There was a thought provoking article on Bulwark this morning by Ezekiel Emanuel: What Would You Give Up to Make American Health Care Better?
It is thought provoking in the sense of things to think about, but not really tackling the big problems. A few things I would be on board with, and a lot of things I wouldn't be.
From the article:
"What are you willing to sacrifice for a much better—if not the best—American health care system?” That was the question I posed to a large group of CEOs and other C-suite executives from hospitals, physician groups, health care companies, and other organizations at a recent meeting."
"American health care is totally dysfunctional. And everyone knows it. It is too expensive. Quality is uneven and declining. It is confusing, time consuming, frustrating. Indeed, at this meeting, one senior health care executive said, “the status quo no longer works.” Another—Steve Hemsley, the chairman and CEO of UnitedHealth Group, the seventh-largest company in the world—said the system needs to be “disrupted.” Ironically, it seems that every discussion about fixing health care ends up focusing on money—and getting more and more and more.... We have to flip our thinking on its head. Instead of asking what people want or think they need, we need to ask people: What are you willing to give up?"
"....An important proviso is that everyone knows that every other participant in the health care system will also give up something. It is only with collective, coordinated sacrifice that we can create a system that will ultimately benefit all Americans—not just torpedo every new reform idea."
I will explore some of the ideas expressed:
"Pharmeceutical companies need to give up monopoly pricing of new drugs and accept that their new drugs should be priced based on how much they improve people’s health." and, "...Pharmeceutical companies should also give up direct-to-consumer advertising." "...Pharmeceutical benefit managers need to give up rebates, spread pricing, and other hidden charges and accept a fixed administrative fee as part of a transparent pass-through pricing system."
I could go along with those ideas, especially the direct to consumer advertising.
"Hospitals also need to give up charging more for the exact same MRI, surgical operations, and other interventions that are paid much less if done out of the hospital. That is, the need to accept that the cost will be the same regardless of where as specific medical service is provided—so-called “site-neutral” payment." This one I don't entirely agree with. If the costs of the hospital are actually higher. then it's fair to charge more for staffing and equipment.
"But truth is everyone needs to sacrifice something, including those of us who are “consumers” of health care."
I thought hard about that one. But the honest answer to what I would be willing to give up as a patient is, not a damn thing. Because the deck is already stacked in favor of stockholders, corporations, and administration. Patient rights have already been stripped down to the bare basics. Here are a few of Mr. Emanuel's suggestions:
"Ritz Carlton-like hospitals with exquisite art in public spaces, luxurious reception areas, and fancy, wood-paneled patient rooms. Instead, I would accept old couches, plastic chairs, and kids’ scribbles on display." I think he has been watching too many "Royal Pains" episodes. I have spent a fair amount of time in hospitals, both myself and accompanying family members. It wasn't Ritz Carlton level. More like Motel Super 8. Which is fine. At least it was decent.
"...I’d accept wait times of, say, ten weeks longer than today for elective hip and knee replacements, spinal fusions or disc repairs, cataract surgery, MRI scans, colonoscopies, and similar elective procedures." This one gets and emphatic, "Oh hell no" from me. Because there probably already is a waiting time of at least that long for some elective procedures (definition of an elective procedure, not life threatening right now, but has to be done)
"I’d be willing to give up today’s super-low generic drug prices, so long as the higher generic drug prices came with the requirement that the generics are produced in the United States and there won’t be shortages." I don't really care where the generics were made, as long as they were held to the same standards as domestically produced meds.
The author didn't say anything about corporate game playing, consolidation of insurance companies, hedge funds, stockholder priorities. the whole for-profit system. If none of those are addressed, nothing much will change.
Your thoughts?
Some of the replies in the comment section were pretty acerbic.
ReplyDeleteI will return later to this. Two problems - the audience e is high level healthcare industry folk. No consumers? I read fast but I think they didn’t bring up the root of the problems - our country’s system is based on the profit motive - an incentive to charge the max and cut patient care costs to the bone. So the US spends way more on healthcare than other countries and gets far less. The fancy hospitals with great art are rare. I do know of one - Cedars Sinai in Beverly Hills. The other big name hospitals we have personal experience with are UCLA, Johns Hopkins, Stanford and Mass General. No fancy art but top notch docs and nurses.
