Monday, August 17, 2009

Question for Whole Foods boycotters

Let me get this straight:

1. Whole Foods pretty much treats its employees exactly the way liberals want a company to*. (Please don't give me a link to any page that quotes the union organizers' words as gospel and accepts them uncritically.)

2. The CEO of Whole Foods writes in the New York Times that he doesn't believe in single-payer health care and essentially doesn't think the Obama plan will work.

3. Insisting that the CEO has a right to express an opinion, which he does, and you have a right to boycott, which you do, y'all are boycotting Whole Foods because their CEO wrote things you don't like, isn't standing with Obama, or however you choose to phrase it. Instead, you're shopping at farmer's markets (best option), Trader Joe's (second) or some supermarket that pays minimum wage but has a CEO who is smart enough not to piss off the "disagreement is treason" liberal establishment.

4. I guess my question boils down to this: Y'all are boycotting because the CEO spoke out against single-payer health care, right? And single payer health care has the government acting as the sole health insurer for the entire country.

So, if you get your single payer health care, and you're not happy with your insurance, who are you going to boycott?

CC
who, all that said, really likes what Returning has to say about "Death Panels. CC had never really understood what people meant by that term and had assumed something more reasonable albeit still unpleasant.

*If you're about to make a joke in my comments about how you're boycotting Whole Foods because you never shop there because it is so expensive, consider that providing free health care for even part time employees ain't cheap. If you're not willing to pay higher grocery prices to shop someplace that gives this health coverage, pays a living wage, etc, why are you fighting for legislation that would but these expenses on your grocery and tax bill anyway?

84 comments:

Bill Baar said...

Re: Death Panels: HR3200 and the Stimulus package create panels to drive protocol based Medicine as a step towards cutting costs. HR3200 is billed as a cost reduction measure. The Panels are there. I know a guy on one. They're building Protocols. They're well intentioned fellow. All Academic docs... that means big egos too. There is no Mechanism to protest these algorithms. No patient bill of rights from the HMO era. As you point out, there is no way to boycott single payor. What the panel says is your treatment protocol, is going to be it. Add in NHS style Quality of Life Years as Zeke and Cass have come out in favor off... well, you end with Death Panels. (Considering so many Chicago guys involved here, you'll also get a way to bribe yourself onto a different protocol path too).

Re Whole Foods: Consider Walmart who has come out in favor of Obama's overhaul. The Administration has done this the Chicago way: bring in the special interests and cut deals. Walmart's gotta see the potential for administering what ever emerges through it's clinics and drug programs. So has Pharma... it's employers who offer good benefits now who get stiffed. The primiums they've offered employees will get slashed.

There are far better bills out there.

Real Reform in my opinion cuts the archaic employer benefit for a portable system. Real reform recognizes we no longer live in traditional Families so insurance that includes a Family benefit is nonsense.

A straightforward tax credit for health care is the best way to go. Poor get a subsidy. Everyone free to buy insurance from an insurance industry free to see accross states.

That would be a Liberal system.

Not what Liberals have proposed which is a nasty authoritarian mess vesting power in the hands of panels.

James Andrix said...

I don't know anything about the health care plan, but I expect it would not direct most of the costs for low income worker's coverage onto those workers or their employers. Those costs would be subsidized by high-income people. Otherwise it's just a hideous regressive hospital tax.

Whole foods should get cheaper.

PG said...

I don't know what you're talking about with single-payer, since neither Mackey's WSJ editorial nor the proposals that have passed committees in the House and Senate are single-payer. Obama said a long time ago that he wasn't going to push single-payer because he knew it wasn't politically viable.

I think people partly are reacting to the WSJ's presentation of Mackey's ideas. Referring to "ObamaCare" is somewhat inflammatory. There is no such thing -- unlike the Clinton White House, in which Mrs. Clinton got together with some folks, came up with the plan, and presented it to Congress with "Here, pass this" -- Obama has deliberately avoided stepping on Congressional toes by dictating precisely how they should achieve the goals he has set out. http://www.kff.org/healthreform/sidebyside.cfm

Given this, why refer to anything as "ObamaCare"? Unlike "Hillary Care," there is no specific plan that he has signed off on, much less crafted.

As it turns out, Mackey's title for his piece was simply "Health Care Reform," and the WSJ editors (whose political leanings you might guess) changed it to "The Whole Foods Alternative to ObamaCare."

However, Mackey also created some hostility by opening with the Thatcher quote. What, precisely, is he calling socialism? Note that Thatcher herself was PM in a country that does have not only "single-payer" (government ultimately responsible for all citizens' health insurance), but also government-run hospitals and health employees.

(This is distinct from the American form of "single-payer for the elderly," i.e. Medicare, in which the government pays for but does not directly provide care. Moreover, the federal and state governments have increasingly moved Medicare, Medicaid and CHIP recipients from fee-for-service to HMOs -- I used to work for an HMO that specialized in government beneficiaries.)

What Thatcher wanted for the UK is something very like what the main Democratic reform proposals would give us: health care providers in the private sector caring for citizens, most of whom have their insurance through employment but some of whom will be covered by government. Thatcher's biggest gripe with the NHS was that she felt it had become a boondoggle to its employees, with no competition to incentivize them to do well, and a huge number of employees who could put political pressure on the government to keep upping their salaries.

PG said...

Moreover, Thatcher's own party has defended Britain's NHS for the last few years. They're even uniting with the current Labor government to defend the NHS from false claims made about it by Americans. The idea that the NHS engages in a kind of passive eugenics by deeming the disabled to be unworthy of treatment, for example, is particularly ludicrous.

Mackey's editorial participates in such misrepresentations.

Even in countries like Canada and the U.K., there is no intrinsic right to health care. Rather, citizens in these countries are told by government bureaucrats what health-care treatments they are eligible to receive and when they can receive them. All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments.
At Whole Foods we allow our team members to vote on what benefits they most want the company to fund. Our Canadian and British employees express their benefit preferences very clearly—they want supplemental health-care dollars that they can control and spend themselves without permission from their governments. Why would they want such additional health-care benefit dollars if they already have an "intrinsic right to health care"? The answer is clear—no such right truly exists in either Canada or the U.K.—or in any other country.


This is imbecilic. Just as my health insurance doesn't cover every possible health expenditure under the sun (I don't, for example, have an eye care benefit), nor does the National Health Service. It is standard for Britons with good jobs to have supplemental insurance to "top up" the government coverage, thereby allowing such employees to access services that the government does not cover. I do the same thing with cash out of pocket to cover my eye care and if I want to visit a provider not in my insurer's network.

Inasmuch as Canada and Britain have a "right to health care," it is like an American "right to education" -- limited to a certain minimum amount, beyond which one must pay for it oneself. I went to public school for middle and high school (partly because I lived in a rural area without any private options), so my parents paid out of pocket for services that would be free at many Northern Virginia schools, e.g. college counseling and assistance with applications, prep courses for the SAT, SAT IIs and AP exams; etc. The state provided a minimum, and if my parents wanted more for me, they paid for it themselves. This doesn't mean that I must have been totally devoid of a right to education; it means that the right was constrained to a certain level.

PG said...

Finally, Mackey essentially blames people for needing health care. It is very frustrating to hear something like,
Most of the diseases that kill us and account for about 70% of all health-care spending -- heart disease, cancer, stroke, diabetes and obesity -- are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices. Recent scientific and medical evidence shows that a diet consisting of foods that are plant-based, nutrient dense and low-fat will help prevent and often reverse most degenerative diseases that kill us and are expensive to treat. We should be able to live largely disease-free lives until we are well into our 90s and even past 100 years of age.

Sorry, but fuck you John Mackey. My aunt was a lifelong vegetarian who never smoked nor drank alcohol and was never obese. She first had tumors discovered in her when she was 24 and died when she was 48. People get sick and need expensive health care even when they live the Approved John Mackey Lifestyle. My uncle and aunt were self-employed (he is a primary-care physician in private solo practice in a rural area; she managed his office) and a year after her death, he is still working through the debt accumulated for all of the services she needed that were not covered by insurance. He had to shut down half his practice for the last 8 months of her life because she relied on him to provide pain management, so he couldn't be away from home as much as a physician normally would be while seeing patients both at his office and rounds at the hospital.

If people who are well-educated, with above-average income and *way* above average knowledge about health, are having these problems when one of them becomes sick, there are a lot of people with fewer resources who are having an even harder time.

PG said...

As for Bill's conviction that the "Death Panels" are out there based on the existence of protocol-based medicine and "single payor," I wonder why there aren't currently such panels for Medicare and the VA. Consider that Medicare is in fact single-payer health care for senior citizens: the government insures every American over 65. Ditto government care for military veterans (who, unlike Medicare beneficiaries, have government-run hospitals). The government already has a Medicare Payment Advisory Commission. Even the National Review editorial board has scoffed at the idea that the Death Panels Are Coming:
To conclude from these possibilities to the accusation that President Obama’s favored legislation will lead to “death panels” deciding whose life has sufficient value to be saved — let alone that Obama desires this outcome — is to leap across a logical canyon. It may well be that in a society as litigious as ours, government will err on the side of spending more rather than treating less. But that does not mean that there is nothing to worry about. Our response to Sarah Palin’s fans and her critics is to paraphrase Peter Viereck: We should be against hysteria — including hysteria about hysteria.

PG said...

Everyone free to buy insurance from an insurance industry free to see accross states.

Ah, yes, I tried that one. When I lacked insurance for several months (gap between finishing school and starting a full-time job with benefits), I looked online for a policy I could afford and found one that would cover me for $1000 for six months. It was called "Golden Rule" and was a product of United Health Group, which I figured should be fine (my then-fiance's employer-provided health care also came through UnitedHealth, and it was pretty good). When I put in my NY address, however, the website said I couldn't buy the insurance because it wasn't sold to NY residents. Huh. So I put in my TX address, and it went right through.

As it turned out, the reason the policy couldn't be sold to me in NY is that NY has minimum requirements for what insurance must cover, while TX does not. I found this out when I tried to get the most basic of preventive care for a woman: my annual pap smear and breast exam. The doctor's office called me back and said that my insurer was refusing to pay for the brief appointment because my policy didn't cover such basic physicals. "Oh, what do they cover? Like emergency care if I get hit by a bus?" The doctor's office said, Um, probably not, this seems to be a policy that just covers hospital room and board if you need to be hospitalized. You'd need to pay for the doctors' examining you, any procedures or treatments, etc.

