There is no deal between the AMA and Obama, and "doctor's fix" does not count as part of health reform cost!

A few days ago the media started piping about the "doctor's fix" - Democrats have promised to cancel a plan to cut the fees that Medicare pays doctors by 21%. The cuts were scheduled for this January. The Washington Post claimed that the cancellation is planned to be passed separately from the reform bill so that Obama can hold up a fake promise of the reform not adding deficits to the budget. In exchange for this cancellation, Obama gains support from the AMA without breaking his promise. Over a ten-year period this “doctor’s fix” will cost $247 billion.

Now please read carefully - the above claim by the Washington Post (which has published more misleading, unsubstantiated articles of late) is false. Here, Maggie Mahar explained, very clearly, why.

With a little bit of digging, the Washington Post would have known that these proposed Medicare cuts were never actually performed even though they have always been budgeted in falsely during the Bush administration, simply because it is impossible to do. Part of the current problems with health care is that our current reimbursements are illogical, with important fields like primary care and palliative care underpaid, while other fields are overpaid. Blindly cutting reimbursements across the board is lazy and stupid - Problems with Medicare reimbursements are obviously complicated and require well thought-out, personalized, specific changes. If the Washington Post had done a little research, they would have known that suddenly accumulating all past unperformed cuts and execute it in one blow years later is a ridiculous idea, not to mention that Congress for all of those years never went through with it - why should they suddenly go through with a ridiculous idea at an even more ridiculous level (21%) now?

This makes me question - what type of irresponsible journalism led the Washington Post to make such false, inflammatory claim when a simple research would have shown that the claim is untrue?

More interestingly, watch this face-off between Maggie and Douglas Holtz-Eakin, a former director of the Congressional Budget Office, and a fellow at the Manhattan Institute. You can decide for yourself who to believe, but for me, Maggie obviously read the bills and knew exactly what she's talking about. She provided specific quotes and numbers that can be easily checked - she told you exactly how to check them. Holtz-Eakin, on the other hand, reverted to same memorized sentences and refused to directly address Maggie's rebuttal, because he didn't seem to know the issues inside out and therefore could not draw on hard facts and numbers to counter Maggie's comments.

I also have to criticize Lou Dobbs for his comments on the senators not reading the bills. He's trying to be tough and put Maggie on the spot but, really, that point is not relevant to the debate at hand and it's not even worth shouting and yelling about. Obviously, senators can't read every bill when each is thousands of pages long, so of course they rely on their staff to digest the bills for them, so that they can make decisions about myriad of issues and actually function. That's called delegation, and irrelevant attacks just so you can be tough is, for lack of a better word, stupid.

Is it possible that Thailand is ahead of the US when it comes to health care? - Part 2

Last time we outlined the inner-workings of Thailand's health care system. Today, we will explore problems within the system and finally examine where we stand compared to the US. Hopefully with all this information you can decide who will emerge on top, maybe 20 years from now.

What are the problems within Thailand's health care system?

1. Lack of oversight - many parts of the system operate haphazardly because the government lacks power/money to impose appropriate control. It does not have enough money to compete for young doctors for underserved areas with rich private hospitals in big cities. The residency process is largely unregulated - with more spots than the number of applicants, graduates flock to high-paying specialties, leaving primary care unattended. Because supply is higher than demand, no one could be forced into primary care spots, and the gov't can't incentivize young graduates with the money it doesn't have. There are no regulations on quality control within health care facilities, but that does not say much considering most hospitals in the US or any other country let doctors practice haphazardly without quality control either.

2. Lack of human resources - there are not enough nurses or doctors to go around. It doesn't help that most of them concentrate in city private hospitals with higher pay, but even if we were to spread them all out, the ratio of doctor/pt is still a whopping 1 per several thousands, which explains long lines at governmental 30-Baht hospitals. The bottleneck is with the limited capacity of major medical schools and also the lack of incentives to persuade doctors to serve understaffed rural areas. It is also precarious that new, inexperienced medical school graduates are sent to rural areas where they are left to their own devices without much supervision to treat patients - great clinical experience should not come at the price of patient safety.

3. Money problem - the current reimbursement system has some good qualities built in, but it is far from perfect. Here we return to age old debate on the pros and cons of various types of payment schedule: fee-for-service, capitation rate/salary, DRG, etc. The capitation rates paid to starting point hospitals is a good thing - it encourages consolidation of medical records, reduced transfer of care, a focus on primary care to keep people healthy and reduce cost/utilization. However, the capitation rates are too low, forcing major hospitals into the red as their popularity draws in 30-Baht customers. Doctors consider giving less care to prevent their hospitals from going bankrupt thereby losing their jobs in the process, since there are no quality control or incentives to consider quality other than their self esteem. Lack of facility fluidity in emergency situations is another problem - starting point hospitals and "emergency" hospitals engage in turf wars trying to rid cases of catastrophic accidents, since the costs usually exceed that paid by DRG rates.