ReplyDeleteI miss Unagidon (Patrick Shannon). Is he still out there? What happened to him? Has anyone heard from him?
ReplyDeleteThe last post I could find is:
https://newgathering.blogspot.com/2019/06/unagidon-on-insurance.html
It is pre-pandemic. He was in poor health! Wonder if he survived?
I was thinking about him too. I hope he is okay.
DeleteI did a quick obituary search but didn't come up with any hits, so that seems hopeful. (I did learn there are a number of Patrick Shannons who are healthcare or health insurance execs!)
DeleteHe was (and, I hope, still is) someone who genuinely believed in the Obamacare model of health care funding and delivery, to the extent that he committed to an insurance endeavor to provide healthcare to people who otherwise would struggle to afford it. I am sure he risked a lot (perhaps all he had) on it. My admiration for him is immense.
I am sorry to say that, as quoted here, most of the ideas don't strike me as effective. But I think one of Unagidon's views was that the healthcare economy can't be reformed piecemeal; it would have to be an all-or-nothing endeavor. It's kind of hard to see how the ideas presented by Emmanuel would fly, at least piecemeal; and if they are components of a grander, holistic vision, I guess I'm not seeing how they all fit together.
ReplyDeleteIf you'll permit some of my Reaganite, Triassic-period railery, we Americans are so conditioned to look to the government to solve our problems that most of us really struggle to think of reforms that don't involve massive government intervention. When we speak casually along the lines of, "they oughta find a way to lower prices", the "they" is almost always "the government". If the goal is to reduce costs to consumers, I'm pretty skeptical that lots of government intervention is the way to achieve it. I'd be inclined to push that even farther and voice my suspicion that already-existing government participation/intervention (such as via Medicare) is a significant reason that pricing seems so distorted.
I'm not getting why Medicare is a reason pricing is distorted, any more than the private sector. Seems like all the parties are playing by different rules, and there is no transparency.
DeleteHealthcare costs soared when corporations started buying hospitals, clinics, and physician practice groups. With a private, profit making corporate model focused on shareholder return it’s not a surprise that costs went up and quality went down. All of our formerly independent or county run hospitals in the DC area are now owned by corporations. We are lucky to live in Maryland where John’s Hopkins has bought and run the local hospitals. They are non- profit but are also plagued with too bigness now. All appointments are now routed through a central scheduling office in Baltimore, even if the hospital is in DC or DC suburbs. Georgetown Hospital was once ranked at the top in the DC metro area, but the quality of car now has fallen dramatically since it was bought by a private corporation. Now that Hopkins has spread from Baltimore I can get care from a Hopkins radiation oncologist near me (;I went to a Baltimore for the surgery though) but It took me an hour last week to set up an appointment with after completing a circuit of pressing 1 or 2 etc and finally ending up where I had started. I can testify from personal experience that it’s been all downhill ever since the profit making owners took over. . My dermatologist, my husbands urologist, etc have all been bought up by huge statewide or multi- state corporations and we can no longer call the phone numbers we had - they get shunted to a central scheduler too, who transfers us or sometimes just contacts our doctors, still in their same offices to tell them to call us to make an appointment. It’s a nightmare. Almost all of our doctors are now owned by huge corporations and have to comply with their rules (limitations) and those of the private insurance companies ( often just 7 minutes per patient visit). Many doctors, our PCP of 30:years included, finally throw in the towel, and join concierge practices so that they didn’t have to throw their patients out the door when time is up., So on top of our Medicare and supplement premiums, we pay the concierge fee — only because our doc is the greatest primary care dr in the whole country I think. We just hope he doesn’t retire - he’s 67 now. Our own Dr Welby.
DeleteMedicare has been a huge improvement ver our employer insurance of years ago ( better then than now from what I hear and read), especially appreciated when I hear the horror stories of people we know including our eldest son, with their employer insurance . The Google son has good health insurance options that don’t cost him 5 figures out of pocket in premiums and thousands more in co- pays and deductibles. I have no complaints at all about Medicare.
