaningless. Member governments were not informed of the methods and sometimes suffered unjust criticism because of the rankings. Judgments about performance should be based on real data, represent methodological consensus, be built from less aggregated levels, and be useful for policy.

drjrvigil Surgery, General
Posted Oct 26, 2009 at 1:36 PM
dximgr I think we are argiung the same thing. Diminshing marginal return is what makes the U curve slope upwards again. Economy of scale can apply to factories as well as organizations (goods vs services). My argument was that while a single payer system may--and the key word is may--work in smaller countries with populations of the European countries, that it is impossible to extrapolate or assume that that type of system would work in a country with a much larger economy of scale and that in fact, there would be the real and likely possibility that applying such a sytstem to our population would result in diseconomy of scale

Judging Health Systems: Reflections on WHO's Methods

Judging health systems: reflections on WHO's methods

Original TextPhilip Musgrove PhD


The attainment values in WHO's World Health Report 20001 are spurious: only 39% are country-level observations. The responsiveness indicators are not comparable across countries; and three values obtained from expert informants were discarded in favour of imputed values. Indices of composite attainment and performance are based on imputations and thus are also meaningless. Member governments were not informed of the methods and sometimes suffered unjust criticism because of the rankings. Judgments about performance should be based on real data, represent methodological consensus, be built from less aggregated levels, and be useful for policy.

By way of explanation

Readers of the World Health Report 20001 will have noticed that although many numbers are in the Annex tables, there is scant reference in the text to the indicators: “Fortunately…the report appears to make very little connection between the results of the performance analysis and the implications for undertaking [the] functions [of health systems]”.2 Text authors were told essentially nothing about how some of the indicators were estimated until near the end of the report's production. Two exceptions should be noted. I participated in the “fair financing” indicator and coauthored two papers describing its construction.3, 4 Chapter 2 of the World Health Report 2000, which I wrote, was the last written, and reflects what I learned from the team working on the Annex in the last weeks. References to “WHO decision-makers” mean Christopher Murray and Julio Frenk—respectively, Director, Global Program on Evidence (GPE); and Executive Director, Evidence and Information for Policy (EIP). References to “WHO staff” include people who worked on the report but who did not make decisions.

Numbers in the Annex

The main feature of the attainment numbers is that most were not derived from any detailed national-level information. WHO decision-makers chose to run linear regressions on real data, and impute values for countries for which there were no data. The imputed values are indicated in the report by italicised numbers, but the footnote which says “Figures in italics are based on estimates” does not explain anything about the estimates. Even for five countries for which all indicators were measured directly, the performance index is the result of imputations. Because it was evident by the time Chapter 2 was written that a large share of the so-called data were going to be imputed, the only comparisons across countries that include the imputed values are figures 2.6 and 2.7 and the accompanying discussion. I now think it was a mistake to have put these figures in the text, which otherwise omitted such presentations.

Ministers of health of the world may have felt, the day the report was published, in the position of parents whose children had been given grades in courses in which they did not know they were enrolled. WHO representatives and liaison officers were also taken by surprise; the advance copies of the report and press materials they were given could not enable them to explain to outraged or baffled officials where the numbers came from. Only 39% of the indicator values represent real data, which falls to 18.5% if disabilityadjusted life expectancy is set aside. This indicator was the only one not imputed by regression for 118 of the 191 member states of WHO. Among these 118 states are 25 in the top 30 positions by attainment and 23 in the top 30 positions by performance. The panel and the table summarise the amount of imputation by country and indicator.


Shares of detailed national data in the overall attainment index
The number to the right of each country's name in the large table indicates whether detailed data were used for one, two, or three of the indicators. Somalia is given a zero, and Botswana a value of 1, because their estimates of child survival were not calculated from detailed national data. Health inequality (child survival), responsiveness (level and inequality together), and fair financing each account for 25% of the composite index of attainment. Therefore, the share of that index for a particular country that is based on detailed national-level information is given by 0.25(N+1), where N is the number above, and 1 is added to account for the share of attainment due to health level measured by disability-adjusted life expectancy (DALE).
The number of countries for each value of N, and the corresponding share of the information derived from detailed national data, are as follows:

