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August 15, 2007
GiulianiCare
It occurs to me that just about every time the GOP actually carries out some of their favored policies, Andrew Sullivan turns violently on them. So he loathes -- rightfully -- their hateful social rhetoric. He's grown suitably contemptuous of their foreign policy (and he quotes Jim Henley to great effect on Giuliani's inchoate, maddening foriegn policy manifesto). But then he goes on to laud the everything they've not been able to do. "[Giuliani's] inclusive and largely right about healthcare policy. I like his low tax emphasis."
I wonder how Sullivan would really feel in a world where the tax incentives were set-up to incentivize sparse health care coverage and high deductibles. That's a land that's very good for the healthy, and quite bad for the chronically sick. Sullivan increasingly strikes me as a first order idealist who ably sees the principles behind things (freedom! choice! equality!) and is stunned when policies based on those concepts don't appear to work.
But here's why they don't work. Take Giuliani's health care plan, which basically rests of tax exemptions to help purchase care. It sets a standard deduction of $7,500 for individuals and $15,000 for families. Everyone will get precisely those deductions no matter what they spend. If you're 23 and your health care costs $2,000 a year, you still deduct $7,500, pocketing the difference. And that's the actual point of the plan. That's the incentive the plan is hoping will change health care -- it will incentivize everyone to buy less of it, and pocket more of their exemption.
If you're healthy, a world in which Giuliani's plan was law would be a world in which it was economically foolish of you to purchase high quality, comprehensive coverage. And that would be fine -- for the healthy individual. But insurance works based on risk pooling. If our hypothetical 23-year-old only uses $10 of health care a year, but is now paying $80 rather than $100 for his plan, that's less money that can subsidize someone with a chronic illness. Their costs go up. Their ability to cover their treatments go down. And they get sick and they die. And one day, ironically, this happens to the 23-year-old, too, because he's now 55 with heart disease, and the current generation of 23-year-olds are purchasing $50 plans.
Sullivan likes the plan because it superficially incentivizes individuals to take more control of their own health. But what it really does is incentivize them to buy less insurance -- we're just pushing them in a different direction. And it's a direction that hurts a lot of people -- people I'm going to guess Sullivan would one day decide shouldn't be getting hurt, and should be able to get medicine. And then he'd become an eloquent and outraged opponent of that plan, too. It would just be too late.
August 15, 2007 | Permalink
Comments
That's a land that's very good for the healthy, and quite bad for the chronically sick.
Unless you're personally wealthy! Which Sullivan is, so he can stick to his insane principles because he's not personally suffering for them.
Posted by: Ryan | Aug 15, 2007 12:32:37 PM
"basically rests of tax exemptions to help purchase care. It sets a standard deduction of $7,500 for individuals and $15,000 for families. Everyone will get precisely those deductions no matter what they spend. If you're 23 and your health care costs $2,000 a year, you still deduct $7,500, pocketing the difference"
I haven't read G's plan, but have 2 questions based on your analysis. 1st, deductions or exemptions? They're different. 2nd, as you describe it, it has nothing whatsoever to do with healthcare - you get $7,500 of deductions or exemptions, no matter what. Are you sure you're accurately describing G's plan?
Posted by: ostap | Aug 15, 2007 12:36:16 PM
Sullivan is Catholic Tory, who transformed himself into a Gay Republican. He advocates political principles, which are at odds with the political interests of his personal identity.
So, naturally, as an overweight, middle-aged man with an expensive, chronic disease, he is going to advocate for the health plan favoring the interests of the young and healthy, on principle!
The man is seriously, hopelessly confused. That's his charm. It is not that he's a "first-order idealist" -- far from it -- it is that his capacity to completely overlook personal self-interest, (to even ridicule and denigrate those who share his personal self-interest along the relevant vector), while advocating policies and politics that favor the smug conformity of the self-satisfied rich, involves a flattery his intended audience can not resist.
Posted by: Bruce Wilder | Aug 15, 2007 12:49:07 PM
Ezra,
I don't agree with end of this thinking:
And that's the actual point of the plan. That's the incentive the plan is hoping will change health care -- it will incentivize everyone to buy less of it, and pocket more of their exemption.
If you're healthy, a world in which Giuliani's plan was law would be a world in which it was economically foolish of you to purchase high quality, comprehensive coverage.
This world would make it foolish to purchase more coverage than they need, but it would make sense to purchase a high quality, comprehensive plan. There are others who agree with me-- you may have heard of this guy, his name is Ezra Klein. Here's what he said a few days ago:
Instead, the more achievable goal is to move towards a universal system that's more cost-effective, which is, in fact, very much the same thing as saving money, and towards an integrated system that readies the ground for tougher cost control mechanisms down the road.