Anne, your primary care doctor sounds a lot like ours. We couldn't have afforded a concierge fee, so I'm glad he hasn't gone that route (maybe that's not a thing in a smaller community). We have done well with traditional Medicare. My sister and brother-in-law who live in our old hometown aren't old enough yet for Medicare. He has an assortment of auto-immune disorders which means that they have to meet their four figure deductible every single year. And just about every year their ACA insurance changes, sometimes they have to drive six hours to see his docs and sometimes only three. And sometimes his appointment is on a zoom call with a doctor in Texas. That hasn't worked out very well. At least now he can get on an ACA plan, even though the carrier company changes every year. Previously he could only get insured through a very expensive state pool for people who had pre-existing conditions.
Delete"Healthcare costs soared when corporations started buying hospitals, clinics, and physician practice groups."
DeleteThe consolidation has been happening in our local community, pretty much as Anne described in hers.
Our local suburban area near Chicago is pretty fortunate to be healthcare "rich" (in the sense that there are a lot of doctors, hospitals, et al). When we moved into this area in the early 1990s, our primary care physicians, the specialists we utilized, and our local community hospital were all independently owned/operated.
But over the ensuing decades, there has been a massive amount of consolidation. Today, all of the hospitals in this area are owned by one or another of three large corporations. One of the three, Ascension Health, which owns hospitals originally operated by a religious order in our area (the Alexian Brothers) is among the largest owners of Catholic healthcare in the US. Our local community hospital is now owned by a system of eight hospitals in a six-county area around Chicago. The third corporation, Advocate, is nearly as large as Ascension; they own some of the legacy-Protestant hospitals in this area.
All three of these organizations (Ascension; Advocate; Endeavor) are not-for-profit. Perhaps our area is unusual in that respect; and surely there are some for-profit organizations operating healthcare facilities elsewhere in the greater Chicagoland area.
Anne's comment addressed a couple of different factors: for-profit vs. non-profit; and scope/scale. The consolidation we've experienced here is the same thing Anne has experienced in her locale, and has been a nationwide trend for several decades now. Hospitals would tell us there are compelling reasons for their electing to be acquired by these large corporations; they believe it is in their stakeholders' (including their patients') best interest. I take "best interest" to mean: better able to afford the provision of expensive treatments; and the reduction of financial risk (i.e. making it more likely the local hospital will survive to continue to provide healthcare in the local community). It's possible that this consolidation into larger-scaled healthcare provision corporations results in less market pressure to cut costs.
Regarding for-profit vs. non-profit, I will note this: another of Unagidon's views, which is surely correct, is that non-profits can't operate at a loss for ever and ever; they face similar financial challenges and pressures as for-profits, even if they don't have to answer to stockholders. If a non-profit hospital's costs go up, it must recover those costs somehow; the primary way is by raising prices to its patients.
Thinking about my local area, in which non-profit hospitals are the only local hospital options: these organizations are incentivized in many ways to engage in activities that raise costs. They must utilize the same medical equipment and dispense the same medications as for-profit hospitals; and these supply items do come from for-profit corporations. The hospitals' parent companies must negotiate with the same insurers (including the federal government) as for-profit hospitals. Non-profit hospitals are subject to the same industry and government medical standards and regulations as for-profit hospitals. They must pay their doctors, nurses, technicians and other employees wages that are competitive in this local marketplace which has many other possible healthcare employers for workers.
Btw, our primary care doctors' practice is still independent. They admit they are dinosaurs: they think they are the last independent practice in this local area, not just of primary-care physicians, but of doctors of any sort.
DeleteFor 2026, this independent practice introduced a new requirement: their patients must each pay a $400 fee, not in exchange for receiving any specific medical care, but simply for the 'privilege' of being able to utilize the practice's doctors when patients do need medical care. In its letter to patients explaining this novel charge, they said that, due to risiing costs and reduced reimbursements from insurers, this was the only way they could stay afloat. My wife elected to pay the $400 and stay with the independent practice. I elected not to.
So now I have a new doctor, an employee of one of those three healthcare consortiums. I've been to see her a couple of times now. Her office is very nice and very professionally run, and she's spotted a couple of things in my health history that my old doctor never mentioned. I feel like my quality of care is, at worst, on a par with what I was receiving before; it may be better.
