Jon Stewart FTW!

Last Dailyshow episode of 2009, arguably one of the best! Very funny interview with Hugh Grant, but more importantly, Jon Stewart FTW @ 747 and 815. Oh Snap! on a stick!

The Senate compromise - hardly a better alternative

The Gang of Ten has recently come out with a new compromise in order to get rid of the public option: expanding Medicare downward to include people over 55 years old and leaving the rest of the population in the hands of various non-profit plans overseen by the Office of Personnel Management (OPM), which oversees Federal Employee's Health Benefit Plan (FEHBP).

The public option was put forward for two vital reasons - it should amass quite a bit of bargaining power, and more importantly its incentives as a government-run entity would be to lower cost while keeping the population healthy.

Keeping these vital reasons in mind, let's look at why the compromise cannot match up to the public option.

In terms of the ability to lower prices through negotiations, breaking up the population only reduces the bargaining power. Moreover, breaking up the population by age asks for a death spiral. Many argue that the public option will select for the sickest people without prior access to insurance - I'm no expert but I'm not so sure that this will be the case. Without the age divide, there could be a sizable number of relatively healthy, self-employed enrollees to balance the sicker counterparts. Keep in mind that there are the uninsured, and then the under-insured. The uninsured are probably sick, but the under-insured could look very much like the self-employed Mary and Mack Kroner - they are not super sick, they have been able to afford some necessary preventive care, if only barely. The uninsured and the under-insured, spread across all age groups, could make a nice, balanced risk group with reasonable premiums. We could be pessimistic and even say we don't know - the public option may or may not create the death spiral, but the Senate compromise to break up the age group definitely aggravates the likelihood. A good plan looks to create the biggest, most diverse group of enrollees for better risk-sharing, not breaking it down, especially not by age. This compromise wants to dump the sicker, older population onto Medicare, while leaving the younger, healthier population to non-profit plans, potentially run by friends of some powerful voices in the Senate?

In terms of incentives, keep in mind that non-profit does not equal government-run. The government on paper has the best interest of its people in mind - non-profit can aim to do whatever it wants as long as it does not make profit. The public option will be held accountable, while the smaller, fragmented non-profit plans will probably not be, considering the fact that OPM currently does not regulate the plans it oversees. In terms of costs, the public option does not need to advertise or lobby like smaller non-profit plans, and its scale could dramatically reduce operating costs, which means lower premiums for everyone.

Considering all the hypothetical arguments against the public option, this compromise only accentuates those shortcomings. The details of the compromise are not yet released, but so far it does not seem to pass as a better alternative. The Democrats in the Senate need to get their acts together, and Joe Lieberman just needs to get lost.

There is only one pie, and it is all we have and all we will ever have...

I unfortunately did not have a chance to go to the IHI national forum this year (or any year before that), but apparently it was Disneyland for quality improvement nerds. Don Berwick gave an amazing opening address comparing health care to the "tragedy of the commons" - in the common grazing area, without ownership, individual sheepherders exert externalities by grazing to the maximum, leaving the commons barren. Eventually, no one gets any grass. In health care, all stakeholders want green grass, but no one wants to stop grazing or pay for fertilizer. Some expect the government to pass laws that will grow grass and also please everyone, which means continued grazing and no fertilizers required - a Deus Ex Machina that is hardly possible in the real world.

Berwick urged us to look at the commons - it is all we have, and it has no one else but us. We, every individual, all need to step up and, instead of constantly taking, learn to give - or there will be nothing left for anyone to take. His inspiring speech says it all:

My friends, we can spend our days ahead fighting for our piece of the pie. We have plenty of role models for that. But, that’s for summer camp and the schoolyard; not for here. Not for this real and fragile world. Not for the Commons. Not when there is only one pie, and it is all we have and all we will ever have, and it is in our hands to preserve, not just for us but for our children and our grandchildren. We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us, but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit. It is a very tough choice. Get everything we can? Or respect everything we have been given?

More on his address here.