4. Lagging medical curriculum - medical schools focus on multiple-choice test scores instead of knowledge application/acquisition and quality attributes that make you a good doctor, such as professionalism, communication skills, etc. They are aware that good test scores do not translate into good doctors, but they claim that without fair and effective measures for these attributes they must rely on numerical outcomes (which is true - what we use in the US is mostly arbitrary, US medical students just have no rights/say in the matter like Thai medical students). There is not enough focus on patient interaction or a comprehensive approach to health care (not that US doctors do), and the lack of role models like their professors or attendings on the floor does not help the matter. Evidence-based medicine is constricted by lack of adequate access to journals, lack of English proficiency, and lack of statistical knowledge to critically digest and understand journal articles, both in teachers and students. Students are overwhelmed by lectures focusing on memorizing knowledge that will become obsolete by the time they graduate, leaving no time for extracurricular activities that cultivate maturity, self-empowerment and leadership. With test scores as the only carrot on the stick, students become walking, obsolete textbooks who barely talk to patients and lack the ability to acquire new knowledge.

5. Low quality of care - doctors are usually only as good as their medical schools. The aforementioned problems in medical curriculum, combined with lack of money/oversight/human resources, result in low quality of care. The system is overwhelmed with new patients who with a snap after 2001 become eligible for care. Doctors never learned how to talk to patients, and now they also do not have the time. Lack of quality control/quality incentives does not help doctors synthesize and come to a realization that counseling their patients is more important than getting rid of them from the clinic to finish a day's work, for they will come right back with more problems, increasing costs for the whole hospital.

So where does that put us?

At the beginning of part 1 I mentioned that I had the opportunity to speak with a few local authorities in Thailand's health care system, one of them being the CEO of one of the three major hospitals in Thailand. We spoke at length comparing the pros and cons of our systems - I told him about incorporating lean manufacturing in hospital management and he was intrigued. A few days later as I was walking around the hospital, I in turn was even more intrigued to find that there was already a lecture on using lean manufacturing in hospital management taking place that week - most US hospital CEOs wouldn't know what lean manufacturing is.

I mentioned the above example to illustrate a point - Thailand has been aware of the right ideas for a long time, sometimes before the US, but they never materialized due to faulty implementation. We know lean manufacturing can be used in health care management, but if the hospital CEO never heard of it, the implementation is doomed. We know test scores measure nothing, but we haven't tried to find better outcome measures that encourage students to focus on becoming a good doctor and not a textbook. We know capitation-based payment is creating problems, but we have not learned to devise a scheme that draws from advantages of various payment schedule to achieve high quality (but neither has the US). We realize the importance of community integration, but our well-planned community-based health care system lacks doctors who recognize the importance of primary care with enough conscience to stay in rural areas and refuse to waste their talents in overstaffed private hospitals. We know primary care residency needs to be boosted, but no organization has stepped in to make that happen.

That's where Thailand stands, and I think that's where the US and most everyone else stand. Providing quality care is not rocket science - we know exactly how to do it and we've known it for years, but we have not achieved it for various reasons. In Thailand I think it is due to inexperience and lack of good management, but in the US I think it is mostly due to incumbent parties who fight inhumanely to keep the status quo and the money that comes with it. I personally think inexperience is easier to get rid of than big pharmaceutical companies, but we might find out in a few months if I'm right.

Is it possible that Thailand is ahead of the US when it comes to health care?

This trip home and a talk with local authorities in Thailand's health care system got me thinking - Thailand is still considered to be a developing country, but when it comes to health care, I'd like to suggest that the citizens of Thailand might be better off than the Americans. This is a big statement to make, but to substantiate it I will start off with the explanations of how the Thai health care system works. Then I will go over the problems within the Thai system, after which I will make an amateur guess on where our system is going compared to the US. This is when you can decide if we are indeed in a better position.

How does the system work?

Thailand consists of 70 or so provinces - Bangkok is one of them. In each province, the smallest unit is called "Tumbol," where local health care centers are run by trained community health workers who are fully integrated into the community. These health care centers are low-capacity clinics without admission capability, and there just simply aren't enough doctors/nurses to staff all these rural clinics. The health workers (the good ones anyway) know their communities in and out, they draw from resources to solve all types of problems affecting the community (income generation, sanitation), and they focus on prevention and disease detection (they use simple symptom-based algorithms to arrive at possible diagnoses and preliminary instructions on how to deal with the illness).

When things get too complicated for the health workers to handle, they refer patients to "Amphur" hospitals, which take care of "Tumbol" health clinics in their areas. Amphur hospitals can take care of simple cases and admit a few patients. They are staffed by a few senior doctors who are also CEOs of the hospitals, and the day-to-day work is handled by new graduates from gov't medical schools who rotate out to these facilities to pay back their tuition before they can move on to residency (gov't medical schools are better than private ones, and the tuition is cheap because the gov't reaps its human investment through these post-graduation rotations). Most graduates consider this to be a great clinical experience, while others who loathe the rural area have to pay a ridiculous sum of money to avoid it.

For patients who are too sick, they are transferred to big provincial hospitals, which are responsible for Amphur hospitals in their jurisdiction. Provincial hospitals have full capacity similar to that of big shiny hospitals in Bangkok. They are staffed by a number of physicians, many of whom are specialists.