This was a great thought-- because it recognized the that we currently cover too many things that aren't cost-effective, i.e. in certain things, we do have too much care and cutting them out won't really impact quality. The question is-- how do you drive progress to this goal? One option is to mandate via government-- cost-effectiveness (e.g. NICE) and other cost control mechanisms. Another option is to create a market mechanism to do the same thing, but better (IMO). In today's system, there just isn't much incentive for insurance companies to provide cost-effective care. HMOs tried in the 90's but because people's health care costs were mostly hidden in employer-paid premiums, the downsides of cost control were not countered with savings at the individual level. If people were actually offered a few thousand a year for reasonable cost control, the trade-off would be very different-- and more acceptable.
This is what Giuliani is trying to accomplish. The issue is instead, he's doing it the wrong way for two reasons. First, the Wyden proposal is a much better way of allowing individuals to purchase care (i.e. cost transparency), pulling employers out of the system altogether. Two, Giuliani's plan ends with this tax proposal-- and as such completely misunderstands the need for further government intervention to make an insurance market work properly-- something on which Obama and HRC have provided some early proposals.
Posted by: wisewon | Aug 15, 2007 1:11:11 PM
The man is seriously, hopelessly confused. That's his charm.
He's more insightful than incisive, IMO; what he sees can be interesting but he's either unable or disinclined to make sense of any of it.
Posted by: latts | Aug 15, 2007 1:25:35 PM
Are you sure you're accurately describing G's plan?
Oh yes. You may be under the impression that Giuliani's plan is not a health care plan but a tax break sold as a health care plan, but that's the beauty of it: that's exactly what it is! Oh, isn't Giuliani genius?
Posted by: amanda w | Aug 15, 2007 1:45:07 PM
Wisewon: It's bizarre to spend a post defending a plan that your final two sentences demolishes. You're right: If this plan had a bunch of other elements, maybe it would be a good plan. But it doesn't. As Kevin Drum said, this car would be a good car, if only it had steering wheel, and an engine, and air conditioning, and seats, and...
Without reform of the insurance markets, Giuliani's plan does nothing to incentivize smart cost sharing, controls, or anything else. It just incentivizes people to opt out of the market, ensuring an insurance death spiral.
Posted by: Ezra | Aug 15, 2007 1:46:45 PM
"Sullivan likes the plan because it superficially incentivizes individuals to take more control of their own health. But what it really does is incentivize them to buy less insurance"
This is such a good point, and I feel it's really under-emphasized in this debate.
Right-wingers keep saying that we need these insurance plans because they will incentivize people to take control of their health, or their healthcare.
But right now, if you don't take control of your health, you get sick. And you die. Really, really painfully and horribly.
Suggesting that the primary purpose of this plan is to make people take more control of their health is simply not supportable. We already have the strongest incentive in the world--death and dismemberment--pushing them very hard in that direction. This will be, if anything, a marginal push in that direction. And given increased exposure to preventive costs, it might actually be a disincentive to take care of their health in many situations.
However, it is unarguable that people will use less health care if this plan passes.
That's what this really is. It's a plan to get people to use less healthcare, with rich people less affected than middle-class and low-income people.
Unreal.
Posted by: anonymous | Aug 15, 2007 1:49:58 PM
Ezra,
I wasn't defending the plan-- I was defending the notion that incentivizing individuals to spend less on health care is not a bad thing, because some is not cost-effective. I think this is very frequently misunderstood, which was why I posted. Not by you-- that was my point of citing a prior post, you clearly understand this-- but felt the emphasis of the criticism of Giuliani's plan was on the wrong things.
The issue isn't with an incentive for people to buy less health insurance, which was implied by the original post. The problem with Giuliani's plan is what you said later:
Without reform of the insurance markets, Giuliani's plan does nothing to incentivize smart cost sharing, controls, or anything else. It just incentivizes people to opt out of the market, ensuring an insurance death spiral.
Posted by: wisewon | Aug 15, 2007 1:55:20 PM
Ezra, since the $7500 is a deduction, the benefit is actually much less. If your tax rate is 25% after other deductions, you will only get a $1875 benefit. How much insurance can you buy for $1875? How much health insurance can a family buy for $3750? Half the taxpayers fall into the 15% bracket or less. Those families will get a $2250 benefit. If they don't have insurance now, they still won't be able to afford it.
Posted by: Marv Toler | Aug 15, 2007 2:28:10 PM
Mr. Sullivan's focus is on principles, which can make him very enjoyable to read on issues like torture, gay marriage, etc..