Number of indicators for which detailed data were used (N)

Table image
For the 191 member states of WHO, the mean value of N is 0.555=[(118X0)+ (45X1)+(23X2)+(3X5)]/191. The corresponding mean share of the composite index derived from detailed national data is 0.389. That is, 61% of the numbers which go into the index are derived from imputations and only 39% are based on detailed analyses without any projection across countries. There are 118 countries for which N=0, because the only detailed national data refer to health level—that is 62% of all the countries, which is coincidentally almost equal to the 61% data share. The mean value of N for indicators other then health level is only 0.234, less than half the overall mean of N. This corresponds to a share of real numbers for those indicators (health inequality, responsiveness, and financial fairness) of only 18.5%, equivalent to having detailed and complete information for 35 countries.

TableTable image
Countries for which detailed national data were used to calculate components of the indexes of attainment and of performance


Groups of key informants were recruited in each of 35 countries and answered a questionnaire about their own country's health system. The heads of the groups agreed that the results could not be used to compare one country with another, because no informant actually looked at any country but his or her own. “There was a unanimous agreement that the instrument was unsuitable in capturing information universally on the domains that were decided by the WHO. We were made to understand that this was a pilot study and findings of this attempt would enable identified issues to be included in some final survey with a representative sample of adequate number. But ranking countries based on this pilot study has been inappropriate and embarrassing.”(From Appendix 2.2; Protest from India to use responsiveness data).5

Five imputed values were published for responsiveness although actual responses were obtained. In two cases the informants gave opinions on one province (Shandong, China) or state (Andra Pradesh, India) rather than the entire country. One part of such a vast country may not be representative of the whole; nonetheless, it surely represents the country better than an estimate based on 30 other countries. In three cases, the informants’opinions were disregarded, without the excuse of incomplete information: Chile (rating improved), Mexico (lowered), and Sri Lanka (improved). Discussion Papers 21 (pages 22, 23 and 25)6 and 22 (page 9)7 give supposed reasons for replacing the informants’evaluations. In two cases the justification is a health reform, and in the other a civil war. Neither situation was restricted to the countries named, nor was there any explanation why war or reform would make an imputed value more accurate than the opinion of well informed observers. Still less is it clear why health reform would make observers err in one direction in Chile but in the opposite direction in Mexico.
When I discovered this substitution, I wrote to Murray by e-mail on Aug 30, 2000, stating “if that doesn't qualify as manipulating the data, I don't know what does…At the very least, it gravely undermines the claim to be honest with the data and to report what we actually find.”8 Murray replied by e-mail the same day, saying that “if results from any survey lack face validity it would be rather counterproductive to simply go with them. It is the careful interplay of infomed assessment of the quality of the results and empirical findings that is the hallmark of the development of good data systems.” I leave the reader to judge the “face validity” of that justification.

I regard these issues as not merely statistical or even political, but ethical. WHO insists that member governments should not misrepresent the data they send to the organisation. It is important that WHO publications meet the same standards. My efforts to persuade Frenk and Murray that publication of these numbers was unethical were in vain.

The question of whether the numbers are honest has an occasional comic aspect. The Russian Minister of Health, without knowing how the numbers were arrived at to rank Russia 130th among health systems, declared himself unperturbed by WHO's judgment, believing it an honest reflection of the situation.8

Use and interpretation of imputation

Imputation can lead to misleading results: a clear example occurs with fair financing. Regression analysis of correlates of this indicator show, not surprisingly, that high income inequality makes it hard to achieve fairness in paying for health care.9 But what is important is how well the system offsets or compensates for that handicap. A country with a high Gini coefficient that achieves a good distribution of finance burden deserves praise for overcoming income inequality, rather than being penalised. Imputed values can of course err in the opposite direction.10 Finally, when imputations are combined into an overall index, they must be clearly interpretable. There are seven components for level of responsiveness, with an equation for each, and an eighth equation for the distribution. When the equations used to impute these values are added up, the same variable sometimes pulls in different directions and enters in different forms, and it is impossible to make sense of any overall effect.

When governments composing WHO's Executive Board asked for more complete technical explanations in time for their meeting in January, 2001, they were given a collection of existing discussion papers, plus some new material.11 No material that explained the imputations was included.

