None of the Republican proposals for healthcare include a
single cost or quality requirement for payment to doctors, hospitals, or even
insurers, which will add rocket fuel to the fee-for-service payment system
which is the bane of U.S. healthcare. This payment method, which originated
with the founding of Medicare in the sixties, is one of the main reasons why
the price for health services is so much higher in the U.S. than any other
country. Essentially, there is no budget and all healthcare providers are paid
on volume, with the exception of some primary care folks. You have undoubtedly read the stories of
patients being charged for services by surgeons who didn’t even perform the
surgery, which reflects the factory mentality of the surgical suite and the
outsized incentive to make more money. The delivery of health services or
improved health to the patient is often a bi-product. Tom Price is the Trump
Administration appointee for Secretary of Health and Human Services, which
oversees all policy making for healthcare, any efforts to assess and improve
quality, most funding for medical research, and patient safety programs for the
country. He is on record questioning the value of Medicare’s Demonstration
Projects, whose sole purpose is to find ways to improve health and reduce costs
as clinically appropriate. Without the requirements of the Affordable Care Act,
for price reporting transparency for medical device companies and other
suppliers, as well as mandating that insurers participating in government
funded programs spend at least 85% of funds collected on program benefits for
enrollees, there will be no incentive for any of these health sector
profit-takers to lower their costs or improve quality. Will the Republicans also
axe the successful Accountable Care Organization incentives for systems which
demonstrate they are delivering high quality health care?
CMS-the Only Agency with
Enough Price, Quality, and Enforcement Power to Fix Healthcare
The Centers for Medicare and Medicaid is the only agency
with enough regulatory power to enforce both price and performance standards
for the national healthcare system. Dr. Tom Price wants to neutralize CMS and
loosen oversight for the healthcare industry. As I illustrated in my 2013 book,
Unraveling U.S. Healthcare (Winter R. E., 2013) , national healthcare
when viewed by outcomes is not better here, just more expensive. According to
2017 data from the Henry J. Kaiser Family Foundation, the U.S. now spends $9,451
per capita for health care. (Cox, 2017) Most of Europe
spends half of that per person per year. And I am not talking about insurance
premiums, but the total, all-in cost of health care. Only three countries spent
more than $6,000 in this time-frame, the wealthy triumvirate of Norway,
Switzerland, and Luxembourg. How can the U.S. still claim that covering
everyone for health care is too expensive when all the industrialized countries
are doing that and spending much less?
American Health Is
Declining
According to a recent analysis by the Kaiser Foundation, the
U.S. is at the bottom of all industrialized countries for life expectancy and
we spend 50% more than most of these countries. (Sawyer, 2017) People live the
longest in Japan with an average life expectancy of 83.7 years, followed by
Switzerland at 83.3 years, and then France at 82.8. The U.S. comes in at 78.8,
this despite spending 50% more on health care. In fact, life expectancies are
going down in the U.S., which is still one of the richest countries in the
world. This should raise alarm bells, yet the ill-informed Republican Congress
apparently believe that reducing access to health care by gutting Medicaid, removing
basic benefits like maternity care (U.S. also has one of the highest maternal death rates in the developed world), and of course, gutting mental health
services will improve the situation. I remember when smoking die-ins were de rigueur, perhaps we need to stage a national die-in to demonstrate the impact of the latest
Republican effort to gut healthcare.
Systemic Overcharging
Contributes to the High Cost of Healthcare
Why is overcharging tolerated in healthcare? People aren’t
willing to spend 50% more for their houses or their autos? Americans are not
getting comparatively better health for this 50% higher healthcare spend, but
many companies are getting very rich because of it. In 2013, I posted an
article on orthopedic surgery for a hip replacement in Belgium, which cost
$16,000 versus $60,000 in the U.S. and the entrepreneurial American who chose to
fly to Belgium for his uninsured treatment because he still saved money. (Winter, 2013)
Why Increased Private
Sector Involvement and Reduced Regulation Won’t Work
As a participant in the Lown Institute’s Right Care
Conference this month[1],
which focused on educating clinicians and the public about cost effective treatments
which improve health, I had the pleasure of listening to Jeffrey Sachs,
professor of Health Policy and Economics at Columbia and a United Nations
Adviser, the day the Republicans came out with their plan to defund Medicaid.
Dr. Sachs has studied microeconomics and unequivocally stated, “Pure market
economics in healthcare does not exist. Corporations are not the guardian of
public health.” Consequently, the expectation that more uncontrolled private
sector involvement will generate a better more efficient healthcare system is
ludicrous. The U.S. healthcare system was created for profit maximization not
maximum efficiency or efficacy. The idea that market economies are the solution
to all public services has been proven false time and again, for national
security, the interstate highway system, regulation of drugs and medical
treatments, and the safety of our food supply. The scariest weapons in the
world are not the missiles of North Korea but chemical weapons, whose carnage the
world witnessed in Syria, and even worse, the biological ones. Trump, the
anti-globalist doesn’t seem to understand that the World Health Organization
provides surveillance and communication of disease and public health epidemics to aid in curtailment. His Budget Director’s proposed 20% cut to
Health and Human Services would impact our health safety. Our survival as a
species and a planet depend on our cooperation, funding, and heeding the advice
from organizations which are providing this front-line work.
Without Price
Transparency Patients Are Not Empowered
As the American healthcare system includes a healthy private
sector contribution, there is an expectation of a competitive environment, but
in healthcare this does not exist. For example, an oversupply of high tech
medical technology increases the cost of care and does not lower insurance premiums
or hospital charges. The burden of paying for duplicitous equipment is born
throughout the health system by the premium payers for insurance and those who
use the health services. A healthy marketplace requires symmetrical information,
meaning there is equal access to price and quality information for all participants.