But he is not good on the details, and when challenged on details, he will often attempt to turn the issue into being about principles. The classic example is his oft-stated charge whenever someone criticizes him for Murray's Bell Curve except in The New Republic, when Sullivan was editor. He claims that critics are simply trying to stifle discussion of a controversial issue. And in so doing, he holds himself out as a courageous promoter of 1st Amendment values. He has said that publishing an excerpt of The Bell Curve is one of his greatest accomplishments.
The problem is, the harshest criticism of the Bell Curve has always been that it's bad science. It's gotten attention because it's bad science in the service of a racist p.o.v., but criticizing bad science is not only NOT stifling discussion, it's the exact opposite.
As far as I can tell, Sullivan has never addressed the criticism of the science itself, always deflecting it into a principled defense of freedom of speech.
Posted by: Ryan Scott | Aug 15, 2007 2:28:33 PM
Ezra, I really think that when ever you write something on Rudy's "Health Care Plan" you should really add the third, fourth and fifth paragraphs from this article at The American Prospect.
Those facts are worth repeating over and over.
If you could at least edit your post and mention the facts contained in those paragraphs.
Please?
For the lazy, paragraph three;
Failure of the press aside, let's examine this "vision." What Giuliani offered is this: A tax exclusion of up to $15,000 for families, and $7,500 for individuals, to help pay for health care. What Giuliani is relying on is people reading those numbers -- $15,000 and $7,500 -- without noticing that they don't denote the amount of money he's offering them, but the amount of money he's not taxing them on. And when we plug it into my magical Rudy Translation Machine (constructed with the help of friendly neighborhood economist, Dean Baker), we can watch how $15,000 can easily become … zero.
Posted by: M.O. | Aug 15, 2007 2:32:58 PM
Uggh! I Didn't close the tags.
Posted by: M.O. | Aug 15, 2007 2:33:58 PM
I know I'm not alone in this but let me very briefly state the reason Giuliani's plan will generally be unpopular is the same reason Bush's Health Savings Accounts are unpopular.
I don't freaking want to take control of my healthcare
Similarly,
I don't freaking want to take control of my investments
I'm an educated person with a technical job. I've got a family. I don't have freaking time to peruse the stock markets for the best investment vehicles and try to compete against market pros. I don't have freaking time to read up on healthcare options and find the best treatment for my inflamed sacroileac.
What I want is a doctor to manage my healthcare so I live the longest my poor body was made to live.
What I want is a secure retirement without scratching and clawing and trying to outthink all the other poor saps who also want a secure retirement.
Enough! Let me be an expert in the things I know and let others help me stay healthy and secure.
Posted by: Curt M | Aug 15, 2007 2:44:39 PM
Interesting discussion. Sullivan always generates a lot of personal animus, which I tend to think confirms his status as an outlier. The most useful observation, I think, is that he prefers broad philosophic questions (the "principles" thing) to diving into the details. And I find his thinking on healthcare to be especially muddled. I don't think he understands all the ins and outs of what we have in America; what he's opposed to (as an old school Brit) is the NHS, and I think he evaluates proposals through this odd lens of that opposition, his own health concerns, and a bias towards "free market" ideas, which is a concept he also leaves undeveloped. Add that all up, and it doesn't surprise me he finds the Giuliani idea interesting (didn't he find Bush's similarly DOA plan intereting too?), and it doesn't surprise me that he's sort of incoherent defending it. I'd argue about the plan, and its supposed notions of "people taking control of their healthcare" but really, why bother when the plan isn't really a plan? It's a tax break that, like the Bush proposal it kind of mimics, mostly would work as incentive to get businesses racing out of healthcare faster than they are now, putting more pressure on the overall system, and probably making a number of things worse, while putting a lot of people into bad policies that leave them stranded or strapped in a crisis (really, we have so little conception of what individual policies for health insurance should realistically contain or be priced at that much of this discussion is just fantastical). So, if I think Curt M is mistaken in his "I want a Doctor to manage my healthcare" (let's just say, your doctor doesn't), and I tend to agree with wisewon that some cost controlling incentives will need to be aimed at ondividuals, both points seem moot in the context if discussing Giuliani's non-plan, and Andrew Sullivan's incoherent backing of it: to follow that car analogy of Drum's, we can't really argue the gas mileage on the thing that has no steering wheel.
Posted by: weboy | Aug 15, 2007 3:06:38 PM
I'd say the vast majority of our people are truly too lazy to give a crap about their health in the first place much less make decisions. If they did we wouldn't have BY FAR the fattest and laziest population in the world. I think money would be better spent to directly incentivize the people. For example, a tax credit for a BMI under 25, a normal lipid profile, an acceptable HgAIC if you are a diabetic and on an on. You would have to be born on the moon to not realize that obesity and smoking are unhealthy, yet we do it like no other country in the world.