Usefulness for health policy

The attainment and performance estimates are of no use for judging how well a health system performs. They illustrate the mathematical truth that the difference between two complex numbers can be entirely imaginary. This fact has not stopped WHO staff from attempting to explain differences in countries’performance, as though the performance itself were real and accurately estimated.12 Such analysis amounts to guessing who built the canals on Mars. To discover that richer countries have more responsive systems is of little help to a poor country, nor is much gained from knowing inequality in child mortality is lower when total child deaths are fewer. What a concerned government wants to know is what it can do about systemic failings.

One reason the results are of no use for policy is that WHO decision-makers avoided any real participation by governments. There were consultative meetings in December, 1999, and January, 2000, attended by academic experts and staff from WHO headquarters and regional offices. Although the WHO framework was explained and the indicators described in general terms, participants were not told how any numbers were calculated, nor about the intention to publish imputed values. So far as I can establish, nothing said by participants at either meeting changed anything about the methods or numbers. Subsequent requests for information, even from ministers of health, were not answered (José Serra. Minister of Health for Brazil in letter to Gro Harlem Brundtland, Director-General of WHO, July 5, 2000). WHO staff insisted “We should not underestimate the intelligence of policy makers”,13 but in my view, the organisation did not respect the intelligence of those policy makers when defining and calculating the indicators and failing to explain them adequately. Murray also exaggerated the novelty of ideas and indicators in the report. He accused William Hsiao of Harvard University of plagiarising the WHO framework in a paper that discussed health-system goals,14 necessitating a refutation by Hsiao in an e-mail sent to WHO on Nov 27, 2000.

Why did WHO decision-makers proceed as they did?

Given the scientific and ethical objections, to say nothing of the political risks, the question arises as to why WHO took the course that it did. I was told in several conversations with Frenk, Murray, or both, why they thought WHO had to publish an index of performance, even with no consultation with the governments and with most of the numbers imputed. These reasons included:
The favourable opinion of Amartya Sen, who led the creation of the human development index (HDI). The HDI is not intended to establish a frontier of what countries ought to achieve, so although it has some of the same deficiencies as the WHO index, in that respect it is quite different.

The supposition that no-one was adequately concerned with health-system problems, thus a ranking was needed to call attention to them. This approach gives no credit to those who have been working on health-system reform in many countries for many years.
The assertion that nobody would have paid attention to an incomplete analysis restricted to real data. Possibly a more evidence-based analysis would have attracted less notice, because policy-makers pay too much attention to scorecards—partly because WHO and other organisations push them to do so.

The claim that the estimates, imputations, shortcuts, etc used to fill in the tables were better than any previous ones, such as those in the World Development Report 199315 or the Global Burden of Disease.16

Finally, WHO had to produce rankings in time for the 2000 report: any such urgency did not arise from the nature of the exercise or the needs of member states.
The frontier of the possible

The attempt to measure performance depends on a production function for attainments that is available to all health systems. The most striking result is that performance scores are correlated with health expenditure per person (figure 2.6 in the report).1 At expenditures below US$100, half the countries receive scores of 50% or less; poor performance is rare at higher spending levels. This result does not imply a minimum level of spending for a well functioning system, despite efforts by WHO staff to interpret it that way in Health System Performance: Concepts, Measurement and Determinants (pages 4—5).12 If a supposed frontier of what is attainable passes through a large area where no observations fall close to it and there is no assurance that countries actually could get closer to the frontier, the prima facie evidence is that the frontier has been drawn too far away.

Most countries that seem to perform poorly—all the lowest-ranked 18, and 33 of the lowest-ranking 36—are in sub-Saharan Africa. “A large part of the explanation is the HIV/AIDS epidemic”(page 43 of the report);1 there is no way to distinguish, however, between two interpretations: that AIDS is making it hard to reach the frontier, or that it has moved the frontier downward, reducing the best attainable health status. Have African countries fallen toward the floor, or has the roof collapsed on them?