Respectfully disagreeing with Atul Gawande

Gawande wrote a new article in the New Yorker about the Senate health reform bill. He argued that the current bill has no "master plan" to reduce costs, because the systematic problems in health care cannot be solved by master plans - it requires management over time and such management cannot be passed as a one-time bill.

I agree and also disagree with such assessment. It is completely true that our bureaucratic medical system could use better management like I have mentioned in prior posts, but our health care problems are complicated - they result from many types of problems, managerial being only one of many. I'd like to argue that another big cause of our soaring medical expenses is the price tags - it is not managerial, we can fix it with a master plan which the House bill has put forward (i.e. the public option), and it is one of the low-hanging fruits that we can easily reach, much more easily than systematic improvement which will take decades.

Consider how much we pay for a pill of medication - I'm going to use Misoprostol manufactured by Pfizer (aka Cytotec) because I do have first hand information on the pricing of this medication. In Thailand, a pill of Cytotec costs 13baht - that is about 30cents with the current exchange rate. According to Epocrates, 60 pills of 100mcg Cytotec costs $72.76 ($1.213/pill), 60 pills of 200mcg Cytotec costs $104.99 ($1.75/pill). That is 4x-8x what people pay in Thailand.

Now consider a can of coke - one in Thailand costs 14 Baht (40 cents), one in the US reasonably costs 1 dollar. I'd like to argue that even taking into account the difference in costs of living (~2x), there is a huge price discrimination at play when in comes to medication pricing. In the US, with our one limited example, it seems that we are paying 2x-6x more than other countries. Could that be a reason why our health care costs so much more than the rest of the world? Is that why pharmaceutical companies make fat profit in times of economic downturn, even fatter than that of insurance companies?

If pricing contributes to the equation, then the public option will amass bargaining power that will lower the price of medical supplies. Allowing Medicare to bargain will also help. Private insurance companies will follow suit due to competition. The public option could be the master plan that quickly reduces costs, while the also necessary managerial improvement takes place over time.

Another point that both doctors and patients must realize is that health is an amalgamation of many factors, medicine being at the end of the spectrum. Most patients get to their doctors when the body is already broken, many times beyond salvage. A morbidly obese patient carrying a heart clogged with fat since the age of 14 cannot be saved by the best doctors or the best health care system - he is most likely destined for a short and unhealthy life. Fixing the medical system will not completely fix our health - we also need to pay attention to socio-economic stability, public health measures, education.

But a successful health care reform will, of course, also be helpful.

Management pearls

Good management lessons do not limit to business - they belong everywhere, including in health care and everyday life. The sooner we realize this fact, the better off our world will be.

Below I list management pearls that I have the fortune of coming across. If they sound primitive, remember that most brilliant ideas are simple - it is the implementation that makes all the difference.

- Leaders are not satisfied with what they are given - they always envision better possibilities. Followers inherit the best freighter in the world and treasure it - Leaders inherit the best freighter in the world, tear it up and make a speedboat.

- Shun the incremental and go for the leap. Meet the basic targets then stretch to the point where the organization almost comes unglued, without punishment for failure.

- Eliminate boundaries and bureaucracy. All good ideas should be valued and encouraged, regardless of their sources, be they from your janitors or your competitors. All employees have equal opportunities of constantly improving their performance and contributing to their workplace. Read more about "work-out" and "best practices" at GE.

- The contract between the company and its employee is not the perceived lifetime employment that leads to complacence, but the promise of personal and professional growth that pushes people to be their best. Each department rents the employees, but it is the company that truly owns them.

- 360 degree evaluation with equal consequences across the board is very important. Smiling up and kicking down should not be tolerated.

- People must be rewarded with both the pocketbook AND the soul. Take care of your A players, and do not waste time getting Cs to be Bs - lose them early and you will do everyone a big favor.

- There are 4 types of employees, based on the combinations of whether they meet the targets (T) and whether they share your values (V). [+T+V] is an easy call, so is [-T-V]. [-T+V] gets a second chance, preferably in a different environment. [+T-V] is the hardest to deal with - they should be removed, because they will fail to deliver in the long term.