"I'm not getting why Medicare is a reason pricing is distorted"
DeleteAs I understand it, Medicare pays a "Medicare approved amount" to our healthcare providers. This is usually lower than the negotiated reimbursement rates the providers are able to charge other insurers. Providers can't negotiate with Medicare, they either take the Medicare approved rate, or leave it. "Leave it" means, "Don't accept Medicare patients". Perhaps there are doctors who don't accept Medicare patients, but I'm not aware of any around here.
Do healthcare providers make money on these Medicare approved rate reimbursements? I don't know. I suspect they make money on some of the rates, and possibly lose money on some others.
Sorta seems to me like a $400 fee (is it one time only or yearly?) to remain a patient with the practice *is* a concierge fee. Just not as high as the one Anne is paying. Don't know what we would choose to do if that were the case with the medical practice we use.
DeleteThe $400 is per-patient, per year. So $800/year for the two of us, if I had stayed with them. Counting my adult kid who still lives in our household, it would be $1,200 per year - and that's before any actual medical care has been provided. There are years where my only visit is for the annual wellness check.
DeleteJim, that’s a concierge fee. It’s low now. But it will go up. Ours goes up every year. Today we got also notices about the increases in our supplementary policy - now quite a bit higher than our Medicare premium. But as a two time cancer patient in a 4 1/2 year time period, the supplement cost has saved us more than we are paying. But it’s getting close to not being worth it - not break even or better as it has been. Unless there is a catastrophe - they happen, as we have learned through difficult experience.
DeleteWhen our doc first switched my husband went with him because of his complicated health history ( including stroke) but I didn’t .i never got sick and had no prescriptions for any conditions. I do now - as of last summer for a mild heart condition, but I went for 78 years without any - no blood pressure cholesterol meds etc. Tylenol for a headache and that was it. Several years later when I got cancer the first time my new PCP was awful - I needed orders for mammograms, biopsies etc and her office was totally unresponsive. I never heard from her until after my surgery. It took multiple calls to get the orders. , I contacted our old PCP (who wasn’t accepting new patients) and asked him if he would take me back. He said Yes. We suspended it while we were in California ( it was literally impossible to find a PCP there who took new patients) and then rejoined once home. It’s been such a relief. Since we got home from Calif I’ve had to call him on nights and weekends several times - at one point two night calls and a weekend call in the same week. He called me back within minutes each time ( they were about my husband). He’s always been that way. When my husband had a stroke when we were in France, he called me every day to check on him and answer my questions about what I understood of the French neurologist’s explanations using my rusty French. He would then fill in the blanks. I did a major research study into European healthcare systems when we got home from France. His care cost a total,of $6000 - for a week, intensive care, every major technology like MRI, CAT, EKG etc, three long ambulance rides and three different hospitals. This was 2005. If we had been eligible for the French national system we wouldn’t have paid a dime. Two nights at Hopkins for tests and observation ( we went there right from the plane) was $80,000. Can’t imagine what it would be now. We were still under his company insurance then and I think we paid 5 figures out of pocket for deductible and co- pays. And of course we had been paying a lot in premiums. I learned then that our system was by far the most expensive, not the most efficient by any means, and that we ranked way down in the 20s for outcomes in spite of being way more expensive than the European countries.
I guess the $400 is a concierge fee, although this practice didn't call it that in the letter they mailed out to patients. And there isn't really anything "concierge" about the level of service they provide.
DeleteIn addition to primary care, they have a few "side hustles" in the practice: they have their own blood-and-urine lab, a sleep lab and a physical therapy practice. So maybe that is concierge-level stuff, although it's nothing I can't get elsewhere.
They also offer a service called Cool Sculpting, apparently a non-invasive way to make the love handles disappear. I just went to the practice's website to make sure I had the name right; the photo on the Cool Sculpting page features five women, all young, all in their bras and undies, a couple of whom have no discernible body fat. The old photo showed a business woman, possibly in her 40s, in business suit carrying a briefcase; presumably that is who they were targeting back then. In this age of GLP-1s, they may have had to start targeting a younger demographic.
I don't really blame the practice for doing what they have to do to stay afloat. But I get the same - or better - level of care (so far, anyway) from the large-healthcare--org-employed doctor, without having to pay the concierge fee.
Anne, if I were in your and/or your husbands' shoes healthwise, I'm sure I'd make the same decision you did.