The second interpretation means that deaths and disruption from AIDS have impaired African societies’capacities to deal with pre-existing diseases. Under the impact of the epidemic, money and education have become less effective in improving health. The first interpretation implies that African governments could and should control the health damage from AIDS with existing levels of expenditure and schooling. What is missing is any sense of the feasibility of controlling AIDS. Some preventive interventions have contributed to slowing the trend toward higher incidence;17 but there is no guarantee that control is feasible everywhere. Beyond the issue of interventions required for control is the question of how much they would cost. Estimates suggest that in sub-Saharan Africa, prevention, care, and antiretroviral therapy would require incremental spending, respectively, of at least $1.17 billion, $1.05 billion, and $0.72 billion yearly by 2007, and two, four, and eight times those amounts by 2015 (Improving Health Outcomes of the Poor, tables A.9—A.11),18 to keep prevalence from increasing. These estimates are equivalent to saying the frontier has moved down because of AIDS.

What money can accomplish depends on knowledge and on how money has been spent in the past. Two countries with the same educational level (measured as average number of years of education attained by the population over the age of 15 years), health expenditure, and other variables, but different recent histories, will not have identical possibilities for progress. Extra money or knowledge takes time to become effective. The time lag differs among diseases because scaling up requires more investment in infrastructure, training or other inputs for some than for others (Improving Health Outcomes of the Poor, page 86).18 In consequence, a frontier of the possible cannot be defined independently of the disease burden and the interval in which a country is supposed to improve.

Where to go from here?

Performance measurement relative to what health systems should be able to achieve is a chimera, at least in the highly aggregated, top-down fashion that WHO decision-makers have pursued. Measurement of attainments of various kinds is still valuable, as is looking for ways that health systems can achieve more and make better use of resources. Breaking down performance along one or more dimensions seems to be a good approach—for example, assessment of how the hospital subsystem functions and contributes to performance. Determining which outcomes to hold hospitals responsible for is complex; outcomes may look bad because primary care does not do its job properly. Getting those assessments right directs attention to specific areas, organisations, and policies. If that process cannot be done in reasonable time and at reasonable cost, it is better to abandon the performance measurement exercise and devote resources to areas of more immediate value to the people for whose benefit health systems exist.

Conflict of interest statement

During Sept 1, 1999, to Aug 22, 2001, I was seconded from the World Bank to WHO, where I served as editor-in-chief of The World Health Report 2000—Health Systems: Improving Performance. The interpretations and conclusions expressed in this paper are entirely my own. They do not necessarily represent the views of the World Bank, its executive directors, the countries they represent, WHO, its executive directors, or its member states. The paper was written after leaving WHO to return to the World Bank. There is no other possible conflict of interest. A full version of this article can be seen at

Sunday, October 25, 2009

Physicians Are Talking About: What to Do to Reform Healthcare

Nancy R. Terry
Authors and Disclosures
Published: 08/07/2009
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As the healthcare debate heats up, the only point on which all parties agree is that the present healthcare system does not work.

An estimated 50 million Americans are uninsured, and the number continues to rise as more people lose both their jobs and their health insurance. Americans spend more than $2 trillion a year on healthcare, which is, by some estimates, 40% more per person than the next most costly country. President Barack Obama and Congress are mobilizing to reform healthcare. Yet, change alone does not guarantee improvement.

In a flurry of postings on Medscape's Physician Connect (MPC), a physician-only discussion board, doctors debate what reform measures would salvage US healthcare. Many physicians are as wary of increased government intervention as they are frustrated by the bureaucratic, profit-driven excesses of private insurance companies.

"As someone who has lived with illness (a congenital immune deficiency) for longer than I have been a doctor, I know first hand how broken our system is," says a dermatologist. "I live in fear of losing my health insurance since I know I am uninsurable through any private program. A public option is the only way to go."

"What would a greatly expanded role for the federal government mean for healthcare in this country?" asks an anesthesiologist. "Rationing for patients, with fewer treatment options and increased difficulty visiting a physician." An infectious disease physician agrees, "Obama's thrust to mandate a Medicare-for-all, single-payer [program] will ultimately lead to healthcare rationing of services -- not for the young and healthy but rather for the elderly, who are the sickest and most vulnerable among us."