In other words, I paid $1000 for six months of basically useless insurance. I would have been better off going completely uninsured and just paying out of pocket (which is what I did for my physical and prescription medication).

This is the kind of awesome opportunity that the folks opposed to state regulations that limit the ability to sell insurance across state lines are trying to offer us.

Joel Monka said...

Just wanted to let you know I quoted you- with attribution and link- in comments at "Aside from the Obvious".

PG said...

Real Reform in my opinion cuts the archaic employer benefit for a portable system. Real reform recognizes we no longer live in traditional Families so insurance that includes a Family benefit is nonsense.

A straightforward tax credit for health care is the best way to go. Poor get a subsidy. Everyone free to buy insurance from an insurance industry free to see accross states.


Yes, in a good Liberal's system, those who had a pre-existing condition would have to find an insurance company willing to cover them at a price that their tax credit would cover. Liberals are all about screwing over those who were less fortunate by the luck of the draw -- and unlike Mackey, I don't believe that pre-existing conditions are just due to people's being bad and irresponsible.

Getting rid of family coverage and treating all people like discrete, unrelated individuals does sound like a conservative's caricature of what liberalism is about.

Desmond Ravenstone said...

Back to the issue of the boycott...

A boycott is an act of protest. Protest is only effective if you have specific demands/goals for change. What are the demands or goals of the Whole Foods boycotters? Force the CEO to "see the light" about single-payer health care and/or Obama's plan(s) for reform?

Not bloody likely.

Besides, our goal is affordable health care for all. That might come from a single-payer system, but it could also come from some other scheme. I've long been a "heretical progressive" so i'm not ashamed to say that the Heritage Foundation's proposal to take regulation from the states to the Federal government, thus creating a single market where all insurance companies could compete and thus drive down premiums and other costs, makes some sense to me. Obviously, there's a lot more that would need to be done (ie, fewer big hospitals and more local level clinics providing preventive care) but we should be willing to consider all options, regardless of whether they come from the "left" or the "right".

And to that end (and coming full circle) I don't see the point of trying to browbeat the CEO of a progressive company into touting a so-called "party line" by punishing the folks who work for him. Better to listen to what he has to say, and come away with a deeper appreciation of the issue from the perspective of someone who has succeeded in putting his values into action.

SC Universalist said...

I confess that to my eyes, the snark has pretty well covered whatever point you were actually trying to make (unless snark was the point - I know it is for those in the entertainment political commentary buisness).

Bill Baar said...

PG...Medicare and VA use protocols from a number of places... they don't typically write them.

The problem with HR3200 and the Stimulus bill is for the first time we have Protocols and Algorithms linked explicitly to cost containment. (Note the HIT panels goal of implementing efficiency metrics by 2015.)

VA has a way to protest if care is denied. Medicare has variety.

Plus we've got Zeke and Cass out there writing about NHS's quality-adjusted life year (QALY) which would add age as a factor now in treatment decisions.

Centralized power into the hands of guys jabbering about efficiency and complete life values... creepy stuff...not very liberal.

Chalicechick said...

Snark free minimalist version, plus a few additional points.

1. Whole Foods is a very liberal company by any reasonable standard. To boycott them because of something their CEO wrote in a newspaper is silly and shortsighted, even if you think he is wrong, which I do.

2. The boycotters will almost certainly replace their grocery shopping at Whole Foods with grocery shopping someplace that doesn't treat its workers as well.

3. As Andrix points out, this might not apply to poorer people, but my general impression is that if you're complaining that Whole Foods is too expensive, yet want employers to treat their employees the way Whole Foods does, there's some cognitive dissonance going on. The only other grocery store to make Forbes' list of Best Places to work is Wegmans, and they also are an upper-middle-class supermarket not known for low prices. Paying grocery clerks a living wage and giving them healthcare is expensive.

4. I find the "with us or against us" attitude expressed by the boycotters really freaking creepy. Again, I don't agree with what the Whole Foods CEO had to say and PC has some reasonable criticisms of his facts, but the opinions he expressed were fairly mainstream ones. It really scares me when groups move toward marginalizing the moderates.

Like what Mackey said or don't, he wasn't calling for Genocide. He was presenting some not-particularly-radical ideas. For liberals to boycott an otherwise good company because the CEO had a different idea and perhaps expressed it poorly makes me wonder if the folks in question really have any respect for dissenting opinons and different ideas at all.

CC

Ps: On "Death Panels." As I understand the concept, Death Panels are something the insurance companies already have, so I'm not sure what all the fuss is about, other than political gamesmanship.

I don't particularly trust the government to have my best interests at heart, but I certainly don't trust them LESS than I trust an insurance company.

Chalicechick said...

Err.. PG has reasonable criticisms.

Bill Baar said...

The gamesmen ship on death panels is a Federal set of them from which there is no appeal versus the thousands of insurance plans we already have.

This whole debate is about power and where we vest it. That's really the ongoing American political debate.

Chalicechick said...

Theoretically, you have lots of choices, but if your insurance company turns you down when you ask for expensive surgery, it's not like another insurance company is going to want your business, or, at least, they will refuse to pay for your surgery for your pre-existing condition.

Again, I fail to see how this is any better than getting the same treatment from the government.

CC

PG said...

For the record, I'm not in favor of boycotting Whole Foods based on Mackey's op-ed, but most of the people who shop at Whole Foods also can afford to shop at farmer's markets and other places for their organic/local/I-feel-so-close-to-the-earth groceries. Farmer's markets support the local agricultural economy without using government subsidies (the subsidized crops like corn and soybeans are a minimal part of what's sold at markets) and reduce the environmental impact of shipping food from Chile (because WFM is a full-service grocery, most of its products will be coming from a distance). So let's not assume a boycott is self-defeating for the bobo lifestyle.

Also, I think Matt Yyglesias had a reasonable point about how CEOs leverage their success as businessmen in order to be treated as "sages" on political issues. An anonymous Joe who had submitted the same op-ed to the WSJ (still using Whole Foods as an example, but not referring to himself as heading it) wouldn't have gotten it published. If they do that, they'd better be prepared for politically-motivated pushback at the base of their power, i.e. their businesses.

PG said...

CC,

If you're worried about people being silenced from expressing their ideas, consider how Bill's assumption that anything academics wrote in a theoretical capacity, if those academics become advisers to a president, must mean that the president has signed onto their academic papers, will affect people's willingness to explore ideas and a politician's willingness to have advisers who have dealt in controversial areas.

I am a lot more troubled by the likelihood that the next generation of Cass Sunsteins and Ezekiel Emanuels will be fearful of discussing controversial ideas, than I am about CEOs losing their incentive to write WSJ op-eds on topics in which they frankly have no special knowledge (if Mackey had written a piece about minimizing waste in the food shipping process, I'd have a lot more respect for his authority).

Bill Baar said...

The Government is writing Treatment Protocols and enforcing them through Electronic Med Systems. People writing these things are looking at UK style criteria which will include age as a factor. (Google quality-adjusted life-year).

You can get denied reimbursement from your insurance company because your treatment wasn't part of your benefits package. You can get denied insurance because of pre existing conditions.

Too have a single payor system though, or a Gov written Panel that becomes the defacto practice standard, which offers treatment to one patient, and denies treatment to another based on QALY standards is a poor direction to go in... that's very different than the system we have now.

You buy insurance and each and every policy holder with the same benefits package gets the same benefits.

There are a lot of reforms to be made to make insurance affordable and available. HR3200 and the Recovery Act implement none of them. They are cost control bills that put price controls on the system via protocols and will reduce demand for health care.

They don't build supply of health care services to meet growing demand.

Obama says we can't afford to do that.

It's a very different way of viewing problems. It's growth vs containment.

Chalicechick said...

I don't have any illusion that Mackey was silenced just because he was criticized. I don't think one can effectively silence the CEO of a major corporation who choses to talk.

I just find the apparent desire to punish him disturbing.

CC

PG said...

Bill, I majored in bioethics. I've actually read Cass Sunstein and Ezekiel Emanuel rather than relying on Sarah Palin's selective quotation of them. I know what a QALY is, and I also know that Dr. Emanuel has *criticized* using them: "Ultimately, QALY allocation systems do not recognise many morally relevant values -- such as treating people equally, giving
priority to the worst-off , and saving the most lives -- and are therefore insufficient for just allocation." (Govind Persad, Alan Wertheimer, Ezekiel J Emanuel; "Principles for allocation of scarce medical interventions," Lancet Jan. 31, 2009).

Cass Sunstein hasn't even been talking about QALYs in allocation of health care, but rather with regard to his specialty (administrative law, of which he is an excellent professor of an otherwise exceedingly dull subject), with regard to the cost-benefit analysis that Reagan made mandatory for environmental, health and safety regulations. Even in this context, Sunstein also has been skeptical of QALYs: "when mortality and morbidity gains are converted into monetary equivalents, QALYs are
insufficiently informative." (Sunstein, "Lives, Life-Years, and Willingness to Pay," 104 COLUM. L. REV. 205 (2004)).

If you're going to hang your criticism of health care reform on Dr. Emanuel's being some kind of scum, you might do the man the courtesy of reading him instead of getting your talking points from Palin. This kind of ignorant character assassination makes me sick. Ezekiel Emanuel's own sister Shoshana has cerebral palsy, yet he's being charged with wanting to deny care to kids with CP. The very first article of his that I read was a criticism of those who advocate legalizing physician-assisted suicide -- he has loudly opposed such euthanasia for over a decade. Yet he's being charged with supporting "death panels" to hurry people into their graves. Do you feel no shame about making such claims without even reading Emanuel's work? You are saying that by simply discussing an idea like QALYs, Emanuel and Sunstein must be endorsing it, even though they've explicitly *rejected* it.

Disgusting.

There are a lot of reforms to be made to make insurance affordable and available. HR3200 and the Recovery Act implement none of them. They are cost control bills that put price controls on the system via protocols and will reduce demand for health care.

Specifics? Please cite either the subsections or the pages of the bills to which you refer.

They don't build supply of health care services to meet growing demand.

Bullshit. For just one example, re-read Division C, Title V, Subtitle D of HR 3200. You have actually *read* this bill, right?