Posted by: DIngo | Aug 15, 2007 3:17:13 PM
Any system based on the notion of subsidizing huge numbers of people to buy insurance is also ultimately going to founder on the fact that insurance is governed by the usual market rules. Put more money in the pot without changing anything else, and prices will go up. (Sure, you can claim that people will be smart spenders and miraculously foresee whatever retroactive rules insurors might put in place and that insurors who mediate good care will actually be willing to take on piles of new customers, but that's not the way to bet.)
Posted by: paul | Aug 15, 2007 3:17:42 PM
Hmmm.
I think Curt M is mistaken in his "I want a Doctor to manage my healthcare"
I'm mistaken about what I want? Perhaps. I should note that I'm extremely savvy about medical matters. I've had my hands in cadavers in anatomy class, sliced up rats and human brain tissue, and worked as a research assistant in a medical research lab where I helped edit grant proposals full of medical terminology. I also helped shepherd a brother-in-law through the medical labrynth while he fought an eventually fatal brain cancer.
But I really do want a doctor to know what is best for me and I really don't want to have to spend alot of effort deciding whether I need an angioplasty or open-heart surgery. Now it's true that if it looks as if I have a heart condition I'll be very involved but I'm in a unique position in that I have enough knowledge to second-guess my doctor. But Joe Citizen surely doesn't, in general. So a system that assumes Joe Citizen is medically-savvy is just going to be a system where Joe Citizen gets soaked by the slickest salesman.
I'd say the vast majority of our people are truly too lazy to give a crap about their health in the first place much less make decisions. If they did we wouldn't have BY FAR the fattest and laziest population in the world.
I'm neither fat nor lazy myself and don't believe fatness and laziness are the biggest obstacles to normal Americans being expected to become medical directors of their own healthcare. Medicine is complicated and requires alot of specialized knowledge to attain any sort of competence on a given disorder or healthcare issue. It truly is asking too much that every adult in America become a medical professional. We need experts to help us and expecting Joe Citizen to save the healthcare system by being incentivized is just fantasy. Any system that relies on savvy decisions from medical consumers as it's primary method of holding down costs will surely fail.
Posted by: Curt M | Aug 15, 2007 3:37:41 PM
I went and looked at Rudy's plan, which his website explains in fairly sketchy terms. It says, "Rudy proposes an income exclusion of up to $15,000 for those without employer coverage to make insurance more affordable." It appears that he means that you can exclude from taxable income the amount you spend on health insurance, which is different from what you said in two ways: it's designed to help purchase nsurance, not "to help purchase care"; and it's difficult to imagine that he is proposing to allow persons to exclude from income expenditures they haven't made.
(Note also: I am not endorsing the plan, just pointing out that Ezra seems not to understand it.)
Posted by: ostap | Aug 15, 2007 4:02:31 PM
CurtM,
I would suggest your depiction is too black-and-white. There are many things that could be done to incentivize consumers with a reasonable level of knowledge. Additionally, there is extraordinary diversion among physicians from using best practices and evidence-based medicine. Helping consumers know which physicians are better would be a tremendous help-- an oversimplified example: Best Doctor A costs you a $25/visit, Average Doctor B is $50/visit and Doctor C is $75/visit. Or perhaps you provide a best practice "score" for A, B and C and let patients choose without the co-pay differential. Or imagine a grading system. On and on. Same thing could be done with procedures.
Don't confuse the practice of medicine with the consumption of it-- there are many things that can be done around evaluation of practitioners and procedures that could allow consumers to make easy and much better informed decisions. You clearly need experts doing the evaluation/scoring, but the power of the consumer would still hold.
Posted by: wisewon | Aug 15, 2007 4:29:51 PM
Curt M is on the mark. It's one thing to be 'informed', it's another thing to require hours of research for every fracking healthcare decision one make. It's another thing to be pushed into amateur self-diagnosis, based upon materials designed for people with actual medical qualifications.
Anyway, Rudy's plan isn't a 'plan'. It's a scribble on the back of a napkin that he can pass off as a plan in order to deliver insults about 'socialism' and 'French medicine'.
Posted by: pseudonymous in nc | Aug 15, 2007 4:38:13 PM
Guiliani's health care mouthpiece, I mean health policy advisor (from the Pacific Research Institute), was on public radio here in Seattle on Monday. All it took was a couple of semi-probing questions from the host (e.g. where did you get that figure?) for her message to turn into total, content-free blather.