The rationing of medical services is frequently cited by a number of physicians as an alarming but predictable component of a national healthcare plan. Yet, other physicians contend that rationing of services already exists. "The private, for-profit insurance carriers have contributed to the healthcare crisis by cherry picking the insureds," says an orthopedic surgeon. "To have a different premium price for those with preexisting illness denies insurance to those who need it most," adds an emergency medicine physician. Another MPC contributor comments, "Instead of making people wait, we just deny elective procedures altogether to people who don't have insurance. That's American rationing."

Advocates of free enterprise favor maintaining a system of multiple insurance providers because, they argue, free enterprise ensures maximum efficiency. In contrast, other physicians claim the exorbitant cost of healthcare can be largely attributed to profit-maximizing insurance companies. "Insurance companies are responsible for the high cost of healthcare," says an MPC contributor. "THEY set the premiums, and the reimbursement and the schemes that are squeezing everyone. All in the interest of profit -- not healthcare."

A national healthcare plan, according to other physicians, would afford no greater efficiency than the current system. "Already doctors aren't accepting Medicaid because of dwindling payments, hassling paper work, confounding delays, long waits, impersonal attention -- medicine DMV [department of motor vehicles] style," quips a pediatrician. "So, everyone will have insurance. Just not that many will have doctors."

Still others see little difference between the options of private and public insurance plans. "The schism between private health insurers and government is a ruse," says a general surgeon. "Medicare is already outsourced to private health insurers. Medicare-for-all will be a big boon for health insurers. Their volume will go up as will their profit margins as government-sponsored cost-effectiveness research demonstrates how much of the expensive medical treatments are "ineffective." Another win-win for government and health insurers. It's all a numbers game -- shift to preventative healthcare and the healthy are happy and the sick are shoved under the carpet."

Obviously, there is no easy solution. The best option, according to some MPC physicians, is to keep open as many options as possible. "Most of the primary care societies and academies favor a one-payer system," comments an MPC contributor. "If we are to give at least basic healthcare benefits to our citizens, we need it [a public plan]. It is not the perfect system, but at present it is the best option available. If a person wants concierge care, he should buy it."

"Will someone please explain what is wrong with a 2-tiered system?" asks an MPC contributor. "A basic plan with some basic coverage for those who cannot contribute and the premier plan for those who do contribute. The water analogy...everyone can drink tap water, but if you want bottled water, you gotta pay."

"Sounds OK to me," responds another contributor. "Coverage for treatments for which there is good efficacy data (not just statistical significance but clinical significance) and everything else, well, if you want it, feel free to buy it."

Few physicians are comfortable with a proposal favored by Congress that participation in a public plan be mandatory for all physicians who accept Medicare patients, although a nephrologist is "okay with mandatory participation for 1 to 2 years to support the government effort, but the mandatory participation should expire automatically afterwards."

Healthcare reform, however, is not simply a question of the number of insurance plans available. Recognizing that any insurance option must coexist with a reform agenda, physicians offer a range of proposals how a more equitable, efficient healthcare system might be achieved.
Hold the insurance companies accountable to insure patients who have a preexisting illness.
Set one premium level for all insurance participants, with varying deductible and copayment amounts.

Establish a fund, patterned after Alaska's Permanent Fund, to cover the cost of insurance for those who cannot afford it. The fund could be built up by taxing commodities and activities that increase the risk for illness, such as tobacco and alcohol use.

Incentivize preventive medicine, especially in the management of lifestyle diseases, such as diabetes and hypertension.

Reduce redundant and defensive testing.

Reform the tort system and eliminate malpractice insurance.

Initiate a national campaign to promote fitness programs, improved nutrition, self-care programs, and disease prevention.

Establish national licensure for nurses and doctors to decrease the costs of multistate practice.

Eliminate state-by-state variations in insurance laws to unify the method of determining eligibility for healthcare insurance.

Eliminate the fee-for-service model, and put doctors on salary.

Physicians, according to an MPC contributor, are in the best position to offer practical, constructive solutions for healthcare reform. "We need to stop coming to the table primarily motivated by protecting our incomes," said an emergency medicine physician. "Instead we should come to the table as citizens who have insight into why our healthcare system is so sick."