Bill Baar said...

Oh PG, it's you bioethicists who spook me a bit...I don't want to delegate the powers-to-decide with protocols to you guys.

CC readers can google Zeke and Cass. I've linked to them in my own blogs. Write Zeke and ask him what are those 2015 efficiency standards he has in mind for the HIT panel. Write Perlin..Halamaka... these guys shouldn't be playing behind the scenes here.

My reforms? Simple principles which should have been clear to you.

Let me repeat.

Break the employer based Health Insurance system.

Every individual should have access to affordable insurance.

Indigent should get a tax credit from the government to assist. Heatlhy Americans Act a step toward this.

No more health insurance sold as single or family options. That no longer makes sense in this day and age with all sorts of family configurations that come and go...

nothing disgusting...

Bill Baar said...

Bullshit. For just one example, re-read Division C, Title V, Subtitle D of HR 3200. You have actually *read* this bill, right?

You mean this? http://thomas.loc.gov/cgi-bin/query/F?c111:1:./temp/~c111AJiV4b:e1196140:

What's the point?

Desmond Ravenstone said...

Bill:

As good as your "simple principles" sound, there is still the question of how to put them into practice.

So, how would you do that?

It's easy to stand on the sidelines and criticize someone else's proposals. Coming up with your own is quite another story.

Short of that, one could look at the whole range of ideas being floated about, and see which ones make sense.

So, how 'bout it?

**********

And ... what about the original topic of this post -- the absurdity of boycotting a company providing good wages and benefits because you don't agree with its CEO on whether a particular approach to health care reform would actually work?

PG said...

I don't want to delegate the powers-to-decide with protocols to you guys.

Of course, you still haven't indicated where any of the proposed legislation calls for the protocols you have in mind.

CC readers can google Zeke and Cass. I've linked to them in my own blogs.

Yes, apparently without actually reading them in full yourself and instead quoting others' commentary on them. (Quoting others without remembering what they said, since Gaulte notes that Emanuel's 2009 Lancet article recommended the "complete lives" system, *not* QALYs, yet you're still going on about QALYs as the crux.) Great analytical work!

nothing disgusting...

What I called disgusting was your character assassination of Sunstein and Dr. Emanuel, not your policy preferences. But keep up the misdirection, it will work on some people... though incidentally, your policy preference of making no effort to reduce costs will keep health care's percentage of the GDP climbing on its same steady pace to be

You mean this? http://thomas.loc.gov/cgi-bin/query/F?c111:1:./temp/~c111AJiV4b:e1196140:

What's the point?


After dozens of references to how terrible HR 3200 on your blogs and in comments to others' blogs, you proudly ask "What's the point?" of actually reading the legislation you're criticizing. Well, that answers my question of whether you can feel shame.

Bill Baar said...

Desomnd: I would start putting my principles into action by holding Congressional Hearings on health care. Something not done yet. I would hold hearings on Healthy Americans Act. A plan Obama has called too radical.

PG: Read my blog. I dicuss the panels, name them, talk about their members. As for Zeke and others. I've sat in a room and watched a few of them take worse than what I've dished.

They can take it.

But do check my blog. UU Updater had many of the same points you made and I went through them one by one there.

PG said...

bill baar,

Where have you seen Dr. Emanuel be told to his face that he favors "NHS style Quality of Life Years," as you claimed in your first comment, and he's "taken it" and said, "Why yes, I am"?

I've already read through your blog, which is how I know you're quoting Emanuel out-of-context (by assuming that any point he analyzes must be one with which he totally agrees -- wow, you really don't get how academic articles work) and depending on Gaulte's analysis of the Lancet article. If you have specific posts that you think I somehow missed because I'm still pointing out that you clearly don't understanding what Emanuel is recommending, put up the links and I'll be happy to read them.

Simply saying "look at my blog" over and over again is a good way to drive up your hit count, but not really specific enough to be convincing, especially after I *have* looked at your blog "Bill Baar's West Side" and found it devoid of the very word "panels" with reference to health care reform (and not used at all since Dec. 2008). Tell me where the legislation proposes these "panels," and who is the guy you know who is on one. As with your claims that the Rezko trial would Bring Down Obama, or that release of the police transmissions of the Gates incident would reveals that Gates was some out-of-control madman, you're once again relying on vagueness, innuendo and a complete absence of specifics to poison people's minds.

Bill Baar said...

Not E, but some of the other players on the HIT panel. I didn't dish it out to them but I watched Congressional Dems dish it out.

Simply saying "look at my blog" over and over again is a good way to drive up your hit count, but not really specific enough to be convincing, especially after I *have* looked at your blog "Bill Baar's West Side"....

Got to my UU blog http://pfarrerstreccius.blogspot.com That's where I've done most of my health care blogging.

My hit count doesn't to anything for me. I'm not making any money at this. It's more courtesy to CC. Email me if you like and let me know who you are if you want. I'm perfectly happy to talk one on one too...

Bill Baar said...

Footnote: A good story by Chicago's Mary Laney on Michelle Obama's Urban Health Initiative with U of C Hospital. An initiative that payed her plenty, dumped patients, and got U of C and Joint Commission citation for it all; besides costing the Director his job. Imagine what this crowd will do with the whole Health Care system.

PG said...

bill,

I find it very difficult to follow your line of thought. You assert that Emanuel favors QALYs, then point me to your blog, where you quote Gaulte saying that Emanuel actually favors "complete life." You assert that "As for Zeke and others. I've sat in a room and watched a few of them take worse than what I've dished. They can take it." I ask when and where this occurred, and you say, "Not E, but some of the other players on the HIT panel. I didn't dish it out to them but I watched Congressional Dems dish it out." I ask for links to the specific posts that you claim will answer my questions (where does HR3200 call for these death panels and protocols? who is the guy you know who is on one? where has Cass Sunstein come out in favor of QALYs?) and you say that out of courtesy to CC (whom I've NEVER seen object to people's posting on-topic links) you won't do that.

I actually haven't had the experience of Chicago pols being so much more slick and slippery than those elsewhere (hi, West Virginia!), but you certainly seem to have picked up some tricks.

Your post on Obama's death panels, which is mostly an extended quote of sock-puppeteer Lee Siegel's Daily Beast piece, indicates for the nth time that you don't understand how academic writing works and moreover will swallow any claim someone makes about a Chicago cabal so long as it is derogatory to Obama.

(1) Cass Sunstein is not a "disciple" of Richard Posner. As is true of many UChicago law folks, both are interested in the law & economics movement, but they come to different conclusions while using some of the same tools. Posner, Epstein and other conservative/ libertarian faculty members still adhere to 1970s, Milton Friedman economics, while others are more inclined to apply newer forms of economic analysis, particularly behavioral economics that, unlike classical economics, focuses on real-life irrational behavior rather than "assuming rationality." Though in fairness to Posner, he is slowly and recently coming to give more credence to behavioral economics, while his erstwhile soulmate on the 7th Cir. (Easterbrook, also a conservative law & econ guy) continues to hold the classical line.)

(2) Posner's remark about Holmes's possible prescience in "The Essential Holmes" was not in praise of Holmes, but rather pointing out that the Progressive enthusiasm for eugenics in the early 20th century is echoed in some progressives' fighting for legal doctor-assisted suicide today. Again, discussing an idea is not the same as endorsing an idea. If you can't get this, please don't try to read academics. I have read so many academic articles that were essentially long discussions of ideas that the author never actually endorsed, but simply wanted to throw up in the air and juggle.

(3) The idea that Obama was in with the whole law & econ crew at UChicago is utterly ludicrous. Richard Epstein, Posner's rival as current leader of the movement, has given interviews and written a string of articles (mostly published in Forbes) pointing out that Obama does not adhere to that movement (which is essentially conservative/ libertarian) and that Obama is a liberal who will enact policies on an ideological basis even if they fail Epstein's cost-benefit analysis.

PG said...

I'm sorry, but neither you nor Lee Siegel know what you're talking about here. If you don't believe me about Chicago Law dynamics (and I admit I didn't go there, although I met and spoke with both Posner and Epstein in the course of their attending debates at my law school, and sat in on one of Sunstein's classes when I was considering Chicago for law school), ask someone who's a student or alum. They will fall down laughing at the idea that Obama's thinking was shaped by Posner.

It's just another example of your using innuendo to smear people by association instead of forthrightly criticizing what those people are doing themselves. Kind of amazing to see Posner as the new Bill Ayers, though. I don't think the legal precincts of the conservative side -- like the Federalist Society -- will let that one go unchallenged.

Bill Baar said...

Comment over on my Blog PG. You found the links. Zeke wrote in favor of a Complete Live Systems. A sort of modified QALYS that sweeps in the young too.

I referenced the HIT panel members as the guys charged with implementing "efficiancy" standards. Zeke is on that panel by the way.

Like I said, commen over there and I'll engage all you want.

We can email the HIT guys and FOIA their efficiency stuff....

which must be definiely inpired considering Obama's partnership with God proclaimed before the Rabbi's yesterday... while the Prez made them listen to Deutchland uber Alles... can this story get any weirder?

PG said...

Imagine what this crowd will do with the whole Health Care system.

Bill, that's just inherently illogical. If "this crowd" is put in charge of "the whole Health Care system," there is no option to move people out of the bit that they are overseeing, which is essentially what the Urban Health Initiative did in an effort to relieve overcrowding at the UChicago Med Center's ER. If they're in charge of "the whole Health Care system," then there's no local clinic or weekend-hours primary care physician outside their jurisdiction to whom the patient with non-urgent needs can be sent -- it's all in their jurisdiction. Indeed, a WSJ opinion piece by a physician last September pointed out how Obama's health care reform ideas ran *counter* to what his wife had started at UChicago. The physician, being a fellow at the American Enterprise Institute, praised Mrs. Obama's focus on community health clinics as a more efficient use of health care dollars, while criticizing Mr. Obama's work as a legislator that the op-ed writer felt made collaboration between clinics and hospitals more difficult.

I don't mean to be rude, but do you actually think through these comments before you post them? You seem like an overall intelligent guy, but you don't treat commenting here as something into which you should bother putting any effort.

As a factual matter, the South Side Health Collaborative that Mrs. Obama started in 2005 seems to have been quite successful. It was its expansion, particularly after she'd gone on leave in 2007 to work on her husband's campaign, that has been more controversial. Also, the 2006 fine for patient dumping was for a 2002 incident -- when Mrs. Obama had just been hired and had not even started any initiatives.

