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dispatches from the new world of work

TomChirp #15

Beauty Bush in full bloom with pink flowers

Robert Samuelson is no right-wing nut. But he is a severe critic of President Obama's health plan. And I agree with almost every word he wrote in an Op-ed in the 15 June IBD. Here are a few of those words:

"Much medical spending is wasted. It doesn't improve Americans' health; some care is unneeded or ineffective. [TP: Some estimates of unnecessary care hit the trillion-dollar mark per annum; and some estimates suggest that in cases like bypass surgery, over 90% of the time it's used it's unnecessary.] The central cause of runaway healthcare is clear. Hospitals and doctors are paid mostly on a fee-for-service basis. ... The open-ended payment system encourages doctors and hospitals to provide more services—and patients to expect them. ... That's the crux of the healthcare dilemma, and Obama hasn't confronted it."

[NB: The same day I read Samuelson's piece, I also perused "The Health Reform We Need and Are Not Getting," by Arnold Relman, in the 2 July New York Review of Books. A brief excerpt: "Economists say that the primary reason for high costs is the ever-expanding use of expensive kinds of diagnosis and treatment, such as new drugs, diagnostic tests, imaging methods and surgical procedures. Physicians in most other advanced countries have access to virtually the same resources, but use them less. This difference is partly explained by a higher proportion of specialists in the U.S. who rely more than primary care physicians on expensive technical procedures for their livelihood, and in general are much more highly paid than primary care physicians—one reason why primary care doctors are now in short supply. The American College of Physicians attributes much of the high cost of the US health system to its relative excess of well-paid specialists and lack of primary care doctors. ... In seeking consensus, Obama's health reform policies do not address the central causes of rising costs, and propose nothing likely to have much effect on them."]

[NB: In short, per Samuelson, Relman and me, if you don't go after (1) fee-for-service, (2) unnecessary care, (3) mal-practice tort reform, (4) evidence-based medicine, (5) geographic spending variations, (6) redirection of resources to wellness, prevention, and chronic-care, and (7) the excess of specialists and shortage of primary care physicians, then healthcare reform is a joke. Ergo, healthcare reform is a joke.]

On a cheerier note: above, an aptly named "beauty bush" outside my studio; below, one of Susan's Peonies.

Pale pink peonies

Tom Peters posted this on 06/15/09.

Comments

Haven't read the articles yet. But now let me say that I LOVE the photos. Beautiful! For the peony in the photo that has not yet bloomed, it would be great to see the blooming process of this beauty. Thanks for sharing these.

Posted by Judith Ellis at June 15, 2009 2:19 PM

And as always the most effective investment in health is not in health ‘care’ but in ‘health promotion’; 'ill-health prevention'; and ‘self care.’ Prevention is a far more effective use of resources but we all know it’s not as sexy as the big acute hospitals. 'Twas ever this. It takes a very big man/woman to suggest closing a big acute hospital and re-investing the money into primary care and prevention. In my lifetime I cannot recall one large acute hospital in the UK being closed resulting in a reduction in the number of beds in the locality. ‘Beds’ are far too emotive - we should be looking at investments in services not beds.

PS Wonderful Peony – my newest Peony has yet to bloom – another reason to look forward to summer! – Susan has set a very high standard!

Posted by Trevor Gay at June 15, 2009 3:09 PM

Actually, TWO of Susan's Peonies plus one bud. Bad math on my part.

Posted by tom peters at June 15, 2009 5:04 PM

Tom, we can partly thank the insurance companies for making this situation even worse. While it would seem to be greatly to their advantage to find a way to make it more profitable for doctors to practice preventative medicine (without overuse and abuse of expensive procedures and tests), they simply refuse to try. The drug companies don't help with their constantly bombarding us with advertising that claims if you take this pill or that pill your whole life will be made instantly better (an oversimplification -- but not much of one.) Not to defend them, but doctors have little incentive to practice wellness-oriented/preventative medicine in our society. Neither do hospitals. Well patients don't occupy beds. Empty beds don't generate revenue.