DeleteIn our case, when we first started going to this independent practice, the doctors were in their 40s. They were great: knowledgeable, personable, responsive. I looked forward to my annual checkup so I could chat with my doctor and see how his kids were doing. Four of these guys had started the practice after medical school. They've all retired in the last 3-5 years. They've hired a new generation of doctors to carry on the practice, but I don't like them as much. (I'm still getting used to doctors who are younger than me; I've seen three or four new doctors in the last few months - they all look like teens :-)). So for me, it felt like a good time to make a switch.
In my wife's case, she has a health issue that has stymied her doctor for a couple of years, and it recently flared up again. I tried to gently suggest that maybe that's a reason to try someone else, but she felt she didn't want to start over with a new doctor and maybe have to redo all the tests that already have been tried. (I get that; that's why I've been seeing all these doctors recently; my new doctor wants to get all my little ailments checked afresh.)
Jim, my doctor’s practice doesn’t call the fee a “concierge” fee that’s just the term commonly used for practices that charge a fee just to be able to be part of it as a patient. He is one of three docs in the group but we only see him. If we hadn’t had 25+ years of amazing care from him (nobody we know has a doctor like him- I’ve had nurses in hospitals and others ask me over the years how we got into the practice because lots of people want this doc but can’t get in. We were lucky that we started with him when he was fairly young - before his reputation got around and his practice filled up - many years before he went into the limited number of patients practice he has now. But he’s Medicare age now himself and we’re praying he doesn’t retire anytime soon.
DeleteI think if we switched from a military designed for power projection to self defense, reduced the military budget by 90%, gave up bribing Arab countries to accept the genocidal, warmongering state of Israel, there’d be enough money for universal health care. Or, as an alternative, drop health coverage for old people like me. But that would crash the vulture capitalists’ business model.
ReplyDeleteI'd be all for the US moving away from military adventurism and toward a policy more oriented to self defense. I'm sure it would save a lot of money. But about Israel, you and I are both old enough to remember why it exists as a state. I see its primary problem as a right wing authoritarian-adjacent Netanyahu government. Kind of similar to our MAGA- Trump one. They need someone like Yitzhak Rabin or Golda Meir again. The surrounding Arab countries hate them with the white hot heat of a thousand suns. I don't think it's wrong for us to try and get them to cool it. But we got rid of all our diplomatic ability to do that.
DeleteBut the Zionist movement started officially in 1897 long before the Holocaust and was backed by the British Empire as an aid in suppressing the Arabs. The Palestinian Arabs rose against the British in 1936. The Zionist militias supported the British in suppressing the insurgency. Although Netanyahu is unpopular, a majority of Israelis support his actions in varying degrees including the genocide. I listen to Israelis in their own words on the Internet and it sure sounds like racist hate to me. Sadistic cruelty is visited on the Palestinians constantly. Israel is a rerun of the United States and indigenous people here were exterminated under both parties. Same in Israel. Palestinians have no rights. They are regularly killed or displaced with impunity. The destruction of olive groves reminds me of the slaughter of buffalo on which our native population depended. You don’t atone for genocide with more genocide. With Iran, the US/Israel axis has bitten off more than it can chew. At this time, I consider the two countries most likely to initially employ nuclear weapons to be the US and Israel. I spent my Easter Day wondering if that was the day. If Iran cannot respond in kind, Iran will rain missiles down on the desalination plants and end Israel. After the Goths destroyed the Roman aquaducts,
DeleteAfter they destroyed the aqueducts, Rome’s population went from 1M to 50K.
DeleteI’m all for reducing our military budget. Even without the trillion $ boost they plan, it’s more than the military budgets of the next ten countries ( including Russia and China) combined.
DeleteBut I’m not ready to drop my health coverage. I’m 78. During Covid a lot of right- wing trump supporters were telling us we old folk ( most susceptible to Covid) should be willing to die to save the economy, because trump feared that closing the economy to save lives would hurt his re-election chances. I’m old like you, Stanley. . I just had surgery again for cancer which should buy me another decade or so of reasonably healthy life. I have children, grandchildren and friends with whom I would like to have more time.