But let's not allow details to get in the way of smears, because that wouldn't be the Chicago Way, eh?

Bill Baar said...

A kid nearly lost his face after a pit bull attack and U of C ER dumped him. It's been all over the papers in Chicago.

The Urban Initiative is Michelle's program. She was paid $300k for a part time job to sell it to the south side.

http://www.acep.org/pressroom.aspx?id=44294

I'll post on my blog later and we can carry on the dialogue over there PG.

PG said...

A kid nearly lost his face after a pit bull attack and U of C ER dumped him. It's been all over the papers in Chicago.

Yes, Bill, it was in an article about that incident (in which the poor child's upper lip was torn off, which is not quite the same as "lost his face") that I read about the 2002 case I just mentioned. I don't understand how the administration of a program over a year after Mrs. Obama left UChicago is nonetheless her responsibility, particularly how it is administered at the ground level of the ER. According to the Tribune, the kid was insured, through Medicaid, which is exactly the government health care program that UChicago touts as where they do lots of work for low-income people. So this story makes your point about the evils of "ObamaCare" ... how?

Chalicechick said...

I wonder if they would have mentioned the breed of the dog if the kid had been bitten by a cocker spaniel.

CC

PG said...

Bill,

A sort of modified QALYS that sweeps in the young too.

No, it's not QALYs at all. It's practically the reverse of QALYs. The whole point of Quality Adjusted Life Years is to assess how much "good" life someone is likely to have in front of him. It is therefore controversial for trying to evaluate what constitutes "quality of life," which almost inevitably will discriminate against the disabled, as one sees in Peter Singer's pro-QALY analyses. QALYs applies to the old, young, everyone.

The whole point of Complete Life is to take into consideration how much life -- of whatever quality -- someone already has had, thereby removing the qualitative, subjective element that makes QALYs so difficult and looking solely at who's already gotten theirs.

It's simply shoddy analysis to pretend that the two are the same, especially after Dr. Emanuel specifically declared QALYs "insufficient for just allocation."

while the Prez made them listen to Deutchland uber Alles... can this story get any weirder?

I hope you are aware that the melody for Das Deutschlandlied is by Haydn, dates to 1797, and is also used in the English-speaking world for the hymns "Glorious Things of Thee are Spoken" and "Not Alone for Mighty Empire." So if you're going to claim that the President's hold music was "Deutschland Uber Alles," I assume you can verify that it actually had the words to that song, and not just the tune?

Bill Baar said...

Look at Zeke's Complete Lives Graph and Ages v P of Care.

That speaks volumes.

Michelle Obama designed the program at U of C. It's her baby.

Playing Deutchsland Uber Alles to 1000 Rabbi's on hold, whom you're trying to persaude to your side, as about as odd a things as I can think of.... it's right out of the Onion... and I don't think any of those Rabbis gave a hoot about Haydn...

I've got posts on it PG... post over there.

We're exhausting CC's goodwill with this back and forth just between us.

SC Universalist said...

I'm sure that if CC was tired of this, she would say so.

Chalicechick said...

SC Universalist is correct. And I know as of yesterday theCSO was still following the conversation too.

TheCSO said...

I am still following this conversation, and I really wish Bill Barr would just post the details PG has asked for rather than just saying "go to my blog". Really, could we just have at least Wikipedia-grade references here?

Bill Baar said...

Details on Michelle's Urban Initiative program?

The Suburban Emergency Management Initiative has a pretty good wrap on the U of C program http://www.semp.us/publications/biot_reader.php?BiotID=602

This landed U of C tentative accreditation from the Joint.

What other specifics do you need? Will try and be as responsive as I can as long s anyone interested.

Be specicfic with the specifics though as it's hard to wade back through the comments...

But ask away... Chicago Observer has another column on how Illinois Democrats have been shaking down Illinois Hospitals. Can give you that link too.

Bill Baar said...

Here's Zeke's article Complete Lives System. http://www.ncpa.org/pdfs/PIIS0140673609601379.pdf

It's a pdf. I think it's an appalling document as I've noted on my blog.

Zeke sits on the HIT committee. Part of their 2015 goals are efficiency measure that would be implemented on every providers electronic medical records system.

Giving the Government the power to set protocols for how Medicine will be practiced, coupling it with "efficiency standards", and making comments on our Health Care system being broken becasue of it's supposedly "high costs" sets up an extremely dangerous senario.

The HIT members aren't monsters. I don't think Zeke is a monster. I know one of the members personally having worked for him for many years...implementing protocols and standards... but these are all ambitious guys too.

Giving them this kind of power not a good thing. Especially with Zeke out there publishing Complete Lives Graphs showing the P of intervention against age.

so, what do I need to respond to next?

I intend to write to Halamka at HIT and ask for the efficiency standards. He blogs over at Geek Doctor http://geekdoctor.blogspot.com/

Comrade Kevin said...

We are very good at cutting off our nose to spite our face and we're also good at proposing boycotts to the point that most people ignore them altogether. We might as well belong to "Boycott of the Week Club".

PG said...

Here's some places where I've asked specific questions (found by doing a "find" on this page for question marks):

Bill: "HR3200 and the Recovery Act implement none of them. They are cost control bills that put price controls on the system via protocols and will reduce demand for health care."

PG: "Specifics? Please cite either the subsections or the pages of the bills to which you refer."

Bill's response was to tell me there was no point in actually reading the legislation he's criticizing.

PG: "Where have you seen Dr. Emanuel be told to his face that he favors "NHS style Quality of Life Years," as you claimed in your first comment, and he's "taken it" and said, "Why yes, I am"?"

Bill acknowledged that he's actually never seen such a thing, and moreover Bill seems to have retreated somewhat from his initial repeated claims that Emanuel favors QALYs, although not until well after PG's comment pointing out where Emanuel specifically rejected them.

PG summarizing some of the foregoing: "where does HR3200 call for these death panels and protocols? who is the guy you know who is on one? where has Cass Sunstein come out in favor of QALYs?"

Bill: No response to any of these questions.

PG: "So this story [about the UChicago hospital attempting to send patients to local clinics and community hospitals, in order to save money for UChicago by putting the cost on other health providers instead] makes your point about the evils of "ObamaCare" [in which costs matter for the entire U.S. health care system, not for a single academic/research hospital] ... how?"

Bill offers a link with info about the UChicago program of offloading patients, which link gives no explanation of how this has any relevance to federal legislation to reduce overall health care costs while increasing access to health care. This link moreover refers to Dr. Eric Whitaker as a "South Side barbershop physician," which has a rather derogatory racial tinge as a descriptor for what (I found upon Googling) is Whitaker's relationship to the "barbershop": he started an innovative health education program, Project Brotherhood, designed to reach low-income minority men with little formal education through the male gathering places in their communities, the barbershop, drawing them in with free haircuts so they can learn about prevention of illness and where to obtain health care.

PG: "So if you're going to claim that the President's hold music was "Deutschland Uber Alles," I assume you can verify that it actually had the words to that song, and not just the tune?"

Bill: "Playing Deutchsland Uber Alles to 1000 Rabbi's on hold, whom you're trying to persaude to your side, as about as odd a things as I can think of.... it's right out of the Onion... and I don't think any of those Rabbis gave a hoot about Haydn... "

(I think Bill's response, in its lack of an actual answer and its derogation of the rabbis as being ignorant of Haydn, is meant to be "No, I don't know that the hold music included the words, rather than just being an old tune that long predates Nazism and that is also part of the Kaiserquartett, a string quartet that's often performed and included in Muzak.")

allcarrot said...

I support a boycott of Whole Foods, not simply because of the CEO's recent comments about health care, but that fact that for me, it capped a string of actions that I find both undemocratic and unliberal.

CEO Mackey operates his company in the finest traditions of other robber barrons we love to hate. Products are overpriced, workers are underpaid. He pushes for rules and legislation that would 'broaden' (weaken) the definition of "organic" to the point where one could not be sure of what one is actually buying. He gobbles up competitors and uses his size to put smaller similar stores out of business (the Wallmart model). He is anit-union and uses similar tactics to Wallmart to keep unions from organizing. He even uses fake IDs on discussion websites to hype his company's stock, going so far as to argue with himself. While it may not be illegal, it's certainly deceptive.

COE Mackey caters to a liberal constituency, and if he choses to slap them in the face, he needs to suffer the consequences.

KitsapMan

PG said...

CEO Mackey operates his company in the finest traditions of other robber barrons we love to hate. Products are overpriced, workers are underpaid.

Robber barons' overpricing was a problem because they maintained monopolies, such that people had no choice but to pay their prices. There is nowhere in America that Whole Foods is the only grocer available. People who want to spend a lot of money in the belief they'll get good quality (personally, I'd rather get a bag of baby carrots at the 24 hour shop across the street than at WFM -- they don't go slimy as fast when they're from the 24 hour place) can do that WFM; if they're focused on saving money, they can shop elsewhere. So I don't know by what measure you're deeming the products to be "overpriced," nor for that matter by what measure the workers are underpaid. Do they make less in wages and benefits than people of comparable skill and experience in similar jobs?

Bill Baar said...

PG I'll get back to you today on the rest, but Zeke favors a Complete Live System. That's QALY's on Steriods. It assigns young people a lower probability of intervention because "society" hasn't invested much in them yet. Complete Lives would just look at their number of years in the future but Complete Lives discounts those future years because of the low investment. Look at Zeke's graph which sums it all up.

"HR3200 and the Recovery Act implement none of them. They are cost control bills that put price controls on the system via protocols and will reduce demand for health care."

The "them" were reforms needed in the health care system unaddressed by HR3200.

Easy...this bill does nothing to break an employer based benefits system. It still chains employee to employer. It is still locked into the concept of coverage for individuals and "families".

It does nothing to allow us to buy insurance accross state lines. True reform recognizes the reality of people moving from job to job, working independently, and many of us living a large part of our lives solo. True reform matches that new reality. It is based on individuals rapidly changing jobs and family configurations.

I'll pick up the rest later today.

Bill Baar said...

Footnote: Another missing reform is Tort Reform. We have a six month wait now for routine ObGyn appointments in my town for lack of providers willing to practice because of liability coverage.

PG said...