We've totally disincentivized (is that even a word?) "wellness" in America. Health care in the U.S. (and I suspect many other countries) is all about big business and not really about overall health.

If we can figure out how to turn THAT around, 99.9% of what we do in the name of health care and the ways we do it would change radically. Perhaps it would result in them needing a few less beds and we could convert the space into "wellness centers," equipped with gym equipment and classrooms to help people GET healthy and STAY healthy. In case anyone is chuckling at this point, be assured, I'm NOT making a joke.

One place we could start is by cutting some of the reimbursements for "fix-it" medicine and start paying more for preventative medicine. For example, If hospitals got paid as much for a patient working out and learning to live healthier as they do for coronary artery bypass grafts, over a few decades we'd start see coronary artery disease decrease. And if drug companies were encouraged to manufacture better vitamins and supplements and we made that as lucrative as manufacturing antidepressants and cholesterol lowering drugs, guess what they'd start promoting equally as much?

As for the patient side of things? That will take decades of reeducating our society away from the notion of "quick fixes" and toward the idea of actually taking better care of ourselves by doing the things that doctors and hospitals and drugs and machines CAN'T do -- like changing our eating habits and lifestyles if needed.

This problem didn't just pop up overnight. We're surely not going to change it overnight, either. But until we decided to take steps to try (radical steps) I don't look for it to improve at all.

Posted by Dan Gunter at June 15, 2009 5:38 PM

Thanks - well said. $200B in fraud, waste & abuse each year too apparently - medical supplies seem to be rampant with fraudulent duplicate billings.

USA "healthcare" is approaching 20% of GDP going to 30% under some dire predictions.

June 22, 2009 Time magazine health cover story:

http://www.time.com/time/specials/packages/0,28757,1903873,00.html

Posted by C Love at June 15, 2009 7:30 PM

My company is developing a next-generation implantable defibrillator (completely intravascular), which is a relatively expensive item at face value. It is however cost effective per year of life saved, and seen quite differently in the US versus Europe. I think how it is seen explains some of the differences in overall medical expenditures. If you have a defibrillator and it does not rescue you because your heart is behaving, Americans see it as insurance and a good thing (you are still alive). Europeans tell us that they see it as wasted money since it never went off. The Europeans buy less of them for this reason and also because they are financially capped. Hopefully for their people they don't need one of these devices late in the fiscal year. Without it, your chances of surviving a sudden death episode are zippo.

However and despite my life spent on developing "expensive" medical devices, I would completely endorse Washington allowing a tax break for the purchase of a Wii game console for everyone, and mandating that it comes with the Wii Fit software, rather than the garbage they are proposing.

Posted by Terry Ransbury at June 15, 2009 9:06 PM

Terry, funny you mentioned tax breaks. I almost included my thoughts in the above post about changing the tax code and offering significant tax incentives for individuals to invest and participate in wellness programs. Taken to the farthest extreme, give even higher incentives for results! I know that latter part is difficult, as we'd get into the arguments of what was preventable (lifestyle issues) vs. genetic predisposition and uncontrollable environmental factors. I say if a family spends $1,000 a year on a gym membership and can prove they actually used it, then give them a direct $1,000 credit toward taxes. My theory is that the $1,000 will be more than saved in the way of avoided costs for health care and drugs. Add to that the indirect benefits, such as reducing the loss of productivity at work (I've seen astronomical figures for annual losses to companies due to employee stress and illnesses.) It's also true that companies with lower health insurance claim numbers can negotiate less expensive coverage (savings for the employer and employee.) Voila! It benefits the company. To wit, dollar-for-dollar tax breaks for providing gym memberships and wellness programs for employees.

All this to say that we can't simply reeducate people to think wellness and prevention overnight. But there are ways to start the ball rolling in that direction. Serious tax incentives could be a valuable part of the equation.

As I said before, we HAVE to find ways to make wellness and health maintenance more attractive than short term, quick-fix, instant gratification health care.

