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April 15, 2006
What Money Is For
By Ezra
Good piece in the Times about the growing demand for orthopedic surgeries among aging, athletic boomers. It suffers from a lack of statistics or hard data, but I'm willing to trust the central premise: Boomers are staying more active, longer, and given the long-term wear on the body, that's requiring more surgery. Another fun mover behind rising health costs. Two thoughts:
1) I wonder how much is saved through the benefits of exercise? Lower cardiovascular, neurodegenerative, and cancer rates? How about increased productivity, time on the job, etc?
2) This is a good thing. If we end up plowing 50% of our country's massive GDP into surgeries and treatments that allows us to remain active, vital, and happy deep into our seventh, eight, and ninth decades, isn't that what money is for?
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The technology to replace a hip or a knee is pretty new, and an important aspect of people's willingness to do it, is the elimination of significant pain and recovery time. You can have a hip replaced and be walking pretty normally within a week. That's amazing. And, of course, quite desirable, if you need a new hip.
Posted by: Bruce Wilder | Apr 15, 2006 6:01:55 PM
There is also lots of money to be made by the orthopedists who do this stuff - much of it is viewed as elective by the insurers and very pricy. This is one of those cases where you have to spend money in order to spend more - travel, etc. is hard if the joints don't work and one is confined to the house/apt.
As a nation, we should be spending lots more on research on how to preserve our bodies for the so-called golden years. Many, many people won't get this kind of surgery because of the cost, and they end up with lives without the sparkle of active living.
Medicine is unlikely to correctly weight prevention against repair and treatment as long as the insurance companies can count on people changing policies with new employers. It would be a good investment to prevent problems instead of fixing them, but only a long-term payer (like single-payer universal health insurance) would have the correct economic incentive.
Repubs say they luv markets and they luv incenting 'correct' economic behavior, but their myopia on health insurance, especially health savings accounts, work in the 180-degree wrong direction.
Posted by: JimPortlandOR | Apr 15, 2006 7:45:01 PM
Continuing my rant from above:
In a way, the existence of Medicare as separate from the health insurance for non-retired/non-disabled provides a perverse incentive for the private insurance carriers to spend almost nothing on preventive medicine. They can rest assured that the most expensive procedures are done well after their watch is ended when Medicare will pay the bills for repair/rehabilitation instead of the insurers paying to prevent the problems.
And another issue related to this: we now know that dental care is essential to keeping healthy - even the heart if impacted by dental disease. Why is dental care not part of standard health insurance? What passes for the separate dental insurance provided by employers is grossly inadequate, resulting in problems being postponed.
This especially impacts the older folks, who often have to pay huge bills to correct problems in the mouth that would have been far less expensive to fix earlier in life.
Posted by: JimPortlandOR | Apr 15, 2006 7:56:58 PM
..and following on Jim's logic, it's one reason why moving everyone to Medicare is not the panacea it appears to be - Medicare is full of perverse incentives.
This story is not new - NY Times did a piece on this like six months ago, I think, and while it's nice to know that aging jock boomers have a recourse when the knees start to go, it is elective surgery by and large and expensive. I'm not sure this is something UHC is envisioned to cover (which makes the selling of UHC also problematic). As well, not to be churlish, you can have an active lifestyle that does not involve playing world class tennis or competing in triathlons til you're 75 or 80; the body is trying to tell us, at times, that we simply need to slow down. Much as it is also telling us, as we wrinkle and sag, that we are aging, which is why Facelifts and other plastic surgeries remain elective, too.
Which brings me to a question that I think UHC advocates need to be clearer on - just what is the goal with this health care plan, anyway? Reasonably healthy? Or body perfection? Or treating everything we can? The answer matters, and how it's presented is really quite crucial to success in outting UHC over.
Posted by: weboy | Apr 15, 2006 8:21:30 PM
Hmmm, weboy. I won't get into your (unspecified) Medicare 'perverse' incentives, but your question on how far a UHC plan should extend is a good one.
In a sentence, UHC should aim for age-appropriate activities that balance a life and preserve the bodies ability to enable reasonable life extending to the bell-shaped curve of how long people will live meaningful lives. We don't know enough about what you should be doing in the teens, 20's and 30's to make the 60's, 70's and 80's good years and less expensive to maintain. So (1), much more research.
(2) Pro-active medical intervention and treatment early to fix problems before they become very expensive to treat.
(3) Hard choices need to be made about what kinds of treatments are included in standard coverage. This would be eased if we had a two or three-tiered insurance system: standard, extended, and comprehensive. The extended and comprehensive coverage should be universally available but cost extra for the person being insured - using standard universal risk pools that include all US citizens (no cherry-picking allowed).