Zeke favors a Complete Live System. That's QALY's on Steriods. It assigns young people a lower probability of intervention because "society" hasn't invested much in them yet. Complete Lives would just look at their number of years in the future but Complete Lives discounts those future years because of the low investment.

I'm going to give explaining this one last shot in case your confusion is in good faith. If anyone else reading this thinks there's a better way to explain, I'd welcome your input because I seem to be failing here.

Emanuel's article, titled "Principles for allocation of scarce medical interventions," was specifically about how to allocate radically scarce resources like human organs. The article has bupkis to do with 99.9% of medical interventions, which are constrained only by time and money. My dad can do physicals and put in stents and pacemakers and hand out Lipitor prescriptions 18 hours a day, so long as patients can pay him and the pharmacist. He cannot, however, no matter how much time or money you give him, produce a viable human heart.

I assume you agree that human organs are indeed radically scarce resources. You can't just hire someone to work an extra hour to produce more, or pay a pharmaceutical company a lot of money to produce one on demand. Some people believe that allowing payment for organs would produce more viable organs for transplant, but current U.S. law prohibits such payments.

Given this situation of radical scarcity, Emanuel and his co-authors discussed what was the best system to determine who ought to get human organs as they become available. We already have a status quo system to do this, the UNOS (United Network for Organ Sharing) point system, which is discussed in the article and found defective because it includes "least justifiable principles of 'first-come, first-served and
sickest-first'; low priority given to prognosis; vulnerable to bias
and manipulation, such as being listed on multiple
transplantation lists and misrepresentation of health status;
allows multiple organ transplants, thus saving fewer lives." Would you like to defend the UNOS system as superior to the Complete Lives assessment? I haven't seen you do so yet. Is there some other system of determining who should get a human organ that you think is better? Please state what that is.

Emanuel recognizes that there are deficiencies in his preferred system for allocating radically scarce resources: "Reduced chances for persons who have lived many years; life-years are not a relevant health care outcome; unable to deal with international diff erences in life expectancy; need lexical priority rather than balancing; complete lives system is not appropriate for general distribution of health care resources."

That last point in bold is the most important for you to consider before you bring up this article as relevant to HR3200 or any other major legislation dealing with the health care system as a whole. Why are you so obsessed with Emanuel's opinion that we should change from the UNOS point system to a Complete Lives system when it has nothing to do with "general distribution of health care resources"?

PG said...

And for the last time, Complete Lives is not "QALYS on Steroids." Let me demonstrate this with an example. Suppose you have a kidney that would be equally viable for any one of three patients: Anne, a 30-year-old quadriplegic who is in otherwise great health and bids fair to live another 30 years; Ben, a 60-year-old able-bodied man who, given the kidney, also could live another 30 years remaining able-bodied; and Charles, a 15 year old whose other health problems are such that even with the kidney, he probably won't live past 35.

The QALY and Complete Lives systems would rank these candidates very differently. QALY would give the kidney to Ben, the 60-year-old, because he has just as many "life years" likely remaining to him as the 30-year-old, but his are thought to be of higher "quality" because he's not a quadriplegic nor likely to become one. Charles, the 15-year-old, probably would be ranked last under the QALY system, because he would get the fewest number of extra life years out of the kidney, and would be suffering from other ailments all the while.

Complete Lives, on the other hand, probably would give the kidney to Charles, because he's had the least amount of life of any of the three. He's only gotten to live for 15 years. Sure, he'll still have other problems after he gets the kidney, but it will get him off the dialysis machine for those 20 years he likely has remaining. Ben, the 60-year-old, would probably be ranked last (instead of first, as he was under QALYs), because he's already gotten to live through the teenage years Charles hasn't even finished, as well as the early adulthood that Anne is in the middle of.

There are problems with Complete Lives, of course, as Emanuel acknowledges. But to say that it's "QALYs on steroids" just shows that you don't know what you're talking about. If it were basically an exaggerated version of QALYs, how could it come to the exact opposite outcome?

PG said...

HR3200 and the Recovery Act implement none of them. They are cost control bills that put price controls on the system via protocols and will reduce demand for health care.

My question, once again ignored, was where in either HR3200 or the Recovery Act are there "price controls on the system via protocols"? Going on and on about how the legislation doesn't accomplish what you want it to accomplish doesn't answer the question of where the legislation says what you claim it says.

Bill Baar said...

PG, Zeke's graph is unambiguous. The probability of anyone receiving medical care is low when young, increases until the 20s then flattens and drops dramatically after age 50.

He calls it his Complete Lives System. I call it QALYS on steroids. Either way, he lays out your odds with Mathematical precision and it's unpleasant for anyone young, or old.

Not to mention he writes it in the passive voice (as do you) and it's not clear who this entity is that's making this decision. That's why with Zeke, and you, the only conclusion can be that passive player out there must be the "death panel".

Bill Baar said...

PG: HR3200 is riddled with price controls. That's why it's the AFFORDABLE Choices Act. It's going to make Health Care Affordable by holding down prices. It's going to deny reimbursement on readmissions it finds inappropriate. It's going to eliminate geographic disparities in prices. When Obama speaks, he tells us of Medical decisions under the current system where the Doc makes expensive decisions because it maximizes his payout. The Tonsil case he cite for example.

Same goes for Halmaka's work on the HIT committee with efficiency standards for the health records.

We don't see any Stimulus money going towards building new Medical Schools, Nursing Schools, no Hill Burton programs to build Hospitals.

The strategy is all on managing Demand to hold done the price, it does nothing to build supply of health care.

To eliminate hunger, we encourage production of food. To eliminate homelessness, we subsidies mortgages to build more houses.

To eliminate obstacles to health care, we ought to promote more supply of care, and this bill does exactly the opposite.

We put it into the hands of guys with graphs about how the young and the old should have lower probabilities of getting care.

Imagine graphs showing lower probabilities for the young and old to get housing and food. We would not stand for it, and nor should we stand for it in health care.

PG said...

Bill,

PG, Zeke's graph is unambiguous. The probability of anyone receiving medical care is low when young, increases until the 20s then flattens and drops dramatically after age 50.

I'm sorry that text is giving you so much trouble that you have to keep referring back to a graph, but the TEXT of Emanuel's article clearly states, repeatedly, in the title and elsewhere, that it is referring ONLY to the allocation of radically scarce medical resources like organs. He specifically declares "complete lives system is not appropriate for general distribution of health care resources." I don't know how much more clearly any human being can write anything than that, although I did try bolding it to see if that would help. I've repeatedly asked how a proposal to replace the UNOS point system for organ distribution has anything to do with general reforms of health care. You've repeatedly refused to answer, because you are determined to pretend that Emanuel's article, despite its numerous statements to the contrary, is about "medical care" generally, rather than about a tiny category of radically scarce resources.

Not to mention he writes it in the passive voice (as do you) and it's not clear who this entity is that's making this decision. That's why with Zeke, and you, the only conclusion can be that passive player out there must be the "death panel".

Bill, it's a LANCET article. Do you know what the Lancet is? It's a British general medical journal. It is not a government publication. As I've tried to explain multiple times, academic articles in bioethics often are at a highly theoretical level. I imagine that Emanuel expected the same people to administer the Complete Lives system as the folks who currently administer the UNOS points system.

You don't want to admit it because it slays your entire ZOMG OBAMA BRINGS DEATH PANELS theory, but responsible adults have been grappling with hard questions like "Who gets the kidney?" for decades now, and have created systems like UNOS to deal with it. If you think people just shouldn't talk about these hard questions at all, then I see why you have such a problem with bioethicists in general. How dare these academics actually think about stuff in advance and try to establish systems to deal with it, instead of throwing their hands up in a panic every time the question presents itself anew? Better that the organ become useless while someone spends a week dithering, than that someone (perhaps, oh noes, trained in bioethics) actually make a hard choice.

PG said...

HR3200 is riddled with price controls.

Give some examples. I could give you an example of a specific place in the bill -- cited by division, title and subtitle -- where it works to increase the supply of nurses. You give me an example with the same level of citation where there are "price controls."

We don't see any Stimulus money going towards building new Medical Schools, Nursing Schools, no Hill Burton programs to build Hospitals.

If you think that the reason some people don't have access to health care is because we don't have enough total medical and nursing schools and hospitals, you really have no clue about the barriers to access in this country.

(1) We do have a shortage of nurses in the country, which the bill addresses. It is not because we don't have enough nursing schools; it is because we don't have enough people completing nursing programs and going into the profession. The bill addresses those issues. We'd need to build more nursing schools only if the ones we already have are at or over capacity for the number of nurses they can educate. Where are these nursing schools where they're setting up trailers as classrooms for the excess students? (As many elementary and secondary public schools are doing when they don't have the money to build more physical space.)

(2) Similarly, medical schools are not overcrowded. Rather, we are hyper-selective about who gets into American medical schools. When I was applying to law school at the same time my cousin was applying to medical school, we had a completely different set of concerns. I worried about getting into a good law school, because if I went to a 3rd tier school I'd have a hard time getting a job. He worried about getting in any American medical school, because you know what they call you when you graduate from the lowest-ranked-but-still-accredited medical school in the U.S.? Doctor.

I know four people who were born in the U.S., went to college here, but didn't do well enough in their grades and MCATs to be accepted into a U.S. medical school. All of these people had higher undergrad GPAs than I did, and I went to a top 5 law school. They went to Caribbean or British medical schools and then struggled to get back into the U.S. system so they could do internships and residencies. Med school in this country is so elite that we have thousands of foreign-trained doctors coming every year. It's not because the lecture halls are overcrowded (my cousin could watch his lectures online whenever he wanted); it's because we're maintaining all U.S. medical schools as being as prestigious as the very top tier of other U.S. professional schools. I got into law school. I could probably get into a mid-ranked B school. I could never get into a U.S. medical school. (We're also importing a lot of foreign-trained nurses.)

PG said...