- Managers promote stability while leaders press for change, and every good organization needs both.

One good thing in a disappointing day for LGBT

Today the NY state senate voted down gay marriage 38-24. I'm ashamed to live in New York City, an establishment that shows so much promise but today has failed to deliver. But I do hope that this amazing speech, although did not win us the bill, will make a difference in some people's opinions. The message is powerful, because it is the undeniable truth that was flawlessly delivered - an epitome of motivational speech.

So much for consumer-driven health care!

Today, I was curious about how a hospital in New York performs compared to the national average, so I went to Center for Medicare and Medicaid Services (CMS) website, which hosts resources on hospital quality initiatives and, of my interest, Hospital Compare. According to the description on the website...

"Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. On this site, the consumer can see the recommended care that an adult should get if being treated for a heart attack, heart failure, or pneumonia or having surgery...The HQA effort is intended to make it easier for the consumer to make informed healthcare decisions, and to support efforts to improve quality in U.S. hospitals. The major vehicle for achieving this goal is the Hospital Compare website."

Reading this paragraph starts to turn me off a little bit, mostly because the part omitted (in the ...) contains terms like "30-Day Risk Adjusted Death and Readmission measures." What does that even mean? Adjusted how and for what? How would a layperson fully understand what that means?

But OK, sounds like a good initiative. Let's give the Hospital Compare website a try.

Well, as of 12/1/09, the website cannot be found! The only other somewhat acceptable alternative is to download data for past quarters to view on your computer. I went ahead and downloaded the zip file for the latest preceding quarter. The file consisted of a complicated PDF file giving legends to possibly the many abbreviations in the database which requires Microsoft Access to view. I do not have Microsoft Access but to give you a glimpse of how complicated this dataset may be, let's take a look at part of the legends listed in the PDF file...

"There are fourteen tables in the Hospital Compare database.

1) dbo_vwHQI_FTNT

2) dbo_vwHQI_HOSP

3) dbo_vwHQI_HOSP_MSR_XWLK

4) dbo_vwHQI_PCTL_MSR_XWLK

5) dbo_vwHQI_STATE_MSR_AVG

6) dbo_vwHQI_HOSP_MORTALITY_READM_XWLK

7) dbo_vwHQI_STATE_MORTALITY_READM_SCRE

8) dbo_vwHQI_NATIONAL_MORTALITY_READM_RATE

9) dbo_vwHQI_HOSP_HCAHPS_MSR

10) dbo_vwHQI_STATE_HCAHPS_MSR

11) dbo_vwHQI_US_NATIONAL_HCAHPS_MSR

12) dbo_vwHQI_HOSP_MPV_MSR

13) dbo_vwHQI_STATE_MPV_MSR

14) dbo_vwHQI_UA_NATIONAL_MPV_MSR"

To be fair, at the beginning of this PDF legend file, the disclaimer reads...

"This functionality is primarily used by health policy researchers and the media... For information about hospitals in a particular geographical area, you should use the Hospital Compare tool instead of downloading the data."

I think it's fair to say that it is out of the question that the underserved patient population will be able to navigate this set of data, considering the fact that they probably don't even have a computer. But consider a college-educated, middle-income family - they will probably have a computer, and access to the internet, and maybe acrobat reader, but will they have Microsoft Access? I don't use it enough to own it, even as an economics major in college. But don't even mind that, how can we expect a college-educated, middle-income person to navigate this monstrosity of a dataset? I'm hoping the Hospital Compare tool/website is easier to navigate and more readily available.

I think this goes to show that free flow of information in health care has a long way to go before the market can become somewhat efficient and patients can make truly informed decisions, because even an effort, like this one, made specifically to help inform consumers, so far isn't informing me anything, because I don't get to see the data. All it's doing is confusing me with abbreviations and Greek terms that are poorly-defined.

The website is set to for maintenance on December 17 - will check back at that time, but until then, I'm disappointed.