How Individual Mandates Make People Worse Off...

From the New York Times' Money and Policy section, 10/25/09, by Tyler Cowan, professor of economics at George Mason University:

AMERICANS seem to like the idea of broadening health insurance coverage, but they may not want to be forced to buy it. With health care costs high and rising, such government mandates would make many people worse off.

The proposals now before Congress would require just about everyone to buy health insurance or to get it through their employers - which would generally result in lower wages. In other words, millions of people would be compelled to spend lots of money on something they previously did not want, at least not at prevailing prices.

Estimates of this burden vary, but for a family of four it could range up to $14,000 a year over the next decade, according to the Congressional Budget Office. Right now, many Americans take the gamble of going without insurance, just as many of us take our chances with how much we drive or how little we exercise.

The paradox is this: Reform advocates start with anecdotes about the underprivileged who are uninsured, then turn around and propose something that would hurt at least some members of that group.

To ease the burdens of the insurance mandate, the reform proposals call for varying levels of subsidy. In some versions, such as the current Senate bill, subsidies are handed out to families with incomes as high as $88,000 a year. How long will it be before just about everyone wants further assistance, and this new form of entitlement spending spins out of control? It's possible to lower insurance subsidies, but then the insurance mandate would impose a bigger burden on the people we are trying to help.

A subtler problem is what economists call "implicit marginal tax rates."

The fiscal reality is that not all income groups can receive equal subsidies; as a family earns more, its subsidy would probably decrease, eventually falling to zero. But then we are taking money away from the poor as they climb into higher income categories. This is a disincentive to earn more, and the strength of the disincentive increases with our initial generosity. For many people, the health insurance aid would phase out when food stamps, housing vouchers and the earned income tax credit also end and the personal income tax kicks in.

This structure of incentives would likely discourage many parents from earning a better life for their children. Congress could tweak the subsidies so they don't phase out so quickly, but then we're back to very high fiscal costs and subsidies for many families in the higher income classes.
Defenders of a broad health insurance mandate argue that it will lower average costs in the health care market. The claim is that many of the uninsured are young, healthy or both, and that bringing them into the insurance pool might lower average premiums by spreading risk across low-cost groups. Yet Massachusetts has had a health insurance mandate for several years and this cost-saving mechanism does not appear to be kicking in.

At this point, it seems more plausible that the cost of health insurance will keep rising, just as the costs of health care services have continued to climb. The upshot is that the burdens of mandatory purchase, the subsidy costs and the associated implicit marginal tax rates will all increase, eventually to the point of unsustainability.

A further problem is "mandate creep," which we've seen at the state level, as groups lobby for various types of coverage - whether for acupuncture, alcoholism and fertility treatments, for example, or for chiropractor services or marriage counseling.
There are now about 1,500 insurance mandates among the various states, and hundreds of others are under consideration. The dynamic at work here is that the affected groups have a big incentive to push for mandates, while most other people are unaware of the specific issues and don't become involved.

Because mandates don't stay modest for long, health insurance would become all the more expensive. The Obama administration's cost estimates haven't considered these longer-run "political economy" issues.

IF there is a problem with mandates, why do they seem to work in countries like Switzerland and the Netherlands? One answer is that mandates are more effective when health care cost inflation is under control, and both of those countries fare better at technocracy than the larger, less tightly ordered United States.

And mandates also fare better in those nations because of their greater equality of incomes. In other words, it's less of a stretch to offer poorer people coverage that is roughly comparable to that of the wealthy.

If anything, however, European mandates will face growing problems, as health care cost inflation is spreading globally.

We're often told that America should copy the health care institutions of Western Europe. Yet we're failing to copy the single most important lesson from those systems - namely, to put cost control first. Instead, we're putting our foot on the gas pedal and ratcheting up the fiscal pressures on the system, in the hope that someday, somehow, it will all work out.
As it stands, we're on the verge of enacting a policy that is due to explode, penalizing many of the very people that it was ostensibly designed to help.

Apples are Apples, Oranges are Oranges, and Never the Twain Shall Meet

In the current national debate over health care reform, how many of us have listened to politicians, pundits, and journalists and even well meaning friends and family members spew out ominous sounding statistics describing just how terrible America's health care system is compared to other more progressive countries?