(3) The problem of hospitals is one of distribution. My hometown of fewer than 25-30k people has two large hospitals plus dozens of out-patient clinics where you can get a range of procedures done outside the hospital. My dad built his clinic to maximize the number of procedures he could do there. This benefits him (he doesn't have to share the Medicare reimbursement with the hospital), but also benefits the patient's health outcomes (you're much more likely to catch an infection in a hospital than in an out-patient clinic, plus the psychological impact and administrative burden of being admitted to a hospital are greater). The people in my hometown who lack access to health care lack it because they have no money and no insurance, not because there's a lack of physical capacity for their treatment. However, there are regions of the country (parts of Alaska, for example) where you have to drive an hour to get to just one hospital. But a hospital with no staff does you no good. You have to get medical professionals willing to live in these places before it does any good to build a hospital. I know it's a liberal cliche to throw money at a problem until it goes away, but you have to understand the problem first.

Finally, the stimulus bill did give billions of dollars to hospitals: to spend on improving their record-keeping. If you care about people's actually surviving being in the hospital, rather than just counting how many are admitted to hospitals, then this is money very well spent. Increased automation of notes and records is associated with a 15% decrease in the odds of in-hospital death. (It also reduces medical malpractice cases immensely by reducing the likelihood of error. Waiters at some restaurants get electronic devices while taking orders to minimize error, but doctors and nurses still scribble stuff in their indecipherable handwriting on paper charts. Almost 100,000 people die every year from preventable medical error. You can do the math on the number of lives saved and injuries avoided (a guy who gets the wrong leg amputated still *lives*, after all) by a 15% reduction in such errors.

PG said...

To eliminate hunger, we encourage production of food. To eliminate homelessness, we subsidies mortgages to build more houses.

Who's this "we"? Certainly not the federal and state governments. The government programs to eliminate hunger increase the affordability of food (through food stamps, school breakfast and lunch programs), not the amount of food produced. The government programs to eliminate homelessness increase the affordability of housing (through Section 8 housing vouchers for the private market, rent control in some cities, government housing projects), not the amount of housing that exists in America. (Indeed, while widespread rent control keeps existing housing affordable, it decreases the incentive to build new housing if that new housing also will be subject to rent control.)

Mortgage subsidies don't build new houses; they encourage home ownership. I have a mortgage and I live in a building that's nearly 50 years old. We'd still have more than enough total amount of food in America to feed everyone even if we eliminated agricultural subsidies -- it's just fatal for anyone running in the Iowa caucuses.

Bill Baar said...

I'm still tracking this if anything I've said still unclear.
-Bill

Bill Baar said...

Give some examples. I could give you an example of a specific place in the bill -- cited by division, title and subtitle -- where it works to increase the supply of nurses. You give me an example with the same level of citation where there are "price controls."

HR3200 does nothing to increase the supply of nurses. A sad omission. Google the 30 day readmission provisions in HR3200 (I don't have the section handy but it's easily found). This comes out of a NEJM article saying Medicare can save $17 Million from medically unnecessary readmissions.
There is really now science or evidence behind the way this appears to be implemented. HIT is marching along with a 10% reduction in 30 day Hospital Readmissions (necessary or not).

Why 10% reduction? Why 30 days and not 25 or 35? There is no science here. It's is strictly 30 days to cut Medicare's program price-paid by $17 million.

As Hospitals approach their ceiling here, there is a powerful incentive set up here to deny care to patients.

Strictly a cost savings move in the guise of improving clinical care. (I hope your reading Dr. Halamka and the rest of your HIT colleagues).

Who's this "we"?

We Liberals. Liberalism has always been about creating abundance. Feed the hungry, house the homeless. Pump money into food stamps, subsidize farmers so more food is grown. Pump up credit, more people get mortgages more homes built. (We have problems with over abundance but that's the price of Liberal success).

...the stimulus bill did give billions of dollars to hospitals: to spend on improving their record-keeping...

Health techno-geek me well aware of the wind fall here. The Stim Bill the health care programmer's retirement act.

The problem of hospitals is one of distribution.

Illinois Democrats have long sponsored an Illinois Health Planning Agency that certifies hospital construction. No cert, no construction. This is where Blagojevich, Rezko, and the rest of the crew were shaking down Hospitals for millions in return for certs.

The classic reason why less Government better. Hospitals should go where they see demand.

Under served areas, let the Government kick in bucks with programs like Hill Burton to build rural clinics / urban clinics.

If indigent can't get insurance, let the Government give them a tax credit to buy it.

The gaps in coverage and physical access can be resolved without resort to this massive bureaucracy of panels, exchanges, and so on that will directly involve itself in the practice of medicine through protocols and algorithms.

Med school in this country is so elite that we have thousands of foreign-trained doctors coming every year.

And the number coming controlled too... try hiring one.

No money for new Med School programs, scholarships for Docs in the stim bill or HR3200 either. Graduate more Docs, supply of Docs goes up, drives down reimbursement to docs, that's why AMA is on board. They link to keep that supply of docs tight. They think like a craft Guild.

Bill Baar said...

I'm sorry that text is giving you so much trouble that you have to keep referring back to a graph, but the TEXT of Emanuel's article clearly states, repeatedly, in the title and elsewhere, that it is referring ONLY to the allocation of radically scarce medical resources like organs.

I'm a Cartesian kinda guy. Cartesian graphs speak volumes. Clean and unambiguous; free of slick language, or Zeke's passive voice leaving us wondering who's invisible hand is going to allocate.

You bet Zeke said this is a graph to implement a system to allocate scarce Medical Resources, and the Prez says that's exactly what we have in America. A health care system that is going to bankrupt the country.

Zekes on the committee proposing the efficiency standars to be implemented 2015. Obama says the system is unsustainable. These guys are getting ready to allocate and ration.

PG said...

HR3200 does nothing to increase the supply of nurses.

Explain why the section of HR 3200 that I cited, "Grants for Comprehensive Programs to Provide Education to Nurses and Create a Pipeline to Nursing," does nothing to increase the supply of nurses.

"PURPOSES.— It is the purpose of this section to authorize grants to
(1) address the projected shortage of nurses by funding comprehensive programs to create a career ladder to nursing (including Certified Nurse Assistants, Licensed Practical Nurses, Licensed Vocational Nurses, and Registered Nurses) for incumbent ancillary health care workers;
(2) increase the capacity for educating nurses by increasing both nurse faculty and clinical opportunities through collaborative programs between staff nurse organizations, health care providers, and accredited schools of nursing; and
(3) provide training programs through education and training organizations jointly administered by health care providers and health care labor organizations or other organizations representing staff nurses and frontline health care workers, working in collaboration with accredited schools of nursing and academic institutions."

You've offered no rebuttal to my explanation of why the shortage of nurses is due to an insufficiency of people (students and educators), not to your hobbyhorse in which the way to fix any problem must be to put up a new building, regardless of existing capacity. HR3200 doesn't build new nursing schools because we don't need new nursing schools; we need new NURSES, which is what the bill does direct money toward creating, through grants for education instead of for the construction industry. Are you invested in an company that builds nursing and medical schools?

PG said...

Google the 30 day readmission provisions in HR3200 (I don't have the section handy but it's easily found).

I don't do third-hand sources who, like you, don't bother reading the actual bill. There's a primary document that is HR 3200. When I read the bill itself, I saw Sec. 1151, "Reducing Potentially Preventable Hospital Readmissions." Is this what you're talking about? I can't tell, because you claim there is something in there about a 10% reduction in hospital admissions, but I see nothing like that in there. Please indicate what part of the bill you're talking about.

With regard to hospital readmissions generally, two points:

(1) You seem troublingly oblivious to the problems of hospital infection and medical error. Again, if you actually care about health outcomes, reducing the amount of time people are admitted to hospitals and instead treating them as out-patients will save lives and avoid injury and illness.

(2) If you have to re-admit someone within 30 days for the same condition that he was just there for, it's usually because you screwed up. Do you really think hospitals should continue to have a monetary incentive not to do the job right the first time? When I got out-patient lasik surgery, the doctor guaranteed that any touch-up or adjustment needed for a certain period of time after the surgery was part of the package. (Beyond that period, the eye degeneration caused by the passage of time -- particularly, the potential need for a "bi-focaled eye" -- might necessitate more surgery, but not because he had missed something the first time.) Sec. 1151 still pays providers for the readmission, but if the provider has a longstanding and widespread problem of readmitting patients for the same damn thing they were just there for less than a month ago, the amount of the payment will be reduced. There's still an incentive to provide care, but it's an incentive to minimize the number of readmissions needed by providing the care properly the first time.

PG said...

We Liberals. Liberalism has always been about creating abundance. Feed the hungry, house the homeless. Pump money into food stamps, subsidize farmers so more food is grown. Pump up credit, more people get mortgages more homes built. (We have problems with over abundance but that's the price of Liberal success).

Good grief. If a lot of people share your delusion that subsidies are about growing more food -- when in fact subsidies are given regardless of whether food, cotton, timber, or anything at all is raised -- no wonder it's so impossible to get rid of the damn things.

Similarly, if mortgages were to get more homes built, why are the majority of mortgages each year given to people who are buying existing homes? I think you are confusing contemporary tax incentives and other support for mortgages with the Homestead Act of 1862, which actually did tie the incentive to improving the property (usually by building a home on it).

Health techno-geek me well aware of the wind fall here. The Stim Bill the health care programmer's retirement act.

Pity that health techno-geek you are apparently unaware of the benefits to patients of establishing electronic records.

The classic reason why less Government better.

Because your state has crappy government? That's like saying the classic reason for all women to become lesbians is because YOU keep marrying wife-beaters.

PG said...

No money for new Med School programs, scholarships for Docs in the stim bill or HR3200 either. Graduate more Docs, supply of Docs goes up, drives down reimbursement to docs, that's why AMA is on board. They link to keep that supply of docs tight. They think like a craft Guild.

Why do you think we need new med school programs or scholarships for doctors? We have thousands of pre-med students every year who would love to go to medical school, who spend time and money prepping for the MCAT, even some who will spend a year in a program to make their grades in the core courses better. They don't need scholarships to provide an incentive. They get plenty in loans and grants. Cost is not the obstacle. The obstacle is that only the creme de la creme of the undergraduate population, as measured by grades in organic chem and score on the MCAT, is considered fit to enter a U.S. medical school. You keep ignoring the actual problem: people want super-smart doctors. Try putting forward the proposal you seem to have in mind -- "we don't have enough kids going to medical school, so let's dig a little deeper down into the group with the lower grades and scores" -- and see how popular that is.