Posted by: mutakhalef | Aug 15, 2007 5:12:58 PM
Helping consumers know which physicians are better would be a tremendous help-- an oversimplified example: Best Doctor A costs you a $25/visit, Average Doctor B is $50/visit and Doctor C is $75/visit.
Yes, that's just a bit oversimplified, isn't it?
How about this counter-example: your primary care physician doesn't quite know what's causing your symptoms, and offers you the choice of a referral to a physical therapist ($X/visit), a neurologist ($Y/consultation), or an endocrinologist ($Z/consultation). Plus, you can get a set of MRIs ($1200 each, and insurance won't cover the first one) which may help determine which choice you make, but there's no guarantee on that.
Posted by: pseudonymous in nc | Aug 15, 2007 5:14:12 PM
Pseudo,
We've been down this road before-- there really isn't anything new to say.
"Doc, what do you recommend?"
As I've said before, our system benefits if doctors and patients work together in making decisions. Someone needs to make the quality-cost tradeoff, doctors aren't trained to do this and even if they were everyone has different preferences. It takes around 5 minutes to discuss the X, Y, Z and MRI cost and determine what the best path forward for your fictitious patient.
Posted by: wisewon | Aug 15, 2007 5:25:29 PM
ostap
ezra understands it just fine. Guiliani has flat-out said that he has in mind something much like the Bush Admin peddled for a couple of days about a year ago.
the Bush plan gave a 15k standard deduction (for families, 7.5k for individuals) for the purchase of health insurance, regardless of what your plan cost.
under the Bush plan, however, that 15k was exempt from payroll taxes as well as the individual income tax, so, the family making 30k referenced above could get a tax cut from this.
Posted by: josh bivens | Aug 15, 2007 5:29:24 PM
I actually like the example as instructive of your views as well.
What are you recommending? The answer being "all of the above" X, Y, Z and MRI? If not, who is making the decision? The doctor? That's what we have today-- they err on the side of doing too much because they'd like to make sure they're not wrong-- this has failed spectacularly. If not doctors, then who?
Posted by: wisewon | Aug 15, 2007 5:30:45 PM
"Curt M is on the mark. It's one thing to be 'informed', it's another thing to require hours of research for every fracking healthcare decision one make."
Seems impossible yet my wife and I just did this research while going through some extremely difficult steps as part of a high risk pregnancy. It's your health for *&*(&% sake; you'd think you want to be involved.
All in all, Wise is right: there's a myriad of small reforms required to drive to the right system. Price transparency is critical; plus, the link between health insurance and work needs to be broken.
Posted by: DM | Aug 15, 2007 5:35:51 PM
I think pretty much everyone (except Sullivan himself) has realized that he's basically a self-loathing liberal. He used to be a really interesting read, and no borders on self-parody.
Posted by: TW Andrews | Aug 15, 2007 5:47:30 PM
I never get my car fixed without buying the Chilton's book, completely reading it cover to cover, and then breaking down my car in my driveway with my own Sears hand tools and reassembling it so that I can make more informed decisions about whether or not I really need my oil changed or maybe have the tires rotated. Why, if I had to get a new water pump or a time belt, I might even get out the Sears hand tools twice and thoroughly retrace all of the assembly steps, so that when I show up at the dealership at 7AM the next morning I can say with confidence "ok, I'll take the new time belt. I know with absolute certainty it's not going to last another 100,000 miles."
Really, why should I treat my body any differently?
Posted by: ChowChowChow | Aug 15, 2007 5:52:08 PM
Curt, I think you've managed to redefine your own statement, so you don't need me; in any case, what I said was I didn't see the point of going down the line of argument you bring up about the desire to have a doctor manage your care - it's not what you want that concerns me (I'd like a personal assistant), it's what you mean by "manage", which is something others bring up as well and which, as you point out, would involve at least some portion of you participating in an active way in your own care decisions. There's a longer discussion to be had here, where these issues only scratch the surface of a number of deeper issues in healthcare. Still, as I said, I think this discussion, while valuable in some ways, has nothing to do with the matter at hand, which is the Giuliani plan (or lack of one).
Posted by: weboy | Aug 15, 2007 6:01:59 PM
There is a difference between being informed as a consumer (about pricing), understanding your treatment options (expertise about the the subject matter which is medicine and in many cases specialized disciplines) and the myriad ethical, social and cultural issues involved in treating people. Just thought I put out there that it seems like people are talking about many different things as if they are one.
Posted by: akaison | Aug 15, 2007 7:32:05 PM
By the way... has anyone tested the link Ezra gave? It looks as though Sullivan may have taken his post down...