I'm sure all of us have heard at least more than just a few times how America is ranked 37th in the world in health care according to the World Health Organization (WHO) or how America is lagging far behind other industrialized and supposedly enlightened--and by inference, 'better'--countries in infant mortality, preventable mortality, and life expectancy despite the fact that we spend more than any other country as a percentage of GDP on health care.

Well, today I had the chance to listen to these same statistics during a presentation on why America should move to a single payer system from some of my classmates in our economics class. It was a well prepared presentation with great graphics and impressive graphs and all the usual rhetoric that is associated with those that argue for a single payer system or other radical change in our current health care system.

At the end of the presentation, there was some spirited debate around the pros and cons of a single payer system in America. One of my questions to the presenters was "do you know the populations of the countries you are comparing us to"? Surprisingly, none of the six presenters could answer the question despite their obvious facile knowledge of the "wonderful" health care statistics that each of those countries had.

I then pointed out to them that the average population of the European nations they had compared us to was about 50 million (ranging from 9 to 87 million) compared to 350 million in the US and that it was rather disingenuous to compare economies of scale in delivering and administering health care between countries with 9 to 87 million people (Sweden, Spain, France, England, and Germany) and ours with 350 million. I reminded them that apples were apples and oranges were oranges and that they were comparing apples to oranges.

During the presentation and the ensuing debate, I kept thinking about one of my old medical school professors who used to say that "statistics were for liars", meaning of course, that if one looked hard enough, anyone could find statistics or at least an 'expert' to support any point of view.

Unfortunately, the time allotted for questions and debate after the presentation was not long enough for me to ask the next most obvious questions regarding their research and statistics which would have included the methodology used by the WHO in making the rankings, the benchmarks or indicators used to make the rankings, the presence or absence of assumptions and confounding variables, and the presence or absence of potential scientific and/or political bias in the methodology.

In all fairness to my classmates, I did not know the answers to these questions and although I had heard these statistics spewed out over and over again during the recent national debate, I had never critically questioned the data. Like so many others, including my classmates, I had just naturally assumed that since the pundits and politicians and other 'experts' were spewing this information out as gospel, it must have been verified and validated.

When I got home from class and actually looked up the data, I was quite surprised to find that the data and statistics presented by my classmates (and the current administration) was from the last WHO report on national health care systems almost a decade ago in 2000. I was equally surprised--and disturbed--to find out that the WHO stopped comparing and reporting on national health care systems because "of inherent problems with methodology and definitions".

In fact, equally disturbing was the fact that the 2000 report was renounced and criticized by the 'editor-in-chief' of the report itself, after he learned the actual methodology used to generate the report!

The intent of this posting is not to denigrate or marginalize the work or the values and beliefs of my esteemed classmates--unlike the current administration's strategy used with those with whom they disagree. In all fairness to them, this was an assignment that was prepared in 2 to 4 weeks and I certainly do not expect them to have become expert economists or health care analysts in our first year of our MBA program--especially, considering that none of them come from a health care background.

What is bothersome to me is that our politicians, pundits, and other media experts are spewing out this information as if it is the Gospel according to Matthew, Luke, John, and Obama. Now while I can understand our politicians 'tailoring the statistics' to their individual agendas, it is deplorable that the so called 'experts' in the media who are supposed to be ever critical and objective, are parroting these same statistics that are grossly outdated, compiled through questionable methodology, rife with statistical and political bias, and just plain horse dung!

If we are to have any kind of meaningful debate in this country regarding health care reform, we need to all play by the same rules which means understanding the common rules and definitions used in any scholarly debate--that is we must always be objective, be always critical of the data, be ever vigilant for potential bias (scientific and political), and we must always remember to leave our personal, religious, and political agendas at home! In short, if we are going to talk fruit--let apples be apples and oranges be oranges and never the twain shall meet (except maybe in fruit salad).

For more discourse on this subject, I have included two recent articles from the New York Times and the Wall Street Journal below.

John R. Vigil, MD, FACPE
Fellow, American College of Physician Executives
CEO and Medical Director,
Doctor On Call