I agree that the AMA thinks like a guild, but it's not building more schools or creating scholarships that will fix that. It's lowering the standards for who can be admitted to medical school. If I'd tried to go to ANY American medical school, even Brody School of Medicine at East Carolina University, with my GPA (which probably would have been lower if I'd had to take more than one science course), I would have needed at least a 27 on the MCAT to make it worthwhile to pay the application fee. A 27 is better than over half of applicants, but the average score for students actually accepted is 31.5. The AMA gets away with keeping med schools elite, just like the state bar associations get away with their requirements, because it's all couched in terms of ensuring that your professional is "the best" (in the case of doctors) or "at least minimally competent" (in the case of lawyers).

Bill Baar said...

Because your state has crappy government? That's like saying the classic reason for all women to become lesbians is because YOU keep marrying wife-beaters.

Illinois has crappy government and we've sent it to DC. Ray Lahood, Rahm, Valerie, David, Dick Durbin and many others... and of course Obama who got where he is because the wife beater opposed him in the Dem primary for US Senate was outed as a wife beater and dropped out...

I'll tackle the rest of your comments in a bit although I think your resort to the wife-beating metaphors may be a signal our debates has left the reality phase of sorting out the issues and impacts of HR3200.

Durbin by the way likely Majority Leader if Reid loses but Dems retain a Senate Majority? That's quite a coup for Illinois: Prez and Senate Majority lead....

Bill Baar said...

Pity that health techno-geek you are apparently unaware of the benefits to patients of establishing electronic records.

Pity, no; pay my bill when I implement.

My issue with EHR is not the record. It's the record as a vector for introducing "efficiency standards".

When HIT proposes a 2015 standard on readmissions of a 10% reduction to be introduced through EHR, then I have an issue.

PG said...

Illinois has crappy government and we've sent it to DC. Ray Lahood, Rahm, Valerie, David, Dick Durbin and many others... and of course Obama who got where he is because the wife beater opposed him in the Dem primary for US Senate was outed as a wife beater and dropped out...

Ray LaHood was part of Illinois government for a single term in the state house, 1982-83. Based on that term, what do you think makes him a bad Sec. transportation?

Emanuel and Durbin were never in IL state government. Ditto Jarrett. Ditto Axelrod, whose entire career has been as a political consultant, not even as a bureaucrat, much less an elected official.

And you're getting worse and worse about defaming people -- there was no accusation of "wife beating" against Jack Ryan. Rather, his ex-wife alleged during their custody battle that he had tricked her into going to sex clubs to have sex in public when she didn't want to do so. That's not even a crime.

I'll tackle the rest of your comments in a bit although I think your resort to the wife-beating metaphors may be a signal our debates has left the reality phase of sorting out the issues and impacts of HR3200.

You're really trying to avoid this conversation here, aren't you? First you claim that CC doesn't want us to discuss it on her blog; now my use of a metaphor (not even a Godwin's Law one!) is supposedly a signal that our debate is outside reality.

When HIT proposes a 2015 standard on readmissions of a 10% reduction to be introduced through EHR, then I have an issue.

How does this work (how does money for electronic record keeping within a hospital affect Medicare payments on readmissions? Medicare billing already is electronic), and where can I read the primary sources about it?

Bill Baar said...

And you're getting worse and worse about defaming people -- there was no accusation of "wife beating" against Jack Ryan.

Blair Hull was Obama's opponent in the Illinos Primary. He dropped out when the Trib got his divorce records unsealed and the restraining order his ex-wife had on him for his alleged violent behavior. Hull would have easily beat Obama in the primary --Hull would have pulled a big chunk of the AA vote. Obama had more enthusiasm in the burbs than city-- but was forced to drop out.

Jack Ryan was the Republican who dropped out of the General Election because it was revealed his ex-wife Jeri Ryan (the ex-Borg character on Star Trek in the skin tight uniform) divorced him because she refused to visit sex clubs with him.

Ray Lahood was most recently a Congressman and last time I saw him a candidate for Ill Gov back in 2006.

Axelrod a political Consultant.

Jarett a chair of the Chicago Transit Authority and Mayor Daley's former CofS.

I suppose it depends on where you draw the line on Illinois Government and Politics, and I throw a bigger net then you do.

After all, the key guy often is the Committeeman and the Precinct Captain. They're the guys who make things happen. Often times the key player in a County or Township isn't elected to anything at all. But they have clout and can make or break candidates.

Danny Davis will give up his seat in Congress if elected Prez of the Cook County Board. In Illinois, Prez of the Cook Board are far more exhaulted position than US Congressman. (How many patronage jobs and contracts has a Congressman?)

Bottom line, Illinois Politics is family (often literally). Regardless of where you play politics, it's the family in Illinois that's never far from mind.

You're really trying to avoid this conversation here, aren't you?

I'm with you until CC stops us. If you're in Chicago, I'd gladly meet you for a beer.


How does this work (how does money for electronic record keeping within a hospital affect Medicare payments on readmissions? Medicare billing already is electronic), and where can I read the primary sources about it?

Good question. Halmaka keeps a blog on HIT activities. Google Geek Doctor. Also visit the CMS website and look around for HIT. I found the powerpoint from their last meeting their with the 2015 efficiency standards.

They're going to ding the admitting MD (I guess) for the readmission. Take it out his/her's next check. If HIT implements at 10% reduction, each Hospital will have to establish it's target and as readmissions start getting close to that thresholds start flagging (which I guess they'll have EHR do) cases and saying we're going to go over and tell the Doc.

But I really don't know exactly how they plan to work this and allocate the reduction in reimbursement between Hospital and Provider (getting the overpayment easy, just offset the next months reimbursement) but the mechinics of it fuzzy...

...and that's the lesson of HR3200. The problem with this kind of law is the devils are deep in the weed and the implementation. In the hands of geeks like me, and, inevitable.. geeks partnered with lawyers looking for the loop holes and ways to shove that penalty off on someone else.

Just hope you don't get discharged from your CABG and break your leg 15 days later and that readmission is approaching someones 10% red line. You'll be SOL looking for a geek and lawyer to wrong an angle for you...

...or if in Illinois, call your Committeemen to smooth things over for you.

PG said...

They're going to ding the admitting MD (I guess) for the readmission. ...

But I really don't know exactly how they plan to work this and allocate the reduction in reimbursement between Hospital and Provider (getting the overpayment easy, just offset the next months reimbursement) but the mechinics of it fuzzy...

...and that's the lesson of HR3200. The problem with this kind of law is the devils are deep in the weed and the implementation. In the hands of geeks like me, and, inevitable.. geeks partnered with lawyers looking for the loop holes and ways to shove that penalty off on someone else.


Yeah, see, this is the problem with your steadfast refusal to actually read HR3200. There's nothing that I can find in there about about 10% reduction, and you haven't even tried to point out where there is.

Sec. 1151, "Adjustment to hospital payments for excess readmissions," applies only to the hospital itself, not to the physician who admits the patient. Seriously, just reading the table of contents on HR3200 would greatly improve your knowledge of it. The whole point of having a 1000+ page bill is to provide as much detail as possible.

If HIT implements at 10% reduction

I'm really confused as to what you think HIT stands for. In this context, I thought it stood for "health information technology." That's certainly how the Centers for Medicare & Medicaid Services uses the acronym. You use "HIT" like it's a specific program. Could you link to this program? If you found a powerpoint online that backs up what you're claiming, why not link that PPT? As TheCSO said, references would be appreciated.

I suppose it depends on where you draw the line on Illinois Government and Politics, and I throw a bigger net then you do.

I put it somewhere around where the Constitution would. A person elected to the U.S. Senate or U.S. House of Representatives is part of the federal government, not state government.

Bill Baar said...

I'm really confused as to what you think HIT stands for...

Health Information Technology... the 10% is in their proposed efficiency standard around "unnessary" readmissions. They pulled 10% out of a hate. Who gets dinged for the readmission it would be the discharging doc --one would think-- but this is all stuff that is in the weeds. Google the Industry news letters and you'll find considerable discussion. Right now it's a CMS pilot. HIT is proposing the metric for 2015. HR3200 is going to make in law, no longer a pilot.

The EHR is the logical place to put all of the efficiency metrics as alerts to the provider. Once you have the data in a file, the next step is to start using algorithims to start using the data. This is good. Can be very good. But when the guy implementing is also the payor --and likely single payor-- you've got a powerful tool to drive practice in ways that reduce the payors burden.

That's an awesome power to wield over health care of millions.

I put it somewhere around where the Constitution would. A person elected to the U.S. Senate or U.S. House of Representatives is part of the federal government, not state government.

Well, go to a fundraiser in Illinois and they'll all be there. Regardless of office. No one draws a line and says Democrats in Federal office go into this room. State office there, local officials to the lobby... it's family (often literally) with everyone united in make a deal.

Once they get to Washington they don't forget the neighborhood either because it's the base back home that usually decides whether they can stay in Washington.

Whatever you think the constitution says, the reality is politics is sport in Illinois and you support your organization where every you may be.

Bill Baar said...

Dr. Halmaka held a town hall. Here is a link http://geekdoctor.blogspot.com/2009/08/hitsp-town-hall.html

They're the guys defining "meaningful use of EHR" for providers to get reimbursed.

The approved matrix is here "HIT Policy Committee Meaningful Use Matrix" http://mycourses.med.harvard.edu/ec_res/nt/9D7DE75F-A15F-4571-8839-B1D1503E3EC8/meaningfuluse.pdf If you go back into the minutes you'll find readmission as a preposed readmission standards and 10% as the suggested target.

Efficiency standards throughout American health care from a Federal Panel a pretty powerful club. Dr. Halmaka, and I'm certain he's following this, ought to explain what the rest of the panel has in mind with this one.

PG said...

They pulled 10% out of a hate.

Who is the "they" that came up with this 10%? Health Information Technology is a concept or a thing, it is not a group of people. To whom are you referring when you say HIT?

HR3200 is going to make in law, no longer a pilot.

Page? Section number? Direct quote? Anything?

PG said...

Efficiency standards throughout American health care from a Federal Panel a pretty powerful club.

I think the problem here is that you read the word "recommendations" with reference to what the Health IT Policy Committee does ("The American Recovery and Reinvestment Act of 2009 (ARRA) provides that the HIT Policy Committee shall at least make recommendations on standards, implementation specifications, and certifications criteria in eight specific areas.") and think that means whatever the HIT Policy Committee says will automatically become law. You might want to learn a bit about how much of, say, the Medicare Payment Advisory Commission's recommendations ever actually became law. Recommendations by federal panel =/= law.

