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 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.
Delete