Education is another place. If you want to tax for results, tax pro sports teams with their megamillion dollar annual profits and earmark every dollar of it for more aggressive wellness and preventative programs in public schools. We have our children in school for twelve years in this country. You'd think that in 12 years we could do a better job of teaching them how to get healthy and a better job of actually helping them get healthy. But I'm seeing less and less emphasis on physical education programs in schools, while I'm seeing more and more news stories and studies showing increases in childhood obesity, juvenile diabetes, etc. We didn't just turn on the fat genes and diabetes genes -- we've taught our kids to live on unhealthy food and told them "If you don't feel like getting sweaty in P.E. class, that's okay... we just won't make you do it." Darn it... I could go for hours with ideas on all this.

In conclusion, the health crisis AND the health CARE crisis in this country are interwoven and result from a lot of factors that CAN be changed. The first step is for us to get serious about it. Then do more than just talk about it -- we have to DO something.

Posted by Dan Gunter at June 15, 2009 11:36 PM

Do we need healthcare reform? Sure. Lots of it, in various places. Now I work for a not-for-profit system so I will admit up front that I am probably biased, but the hospitals are just workshops for the physicians. The hospitals can't admit patients, can't authorize surgeries or any medical tests. That is what physicians do and only they can to that. Now hospitals do buy the big expensive, latest and greatest, gee whiz bang toys for the physicians to play with, so they will come to our place to play instead of the folks down the street.

Are all hospitals bastions of do-good? Not all. There are the HealthSouth's that doctored the books more than the physicans doctored patients. But most are reasonable places and even where I work we are trying to be better at what we do and at helping people so they don't need to be admitted or readmitted.

Posted by MikeC at June 16, 2009 12:03 AM

Well said DG - 1st do no harm - hard to even get that! Vaccines & the flawed USDA food pyramid still pushed on the masses. McDonalds as perfect for our kids. "Trevor" in NHS is a perfect example of madness at its best (AIG soon to own NHS)! :>)

Posted by C Love at June 16, 2009 6:40 AM

C Love, I think maybe the oath got updated and we all missed it. It must now read "First, do no harm to short-term revenue."

That would serve to explain a lot of the ill-conceived health care schemes and short-term thinking that is rampant in the field of health care today.

Posted by Dan Gunter at June 16, 2009 1:45 PM

C - The lunatics are running the asylum over here :-)

Posted by Trevor Gay at June 16, 2009 2:23 PM

"The lunatics are running the asylum over here..."

So when are we all getting together to celebrate your promotion, my friend?

LOL.

Posted by Dan Gunter at June 16, 2009 2:33 PM

Hi Dan - I'm already Chief Executive :-)

Posted by Trevor Gay at June 16, 2009 2:38 PM

The French system never looked so fabulous. No. 1 in health care quality per the World Health Organization; governance pays 60% so the patient is in the prevention game with coin/motivation; they have the Camelot couple - center right leadership; 11% only of GDP for health care; 80%+ safe nuclear power so terrorist regimes do not hold them hostage for any oil dependence.

I volunteer to be a French citizen & have kids there & live on their social welfare & world class fine dining & wine. :>)

Posted by C Love at June 16, 2009 3:40 PM

Sounds like a fun plan, C Love, but you can have my share of the escargot. Or I'll trade it for your dessert. The French rock in that category.

Posted by Dan Gunter at June 16, 2009 5:00 PM

Deepak Chopra said it long ago: He could just tell people to stop smoking, exercise and eat better, but he would not get paid for it. I do not have an answer on how to estimulate prevention, maybe make gym or sports participation an integral part of our health system. C Love mixed his comment on French health with energy dependency. I believe safe nuclear (along with wind and solar) energy is the way to go. but that will not solve our dependency. 60% of our energy use goes to transportation, I think we need radical changes there. Mr. Romney (my choice for president) was the only candidate I heard talking about reducing conmuting time, if we invest heavily in public transportation (rapid trains, local and interstate) and redesign cities so people walk and interact more, there will be a direct impact in energy usage and level of stress, which will also impact health.

Posted by Ricardo Ortega at June 25, 2009 5:09 AM