There are more than 20 different models out there among the OECD countries of universal healthcare that cost far less than our system and produce higher quality outcomes. Most are a partnership of some kind ( gov + private) but they are regulated and thus affordable. Maximum profit for shareholders is not the goal. Quality, affordable accessible to all healthcare is the goal. In Switzerland people are legally required to buy health insurance. It’s regulated so the costs are the same for everyone and are affordable. Subsidized for the few poor people in the country. A bit like a Obamacare but better. The number of uninsured Americans is projected to double again with the cancellation of Obamacare subsidies. So emergency rooms will be overcrowded even more with people needing only routine medical care, like a strep test. I recommend that everyone take out a one month trial HBO Max ( less than $10 I think) and stream a program calked The Pitt. I finally broke down and bought the month for two seasons - even doctors ( including a goid friend) say it’s by far the most honest medical drama they’ve ever seen because it highlights so many of the broken parts of our system. It’s not like some of the other medical dramas that are romantic soap operas.
The cost of procedures are regulated also — a hip replacement in Zurich is the same as one in Geneva. Prices are regulated and transparent to patients. It’s the second most expensive system after the US but is still 50% of what America spends on healthcare.
Turning the healthcare sector over to unregulated profit models is a disaster. Greed is the point of it — not healthcare —and so the US ranks very poorly in quality of health outcomes in international rankings even though we spend far more as a % of GDP than other developed countries. It can’t be stupidity or ignorance, so it comes down to capitalist greed. I’m a believer in capitalism as a driver of economic growth - but when it comes to some public goods, greed should be regulated.
In some ways I see parallels of healthcare with the airline industry. A shrinking level of service and increasing prices. They used to give you a little legroom, and a meal if it was a longer flight. Nowadays you are squashed in like sardines, and are lucky if you get a little packet of pretzels. So in order not to have a miserable experience, some people elect to upgrade to business class. With medical care, to avoid some of the hoop jumping-through and flow restrictors of care, people go with concierge plan. The difference is that airlines actually are a for-profit industry.
DeleteSomewhere in these comments, Anne rec)mended the HBO series The Pitt. I second the recommendation! It's the best of the shows we watch. Second place in our little pantheon is Shrinking on Apple TV. Just be aware it has profane language (doesn't bother us, but not sure if that's a downer for some folks here); and some of the charcters' problems are more than a little upper-middle-class. But highly amusing!
ReplyDeleteThe Pitt sounds like an interesting series. Unfortunately we don't get HBO. I wonder if it is available on any other streaming services?
DeleteKatherine, Season 1 of The Pitt also has been shown on TNT,Cl in case you ger it.
DeleteKatherine, we have Amazon Prime ( unfortunately- very dependent on them especially for medical supplies). We ordered HBO Max through Amazon for one month only just to watch the second season of The Pitt- they have both seasons. I think it was about $9 for a month. I canceled yesterday. It was easy, and confirmed by email. You might not need Prime to order it though - just go to Amazon video. Or maybe to the HBO Max website and order one month.
DeleteIt’s on Amazon Prime at $10.99/ month. You can order through the Prime Video store without having a Prime account. You can also get it at their website for the same price. But I think the price is a bit higher than what we paid. It looks like the price went up $2.00. But still way cheaper than going out to a movie!
Deletehttps://www.amazon.com/The-Pitt/dp/B0DLSVY5NS/ref=sr_1_1?crid=NOX1B0IJ2FLN&dib=eyJ2IjoiMSJ9.doIP1IYAKK31lkxPKstE6TIIapHglf0VBsOwt8VbKs8a9P75n9mb0rqcQRKwWX5TC8p094KyfZNcnANynQuHsgw0ZBX_3f6pCy6h8yl-TjYKB9t3k9NWbMw6AU7BIGGOnUrd5I24MVC02cFEQbS5XfzUHgJQEOBTzW7SMB4Zfx5ysohsYw13scWt_vW3nVRr1NuRBz3bd8bXoiV5D-NXgNRiHn0BATcwRrbapS6KXMs.RlCzViK82oRHn7l2NtlwVwZHgm3qgoEgjsoaAdFmXig&dib_tag=se&keywords=The+Pitt&qid=1777217421&s=movies-tv&sprefix=the+pitt%2Cmovies-tv%2C101&sr=1-1