Posted by: weboy | Aug 15, 2007 8:22:01 PM
It takes around 5 minutes to discuss the X, Y, Z and MRI cost and determine what the best path forward for your fictitious patient.
Alternatively, it takes about two years and several thousand dollars.
It's your health for *&*(&% sake; you'd think you want to be involved.
'Involved' is one thing. 'Playing amateur diagnostician on the internets' is another. But I can't beat ChowChowChow's analogy.
What are you recommending?
I'm not a medical professional. I spent several years at college in the company of people getting medical degrees. I respect medical professionals, but I hate the way that the US system makes me start from a position of distrusting them.
There are obvious examples where consumers can make cost-control decisions: generic vs. branded is an easy one. But to pick up on akaison's point, pricing leaks into issues of expertise and ethics, and to pick up on something Ezra has noted repeatedly, people make bad decisions about their own healthcare.
Posted by: pseudonymous in nc | Aug 15, 2007 8:43:21 PM
That's not an answer to my question, though.
Someone's got to make the call on your example: X, Y, Z and MRI-- who do you want making the decision?
Who is making the tradeoff between what's best for the patient and what makes sense from a cost perspective?
I've said doctor AND patient (not just patient) in dialogue is the best option. What about you?
Posted by: wisewon | Aug 15, 2007 8:50:26 PM
The doctor? That's what we have today-- they err on the side of doing too much because they'd like to make sure they're not wrong-- this has failed spectacularly.
If it has failed in America, that may well be a result of other issues with the American health system. Other countries remove the whole issue of shopping for health care, apart from very rare experimental surgery - if it's not covered by the public system, it's covered by a private insurer. And, as pointed out many times, a large number of other countries get better outcomes.
Posted by: slightly_peeved | Aug 15, 2007 9:11:12 PM
There will never be the transparency in pricing that patients want unless you amend the Taft-Hartley act. Physicians are not allowed to talk with other physicians about their pricing schedules, which essentially makes it the equivalent of going to Walmart and seeing nothing but barcodes and no price tags and seeing how much you owe when you check out. If there were pricetags on everything it would be illegal.
Posted by: Dingo | Aug 15, 2007 9:45:28 PM
I've said doctor AND patient (not just patient) in dialogue is the best option. What about you?
Perhaps I didn't say it explicitly. I'll say it explicitly: the conditions for a proper doctor-patient dialogue are broken in the US system.
And I'll pick up on slightly_peeved's point, for the sake of contrast. The dialogue in the British NHS goes something like this: we'll start off with the cheap and simple option, and see what happens. If that's not working, we'll go with the next option, and if time's of the essence, we'll go straight to step three.
Obviously, doctors within the NHS are trained and work within a system that makes the cost-benefit analysis every single day, from the GP up to the specialist consultant. Yes, that means extrinsic factors play a role. Yes, it can encourage doctor-knows-best. But there's an incrementalist rationale which at least seems more coherent than having primary care physicians get grumpy because their patients are reluctant to stick ten Benjamins in the bill-slot of the Magic MRI Machine.
Posted by: pseudonymous in nc | Aug 15, 2007 11:44:33 PM
And to state it outright: I want the doctor making the call, with patient input. But the doctor is the one with the damn diploma on the wall.
Posted by: pseudonymous in nc | Aug 15, 2007 11:47:18 PM
"Perhaps I didn't say it explicitly. I'll say it explicitly: the conditions for a proper doctor-patient dialogue are broken in the US system."
Wow! I'd be interested in knowing why you think this. Other than there being no discussion of cost/benefit, I've found good doctor-patient dialogue in my wife and my interactions with the system.
Posted by: DM | Aug 16, 2007 12:41:18 AM
Curt M is right that people don't want to be experts, and any system that requires the average person to become an expert is bound to fail. Weboy is right that we need to find a way to get patients involved in selecting physicians and courses of treatment that are most likely to provide the best outcomes for lowest cost (not so easy to define, but that's another matter). These can be reconciled.
We can get patients to make better decisions through third parties that provide quality and cost information (CMS is doing it, multi-payer performance organizations are forming to do it as well). This information can then be assembled by insurers and simplified in the form of tiered networks and tiered pricing for treatments. This is also already being done.
I only need to know I'm paying more for doc X than doc Y, or that treatment X will come with a $20 copay but treatment Z will come with 50% coinsurance. If I know that the higher costs indicate lower expected bang for the buck, even if I don't know the details of how, then I can make an informed decision. I will tend to choose the highest value choice first, and if that doesn't work for me, I can try the next highest expected value, and if that doesn't work..., etc.