To recap: Tumbol health clinics --> Amphur small hospitals --> Provincial big hospitals

How do we pay for it?

Before 2001, most people did not have insurance - they pay out of pocket. The lucky few to have insurance were government workers (gov't insurance), the poor (Medicaid-like insurance), social security (this has a different meaning than social security in the US - in Thailand it means insurance for retired people who contributed to the fund during their lifetime), and the rich (private insurance-very small %, insurance wasn't and isn't big in Thailand).

In 2001, the gov't introduced the 30-Baht program - everyone can get comprehensive care at participating hospitals (all gov't hospitals and some private) for a co-payment of 30 Baht (it's so puny you can maybe buy just a meal with it - after a while this co-payment was canceled and people can get care even if they forgot their wallet at home). People can pick any hospital as their "starting point," where ideally they will have primary care doctors who then refer patients to specialists anywhere when needed. Each hospital gets capitation (per head) payment based on the number of people who signed up, and that's all the money they get no matter how sick their patients are. Patients can get care outside their starting point only in emergency situation. When patients are stabilized, they can be transferred back to the starting point, or if the base hospital refuse to take their patients back, the "emergency" hospital can collect money from the base hospital based on Diagnosis-Related Group (DRG) rates.

As for the fate of other programs: Medicaid was eradicated. The rich continued to pay out of pocket at private hospitals to avoid the now much longer lines at participating hospitals. Old gov't workers can keep their gov't insurance, but the new ones will only get the 30-Baht program (most gov't institutions are now "leaving" the gov't systems to become private-like entities - the gov't still controls the policies, but to encourage efficiency, the management will resemble that of private entities and the gov't worker benefits will no longer be offered). People getting social security refused to let their program and their hard-earned savings vanish, so they get to keep social security if they want to. However, if they choose social security (usually with better benefits), they are not eligible for the 30-Baht program.

And that's where we stand now: the system remains fragmented, but arguably anyone in the country, regardless of ability to pay, will now be able to get health care.

What are our problems? - Find out in part 2!

Want to cut cost as part of health care reform? Start here!

Reiterating once again that Pharmaceutical companies are the big cost inflater in our health care business (they consistently make huge profits among the Fortune 500 companies even in an economic downturn), this video points your attention to biologics and under-the-radar pharma proposals to keep these life-saving medicines overpriced far longer than it needs to cover the R&D costs that it never spent (many of these drugs are developed by governmental/non-profit organizations like the NIH or university research labs).

Take action now. Call/email/fax your congressmen. Here is your chance to make a difference in health care reform!

Analyzing Glenn Beck...

Glenn Beck recently did an interview with Katie Couric. I would post a link here but, really, Glenn Beck has more than enough air time as it is, and I would hesitate to contribute to alerting more people about Glenn Beck because if someone does get hurt because of what he says, I would feel guilty.

But watching the interview I understood why people listened to him and believed what he said - He really appealed to the frustration of the common man and combined that with sound bites to manipulate people's beliefs and behaviors. Manipulate is a strong word, but it was much deserved for Glenn Beck. Much of what he says lacks evidence but is fueled with strong words, all of which totaled up to irresponsibility. Responsible media would not give idiots airtime and paint them up to be experts on the matter (like Betsy McCaughey or angry mobs at town hall meetings - whoever yells gets to be on TV!), but putting Fox's dirty paws aside, if Glenn Beck is such a government buster like he makes out to be, he needs to bust with facts and not hate words. Otherwise, he's a big fat hypocrite in the hypocritical world of government that he sets out to burn.

Katie Couric, on the other hand, is quite genius. She was always calm and collected, but more than that she busted Glenn Beck many times, not with accusations but simply with questions, fair and square questions. On another level, she humanized him with personal questions that showed him to be a normal, vulnerable human being - like a wounded enemy you can't sucker punch in your right mind. She showed Glenn Beck as he is - a manipulative, irresponsible bag of hate words - but Glenn Beck, watching the interview, wouldn't be able to point the finger at Katie Couric.

The public option: do not give up hope or your dissatisfaction for the lack of it!

Interesting (and encouraging) post from Maggie Mehar, making a point once again that the Senate Bill is not everything. SOMETHING just needs to pass so that it can be debated in conference, at which time the administration just needs to realize that:

1. They cannot pacify the conservatives - the conservatives will never be happy unless the status quo remains or the incumbent parties benefit at the cost of the disadvantaged

2. So if you cannot make the conservatives happy, the best thing you can do is make someone happy, that someone being the average Americans and your voters, because without a real change that cuts costs and makes health care accessible to everyone, NO ONE will be happy.

Maggie puts it best here:

President Obama and White House budget director Peter Orszag understand that if health insurance isn’t affordable, reform becomes a sham. The political penalty for promising what you can’t deliver would be steep. Thus they understand that for health care reform to work they must do what Massachusetts didn’t do: reduce the cost of care before rolling out full coverage.

So if you're upset at the lack of the public option in the Senate Bill, please continues to voice your concerns to your representatives, and do not give up just yet. The only thing that really matters is that the public option make it out of conference, and your voice can make that happen.