Bill Baar said...

Who is the "they" that came up with this 10%? Dr. Halmaka's committee. The folks charge with defining meaningful use.

Page? Section number? Direct quote? Anything?

Just search for readmissions. Google readmissions medicare cms or some combination and you'll get a ton of analysis. We geeks are lumbering mightly with it as it is big bucks involved and many uanswered questions (more things for the consultant to bill for!)

...and think that means whatever the HIT Policy Committee says will automatically become law.

If HR3200 passes the pilot becomes law, and folks like HIT work out details and then it goes into the hands of the GS13's through out CMS and in the case of HR3200 the Health Exchanges to really work out the details.

That's the real problem. Pretty significant power put in the hands of unelected people. The only things stopping them are court cases, and the lawyers certainly getting ready to sue (and bill) too.

HR3200 a windfall to the geek, legal, and fiscal communities.

PG said...

Google readmissions medicare cms or some combination and you'll get a ton of analysis.

From more people who haven't actually read the law in question? No thanks, I have better uses for my time. I don't bother reading analyses of HR3200 that can't specify which part of a 1000+ page bill they're talking about. If someone does note which section they're talking about, I go to that section and see if it matches anything that the person is talking about.

For example, the other day I saw someone claiming that "Section 163 allows government real-time access to your personal bank records, bypassing traditional privacy protections." That didn't sound right, so I re-read Sec. 163. Nope, it says nothing about bank records, and it specifically provides lots of privacy protections. This person may well not have been a malicious, intentional liar; she probably was just regurgitating what she's seen on a right-wing blog or heard from Rush Limbaugh. But a lack of malice doesn't make this kind of rumor-mongering, untethered to reality, any better for the public square.

If HR3200 passes the pilot becomes law

Where does HR3200 refer to this pilot?

Also, you don't seem to understand the meaning of "pilot." That means they try a program out to see whether it works and if the relevant constituencies are happy with it. If it doesn't work out, it gets dropped. See, e.g., some of the pilot programs to privatize child welfare services in Florida -- the pilots allowed them to see which private entities could handle this, and which couldn't.

HR3200 a windfall to the geek, legal, and fiscal communities.

Almost all regulatory legislation is a windfall to the legal community. Even before I was a lawyer, HIPAA created a reason for my employer to hire me to ensure their compliance. Does that mean HIPAA's privacy protections are a bad thing? Securities law generally, and Sarbanes-Oxley particularly, employs literally tens of thousands of lawyers just in the private sector. Ergo the ban on insider trading is a bad thing? Calling a law a windfall to lawyers is about the most pointless thing one can say about it, unless one can explain why it is a greater windfall than any other complex piece of legislation. Since the geek and fiscal communities aren't generally loathed like the legal profession is, I doubt you'll get much opposition going by saying "requiring greater use of electronic records will involve more work for IT workers, oh noes!" Putting legislation online has created jobs for IT workers -- so that means this increased transparency is a bad thing?

Bill Baar said...

Where does HR3200 refer to this pilot?

It doesn't. HR3200 makes the CMS pilot law. CMS pilots policy and if it makes sense Congress can make it law. In this case Congress moving a little faster than the pilot. I'm working on the pilot as our many of use in Health Care.

Almost all regulatory legislation is a windfall to the legal community.

Indeed it is, as well as inducement to lobbying and corruption. It's why after 32 years in Government, I've come to appreciate the case for limited government with less regulation the better.

PG said...

HR3200 makes the CMS pilot law. CMS pilots policy and if it makes sense Congress can make it law.

OK, where does HR3200 describe the CMS pilot that it would make into law? I just keep coming back to this problem of not understanding where in the legislation you're seeing all the stuff you talk about. And you still haven't cited a single section or page of the bill to back up your claims of what the bill will do. You would be drastically more convincing, not to mention keep this thread from going to 100 comments with half of those comments being "PG: Where does it say that?" if you could just start citing the part of the bill that says what you claim.

PG said...

It's why after 32 years in Government, I've come to appreciate the case for limited government with less regulation the better.

Really? So inside trading, not a problem? Lack of privacy in medical records, not a problem? I don't think the government should get too involved in regulating things like wages and prices, but I kinda like not having to run my own tests on milk to make sure it doesn't have melamine.

Bill Baar said...

Oh PG, you must be using some ancient software witout a find feature for your document searches.

Section 1151 amends the Social Security Act for REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS. Of course it doesn't refer to CMS's pilot or the NEJM article that cited the savings.

HR3200 doesn't even cite 30 days. It just uses words like potentially preventable readmissions.... it's up to the Geeks and Policy types to implement this. HR3200 doesn't write Federal Regulations or implement policy. CMS writes the regulations and policy after the law.

It will have the CMS pilot to fall back on for guidenance. That's how the process works.

Then of Hospitals and Docs don't like the outcome, they go to the courts to sort out the way CMS will implement versus the Law. That's the way Medicare Medicaid work... it's the way every federal program works.

Bill Baar said...

The Jenks April 2009 NEJM link with the $19 billion estimate.

Note HR3200 fussy on who is supposed to prevent the preventable readmission and take the $19 billion hit out of their reimbursement. The Hospital but than to they ding the discharging MD?

The Thomas link expired. Just search for the word "readmission" and it takes you right there.

PG said...

"Oh PG, you must be using some ancient software witout a find feature for your document searches."

Uh, Bill, I pointed out many comments ago (on Aug. 26 at 8:02PM) that the only place where I could find "readmissions" was indeed Sec. 1151, but noted that there is nothing in that section about a 10% reduction (which seems to be the centerpiece of your belief that this is going to be disastrous). Contrary to your repeated claims that:

(1) there's no details in the bill and it will all got sorted out by unelected bureaucrats in dark corners; and
(2) physicians will have their reimbursements reduced

in fact

(a) Sec. 1151 has very detailed formulas that, with regard to determining the readmission measure methodology, do not rely on random NEJM articles but instead
"(ii) measures of such readmissions— (I) have been endorsed by the entity with a contract under section 1890(a); and
(II) such endorsed measures have appropriate exclusions for readmissions that are unrelated to the prior discharge (such as a planned readmission or transfer to another applicable hospital)."

In case this language is difficult to understand, it's saying that the hospital itself decides how to measure readmissions with the goal of reducing them (because despite your reluctance to admit this, due to your belief that the more "health care," the better, being in the hospital for a long time is not good for your health). If the hospital itself has signed off on the methodology, it's going to have a difficult time (unclean hands, in a sense) suing to prevent the methodology's being applied.

(b) Sec. 1151 is ONLY about reducing payments to hospitals with excessive rates of readmissions. You don't explain how this alleged "dinging" of physicians is supposed to work. Maybe things are totally different between Illinois and Texas, but in Texas doctors bill directly to Medicare using their NPI numbers. How does it work in IL? The hospital is expected to do the billing for the physicians?

Since you apparently regard the NEJM as an extension of the federal government, let me quote from the Feb. 12, 2009 issue:

"Although all these approaches might provide some short-term relief, I believe the key to reforming physician payment is to develop a more aggregative payment strategy. In the near term, payments need to be developed that cover all the services that a single physician provides to a patient for the treatment of one or more chronic diseases. This approach is consistent with, and could be related to, the work that CMS and others are doing on medical homes. In addition, bundled payments should be developed for high-cost, high-volume DRGs, to include, at a minimum, the reimbursement for all physician services associated with the DRG and perhaps the hospital payment as well. For example, a single payment could be made to cover all physician services and hospital care related to coronary-artery bypass grafting, rather than having each physician bill Medicare separately. In the 1990s, a demonstration of such bundling was conducted by the Health Care Financing Administration, the predecessor to the CMS. The results were promising in terms of clinical outcomes and savings, but as often happens with demonstrations, no further movement has occurred."

Pilot demonstrations often don't go anywhere? Craziness, right?

Bill Baar said...

So inside trading, not a problem? Lack of privacy in medical records, not a problem? I don't think the government should get too involved in regulating things like wages and prices...

There are all sorts of problems PG. The ongoing question in American Policis is should government solve each and every problem, and then for those needing a Government solution: which level of government is best suited to solve it, Federal, State, local... or maybe even consider something creative like empowering those in need with a voucher to pick their own schools (buy their own health insurance?).

Read Brink Lindsey's book The Age of Abundance. It's the best description yet of our times that I've read. He speaks of the solid Libertarian center in America. That's really what Obama and the Congressional Democrats have run afoul here. HR3200 reads and sounds like Federal intrusion into peoples lives and the Libertarian majority mad about it.

No one denys the problems, it just Health Exchanges and Clinical Protocols delivered via the Med Record derived by a Federal Comparative Effectiveness panel just isn't an appealing solution for many Americans.

Why not give the indigent a voucher instead? Open up the Fed Emp Health Plan members of Congress use instead?

I'm in the policy weeds enough to know the drawbacks to those solutions too, but Obama and Congress aren't even trying to address the alternatives. No hearings on HR3200 to speak off. No consideration of bills like the Health Americans Act. They just want to steam roll this through and people are rightfully mad about it.

PG said...

No one denys the problems, it just Health Exchanges and Clinical Protocols delivered via the Med Record derived by a Federal Comparative Effectiveness panel just isn't an appealing solution for many Americans.

Which is all dealing with Medicare. If someone is on Medicare while claiming to be Libertarian and not wanting federal government intrusion, they're either tragically ignorant (of the fact that Medicare IS a federal government program, a massive subsidy to all elderly people including those who can afford to pay for their own health care) or an utter hypocrite (who is enjoying having guaranteed coverage but doesn't want anyone else to). Which do you think it is?

I'm in the policy weeds enough to know the drawbacks to those solutions too, but Obama and Congress aren't even trying to address the alternatives. No hearings on HR3200 to speak off. No consideration of bills like the Health Americans Act. They just want to steam roll this through and people are rightfully mad about it.

Since you're so far in the policy weeds, could you point out where Obama has endorsed HR 3200 above the Healthy Americans Act or any other alternative presented by Democrats?

I'm not claiming HR 3200 is the best option. I'm just trying to figure out where you get all these ideas about its having death panels, single payer, QALYs, etc. So far, you're citing academic journals an awful lot and the bill itself very little.