The other thing we need to do is incentivize health. Simple rewards for achieving health targets are what we need. it's good to give people the best care when they are sick, but it's better to stop them from getting sick in the first place. And prevention is an overwhelmingly non-clinical matter. Doctors only play a minor role in this, and we shouldn't ask them to be our lifestyle coaches.
Posted by: jd | Aug 16, 2007 1:09:25 AM
I really don't understand the politeness and deference people give to Sullivan, as though he were a bright but ignorant child who liked to spout off charmingly uninformed opinions. But he's an adult, not a ten-year-old. He's published everywhere, treated as a serious and informed thinker, and yet the dewy ingenue act continues--every revelation of the realities of bad policy comes as a shock to our bemused hero.
Enough, already. Ignorance or willful blindness to the consequences of the policies he supports is no excuse, and recanting later with a grin, shrug, and an "oopsie, my bad!" does not take away the damage he did in supporting things like the war in the first place. I don't care how "sparkling" his wit may be--his record shows him either an idiot or someone who affects willful ignorance in an attempt to play both sides. Republicans give him approval when he says what they want; Democrats give him approval when he recants later.
Posted by: emjaybee | Aug 16, 2007 3:28:35 AM
Sullivan feels the way he does because he is wealthy and will never have to worry about lacking health care. I think it's as simple as that.
What really makes him outrageously intellectually dishonest is that he does not even acknowledge that many Europeans can buy private health insurance--even to rout around the NHS he hates so much. I've sent him a few emails on exactly this point, but I've never seen him acknowledge it.
Fortunately, groups like the Abigail Alliance actually do bring together libertarians and those who want adequate funding for health care.
Posted by: Frank | Aug 16, 2007 7:30:37 AM
The last two posts defines my problems with a site like Sullivans. And, yes, he often either deliberately or with willful ignorance mischaracterizes or is down right wrong about the issues and/or groups he discusses. Until now, I hadn't thought about it, but yes the English do allow for people to buy a secondary insurance. I have a friend there who has both the public and private. It would seem that NHS is a basic net rather than a cap on what people are allowed to have. The problem with the U.S. can be succintly described in those terms. Pure capitalism here leads to a lack of trust of doctors and the system. One can not be sure of motives or intent. No private intermediary can help with this because it doesn't solve some of the basic problems- in fact- it makes it worse. The more layers you put in there, the more its going to cost. It's funny how people who say they are worried about cost would then add an extra layer of bureacracy.
Posted by: akaison | Aug 16, 2007 7:51:35 AM
"the Bush plan gave a 15k standard deduction (for families, 7.5k for individuals) for the purchase of health insurance, regardless of what your plan cost"
If that is the case, then it wasn't for the purchase of health insurance. If I promise to give you $15k for the purchase of a car, no matter how much you spend on a car, then I'm just giving you money -- I'm not giving you money for a car.
Posted by: ostap | Aug 16, 2007 8:02:21 AM
And to state it outright: I want the doctor making the call, with patient input. But the doctor is the one with the damn diploma on the wall.
I'm genuinely interested in this topic, so let me add a few thoughts here:
Wennberg from Dartmouth, one of the foremost experts in variation of/unnecessary care, has put out some interesting research over the past few decades.
Around 50% of hysterectomies that are currently conducted are not medically necessary. Slow down for a second and think about that. Invasive surgery-- taking out a woman's uterus-- and HALF of them didn't need to be done.
Another example. Cities where there are more heart surgeons leads to more heart bypass (CABG) surgeries being done. No difference in outcomes, implying they were not necessary as well. Think about this one for a second as well. Crack the chest-- perform surgery on the heart itself-- and some of these patients didn't need to go through it.
I could give many, many examples here but they're all in the literature. Before we rail on the evils of fee-for-service and greedy physicians, that's probably not the issue. The staff-model HMOs of the 80's (where docs are employees on a flat salary) aimed at exactly this thinking and were not successful. Why? Because the real driver of this unnecessary care is classic human behavior-- doing something must be better than not doing something. Those in the medical profession joke that surgeons just look for excuses to "cut." It isn't meant literally, of course, but it does point to their mentality-- that's why they DO, so that's their solution. Its true for all specialties, they're all human.
A completely different point is the wide divergence between actual medical practice and what's determined best practice. The "diploma on the wall" sounds good-- but the reality is that medicine is an evolving field, and once you get that diploma, what you've learned starts immediately becoming obsolete. Once that diploma is 10, 15, 20, 30 years old, 30-70% of what docs have learned is no longer correct. If you don't keep up with best practice (few community physicians do) and instead you practice what you know, you end up with the divergence that's been demonstrated between actual practice and best practice. We all can't go to a 40 year old doctor that's probably the sweet spot between recent training and experience.