In the U.S. insurance price information is available, but consumers must go to
a lot of work to assess reliable scientific health care quality data. Specious clinical
results which do not improve population health are published all the time by
drug companies, hospitals, and medical suppliers through direct-to-consumer-advertising. Hospital services
are dominated by a handful of huge corporations as is the insurance industry.
The profit motive is so enticing in healthcare that the nonprofit Blue Cross Blue
Shield entities became for-profit cash machines years ago. This decision did not lower
the cost of your health insurance or your health services. Equal access to
information, meaning, the healthcare purchasers have access to actual price and
quality information is impeded by organizations which are not required to
provide this information. At least the Obama Administration required companies
to report wholesale and retail price information, as the start toward building
a database for price transparency in U.S. healthcare. Cardiac device companies have successfully
fought to prevent the public from learning how much we are overpaying for their
heart valves. This phenomenon is very different in other countries, like France
and Australia where price lists must be posted. In the U.S. if you ask for the
cost of your scheduled procedure and hospital charges, providers will typically
not be willing to give you that information. Insurance companies would seem to be in the
best position to communicate to their customers what they can expect to pay for
a procedure at a facility, because they negotiate price with all their
contracted providers. Private sector companies are investing in price detection but their services are not readily available to the public on a national scale. The mega healthcare conglomerates, including medical
device, pharmaceutical, and skilled nursing facilities are by and large for-profit
entities and they have no interest in delivering unprofitable care. Dr. Sachs
also stated, “Anti-retroviral drugs to fight HV cost $25,000 in the U.S. and
$160 everywhere else in the world.” Drug distribution and patents are based
strictly on profit maximization, not getting the most benefit for the health
system.
This Country Is Making
You Sick
The U.S. has the highest income inequality in the developed
world, which means there is a decreasing middle-class and growing poverty class.
About 14% of all people in the U.S. live in poverty, but 25% of all
children do. Yet the Trump administration wants to cut school lunch programs,
Head Start, public school funding, and access to health care for these children,
while the top 5% expands its wealth exponentially. This worrisome trend is reflected in the ill
health of our people as evidenced by the epidemic of suicides and opioid
addictions. As I write this column within the past week two teenage boys chose
death-by-cop as their suicide method, because in this country, you can have a
fake gun, have committed no crime, and still be reasonably certain you will be
murdered by the police. In the 1990’s Congress reduced funding for gun violence
research, cutting 2.6 million from the Centers for Disease Control and
Prevention’s budget. Congress also passed a ban on any research which would
advocate or promote gun control, because of alarm over a 1993 study which
analyzed risks of keeping a firearm in the home versus the benefit for personal
safety. (Sudermann, 2017) Now, gun violence in
the U.S. kills as many people as sepsis infections. We treat infections, yet
our elected officials lack the backbone to enforce strict licensing and distribution of firearms to protect the public. Under the Trump Administration
we can look forward to ever more mentally ill persons obtaining Uzis and the
ensuing destruction. Peggy Noonan asserts that societal ills would go away if
parents only loved their children more. I can assure you, Ms. Noonan, poor people
love their children and it is a herculean struggle for them to make ends meet
every day. It should also be noted that the wealthy are just as rife to suicide
and drug addiction, so perhaps love isn’t the answer, and informed health and
welfare policy making is the solution.
And this is the healthpolicymaven signing off wishing you
fully informed consent, and remember, as Dr. Rosenthal, author of An American Sickness-How
Healthcare Became Big Business and How You Can Take It Back (Rosenthal,
2017)
recommends, don’t sign generic hospital release forms and do add a codicil
which states, “I agree to be responsible for charges for in-network providers.”
This column is completely independent of corporate support
and has been since 2007. Roberta Winter is an independent journalist and
healthcare writer. She is the author of Unraveling U.S. Healthcare-A Personal
Guide, a guidebook to the U.S. healthcare system written expressly for
consumers.
References
Cox, C. (2017). How Does Healthcare Spending In
the U.S. Compare to Other Countries. Henry J. Kaiser Family Foundation. Retrieved
May 21, 2017, from
http://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/?_sf_s=health+spending#item-start
Rosenthal, D. E. (2017). An American Sickness-How
Healthcare Became Big Business and How you Can Take It Back. New York,
New York, USA: Penguin Press. Retrieved from
http://www.nyjournalofbooks.com/book-review/sickness
Sawyer, S. G. (2017). How Does Life Expectancy
Compare to Other Countries. Kaiser Family Foundation. Peterson-Kaiser
Health Systems Tracker. Retrieved May 21, 2017, from
http://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/?_sf_s=life#item-start
Sudermann, H. (2017, March 1). Prevention
Revisited-A Harborview-based Center Looks for Ways to Prevent Injuries and
Violence. Columns-The University of Washington Alumni Magazine, pp.
38-39.
Winter, R. (2013, August 6). Save Money On Your
Health Care By Going To Europe. Retrieved from Straight Talk on
Healthcare, healthpolicymaven: http://healthpolicymaven.blogspot.com/2013/08/save-money-on-your-health-care-by-going.html
Winter, R. E. (2013). Unraveling U.S. Healthcare-A
Personal Guide. In R. E. Winter, Unraveling U.S. Healthcare-A Personal
Guide (pp. 3-15, 31-38). Lanham, MD: Rowman and Littlefield.