Several years ago in Oregon, all of the stakeholders involved in medical care came together to define the standard coverage that would be provided by the Oregon Health Plan (Medicaid plus other eligibles). It took research, mutual education, and hard negotiations to arrive at definitions for all the standard components, conditions covered, and treatments allowed, but they showed it could be done. OHP itself didn't work as planned for budgetary reasons (cutbacks by the federal government being a principle factor). But, in principle, this can be defined. I suspect, but don't know, that other nations have wrestled with this problem and have reached some agreements. But this will always be a work-in-progress, continually subject to modification.
But, to defend Medicare, it is really unrealistic to blame Medicare for having to deal with problems that orginated much earlier in life and were ignored or inadequately treated because of the defects in private health insurance plans that measure their performance solely on an annual basis of profit. They don't have to and they don't look ahead.
Posted by: JimPortlandOR | Apr 15, 2006 8:46:11 PM
I'm going in for a hip replacement in 3 weeks (I'm 59.) My cartilage has broken down and it's just bone against bone in that joint. The surgeon will make a couple of 2-inch incisions, and expects to finish the surgery in an hour. I inquired as to how long I might be recuperating in the hospital, and he said that he has sent quite a few patients home the same day. Incredible....
Posted by: old and wobbly | Apr 15, 2006 9:40:27 PM
That's why I advocate a French-style system. Basic health insurance for the populace, subsidized supplementary insurance for the poor. Everyone should have a floor and we should work to give those in financial straits an elevator.
Posted by: Ezra | Apr 15, 2006 11:31:53 PM
If we end up plowing 50% of our country's massive GDP into surgeries and treatments that allows us to remain active, vital, and happy deep into our seventh, eight, and ninth decades, isn't that what money is for?
If other countries are doing it with eight or nine per cent of their middling GDPs then the answer is no. There's alot of waste in the medical-industrial complex and orthopedics is close to or at the epicenter.
Posted by: quietstorm | Apr 15, 2006 11:42:04 PM
I agree with you, Ezra, about setting a floor - I think the question of putting that across successfully is realizing that for some people it will mean a reduction in benefits and/or an increase in supplemental costs (i.e. at the very least some companies will drop out of expansive coverage plans when their workers receive basic benefits in the "floor" plan). That's not a place where American workers wth health coverage necessarily are, at this point, and to some degree it may underline class differences rather than reduce them if companies use, say, a sliding scale of additional supplements to the "floor". I'm not saying that's not the case now, but I think some of what's being sold is a utopian vision that UHC will help reduce class differences in access to care.
I think this also goes to Jim's "hard choices" about what's covered and what isn't. And to some degree I think with Congress trying to wade about in the details, bad things will come of it.
Finally, I'm not complaining because Medicare covers things that have to be covered because people didn't know or didn't take advantage of options earlier in life; my point is that Medicare provides incentives to providers and to hospitals that don't necessarily reduce costs, improve care, and/or decrease beaurocracy. That's where I'm concerned about a system that is built along very traditional models of fee for service and hospital based care really having the flexibility to address advances not just in improved procedures and treatments, but in more efficient methods of delivery and flexible approaches to how we obtain care. I tend to think what we really want is the VA health system for everyone, but I think the reality of that is that it is even more cost prohibitive.
Posted by: weboy | Apr 16, 2006 12:55:56 AM
Weboy, why would a VA for everybody system be cost prohibitive? For alot of reasons (drug pricing, preventive care) it might turn out to be cheaper.
Posted by: quietstorm | Apr 16, 2006 1:06:06 AM
The real problem is that everything costs twice as much as it should. No generally available added benefits have a chance as long as that's the case.
Posted by: opit | Apr 16, 2006 1:08:23 AM
ok, weboy, I agree that a VA-like system solves many of the problems in today's US system of medical provider-group capitation payments adminstered through private insurance companies. It doesn't solve the problem that the VA budget is an annual appropriation from Congress and is therefore subject to the winds of fiscal policy. No such annually funded system could ever look to the long range to plan optimal lifetime health care.
But a VA-like system, funded by a Medicare-like payroll source of funds starts to get interesting, particularly if it offers several tiers of service which the individual chooses and pays additional funds for higher levels of coverage.
However, a VA-like sytem will get lots of opposition from the medical service providers, particularly those who gain much from doing the private market thing (dermatologists and orthopedists among them, but there are many others).
But since this utopia, why not dream big. Perhaps the dreams can shape the real outcome.
Posted by: JimPortlandOR | Apr 16, 2006 2:11:36 AM
Many people suffer from the high taxes in our health system but one of the greatest disadvantage in my opinion is the expensive dental care and dental insurances. Nowadays dental hygiene is so important that it's a real burden to be incapable to afford it. No wonder then that some people go abroad to have their teeth taken care of.
Posted by: Monica Nickoles | Jul 3, 2007 12:24:03 PM