So what to do? Wennberg has done research here as well. Going back to the hysterectomy example, Wennberg found that if patients were aware of the unnecessary hysterectomies issue, and asked a few related questions to their physician, the number of unnecessary hysterectomies dramatically fell. As the top-line message, as medicine becomes increasingly complex and evolving, physicians can't know everything and patients DO need to be an active participant in their care. And its happening, a NY Times article this past weekend showed that the percent of people looking up their health conditions online has jumped from 20% to 50%-- and that's without any real good tools/reliable data sources to depend on. Again, this is to enable the write dialogue between doctors and patients-- as Wennberg's research emphasized, not for the patient to play the role of doctor.
My next thought-- this whole post so far has purely focused just on the quality of care. In other words, doctors have enough to work on in improving their quality alone-- asking them to be the ones responsible for trading off costs and quality is just not realistic. That was my earlier point.
My last thought related to the NHS physician. Putting the rhetoric aside, the UK isn't better at managing the quality-cost tradeoff issue. There is no question that when comparing systems, we do spend twice as much for similar outcomes. There are things to quibble with on the margins with that analysis, but clearly our system is in worse shape than others. However, when looking at cost growth since 1990, you find something interesting-- there's not a huge difference between US and Western European countries. In fact, the UK and Canada are both countries that have seen costs rise slightly faster than the US compared to GDP growth, while others like France, Germany and Japan are slightly lower-- but all are looking at similar cost growth curves eating up GDP over the next thirty years. In other words, no system has figured out the cost growth issue.
As I said in the beginning, asking physicians to be the arbiters of the quality-cost issue is a failing proposition. There is not clear answer that already exists in another system, and I believe strongly that there are mechanisms we could put in place, as I suggested earlier, that jd echoed later (and Ezra has said as well) that can enable patients to play a greater role in managing the quality-cost tradeoff-- WITH their physician, which will be better than any alternative approach.
Posted by: wisewon | Aug 16, 2007 9:06:00 AM
I'm curious as to how one determines a hysterectomy is not medically necessary.
Posted by: amanda w | Aug 16, 2007 9:40:31 AM
Amanda,
You compare treatment options in a clinical trial for a given diagnosis. For example, for uterine fibroids there are multiple options-- hysterectomy, medical management, uterine artery embolization, ultrasound techniques, etc. When less invasive techniques are just as or more effective than a hysterectomy-- its no longer medically necessary.
Posted by: wisewon | Aug 16, 2007 9:56:34 AM
There will never be the transparency in pricing that patients want unless you amend the Taft-Hartley act.
What, you work for your doctor and you want to organize a secondary boycott against him? The Taft Hartley Act? Whatever are you talking about?
Posted by: rea | Aug 16, 2007 2:59:28 PM
ostap
nope, it's a standard deduction for the purchase of health insurance. you don't buy health insurance, you don't get it.
i think you're confused (and it's confusing) with the generic standard (ie opposed to itemizing) deduction.
think instead of the standard deductions you get for other things in the tax code - say for dependents. no dependents, no deduction.
in the bush/guiliani non-plan, no purchase of health insurance, no deduction.
Posted by: josh bivens | Aug 16, 2007 4:15:42 PM
wisewon: I take your points. The 'surgeons will cut' thing -- broadened, that specialists will be inclined to look for things they can do with their specialisation -- is something that seems to be encouraged, at least tacitly, by the US system.
Like I said, there's at least a degree of coherence in the incrementalism of a more joined-up system. And I'll repeat what akaison said -- "One can not be sure of motives or intent." -- with qualifications. The current system is obviously not pure capitalism, because the opaque nature of pricing (and the financial relationships between various bits of the healthcare juggernaut) is the perfect breeding ground for scepticism towards motives.
Posted by: pseudonymous in nc | Aug 16, 2007 7:56:17 PM
There's way more to Giuliani's health care proposals than what has been discussed here, including tort reform and allowing people to buy insurance across state lines, both of which would help drive down the cost of health insurance and help to ameliorate any increases in health insurance premiums due to a decrease in risk pooling. Over all, it looks like a helluva good proposal which the Dems will fight tooth and nail because it's market based.
http://www.investors.com/editorial/IBDArticles.asp?artsec=16&issue=20070813
Posted by: mmctrab | Sep 1, 2007 4:03:04 PM
You are conflating conservatism and neoconservatism. Sullivan is starting to realize that he's not a neoconservative. Cut him some slack, please.
Posted by: wilson | Sep 2, 2007 3:21:57 PM
