Assumptions and Guesswork

A New York Times editorial outlines and opines on the differences between the House and Senate HSR legislation. Their opinion is wrong on two provisions that affect physicians:

• They note that the House bill relies heavily on Medicare pilot projects to determine which approaches to restraining medical costs might work best. The Senate bill would, instead, empower an independent board to carry out 'successful reforms broadly within Medicare and recommend changes in private programs'.

The Times prefers the Senate bill because the House bill lacks a strong mechanism, like an independent board, to drive successful reforms into widespread use.

The Times incorrectly characterizes this board as a 'crucial cost-control mechanism'. This opinion is misguided because we've essentially been doing this for the past 30 years - only we've called it managed care.

Simply granting an 'independent board' authority is insufficient. After all, Medicare pilot projects have been ongoing for more than ten years! Sustainable, effective cost control will require integrative strategies and they'll need to be physician based. Physicians are truly the only entity, once empowered, that can initiate and sustain cost containing/integrative reforms.

• The House Bill provides for the paying of primary-care doctors the same (amount) that Medicare pays.

The assertion that this would make it more likely that poor patients could find a doctor is spurious - inadequate reimbursement, albeit more generous, would still be inadequate. Just look at the access problems faced by (and those that threaten) the Medicare population currently.

Journalists and elected officials could better serve their clients were they to consider the vast experience of the provider community when they prepare their opinions. Some folks would refer to that as 'evidence based.' As in industry, a quality health care initiative (like the principles of six sigma) , ought to be driven by a commitment to making decisions on the basis of verifiable data rather than mere assumptions and guesswork.

AMA and House-Senate Conference Committee

SP wrote that he had been ambivalent and confused about recent ama performance. But upon reading the ama hsr bulletin, he has decided to remit his ama dues. Below is an excerpt from that bulletin that clarifies ama position on the upcoming House-Senate Conference Committee, the committee that will craft the final hsr bill for the president to enact.

"The AMA has made it clear to senior White House staff, the Senate leadership and the House leadership that its support for a House-Senate conference agreement is contingent upon:

• Movement on a clear pathway for passage of legislation to permanently repeal the SGR by the end of February
• Modifications of the proposed Independent Payment Advisory Board
• Refinements of the quality improvement and Medicare data release provisions
• No new major problematic provisions surfacing in conference

While there were some earlier reports about efforts to circumvent the House-Senate conference committee process, recent statements from the House leadership indicate that the House will not take the Senate bill as is or with minor changes. As noted earlier, the House bill does not include an Independent Payment Advisory Board, and 53 House members signed a letter objecting to that concept.

The AMA's strategy of constructively working for changes at each stage of the process has put it in a position to have significant influence in the House-Senate conference committee negotiations. The AMA retains the ability to withhold support for a conference committee agreement if it fails to achieve our priority objectives.

We still have not seen the final bill that the president hopes to sign into law. The AMA will be actively engaged throughout the conference committee negotiations to positively influence the key issues for medicine."

No Caps Because 'The Lawyer Has to be Paid'

Last summer, Tom Baker, professor of law and health sciences at the University of Pennsylvania School of Law and author of “The Medical Malpractice Myth,” was interviewed by a free lance author for a piece (published in the new york times blog) on medical liability.

He believes that making the legal system less receptive to medical malpractice lawsuits will not significantly affect the costs of medical care (because he measures the cost of liability as a percent of total health spending, yet he ignores that the burden falls disproportionately upon physicians). He acknowledges that:

• "The medical malpractice system only works for serious injuries...
• Lawyers discourage people from bringing suits if their injuries are not serious in monetary terms — a poor person or an older person who can’t claim a lot in lost wages ...
• Gerontologists’ premiums are exceedingly low."

Still, he opposes caps on pain and suffering because (in states with caps) a plaintiff gets reimbursement of medical costs in principle... "(but) in fact, they don’t, because the lawyer has to be paid. These cases can cost $100,000 to $150,000 to bring, so the patient has to deduct that amount from any award. I’ve had lawyers tell me they would not take a case ... even if it’s a slam-dunk. The damages wouldn’t be enough."

So why is congress afraid to remove the lawyers from the equation - and allow a reliable system of justice that compensates victims better and at less cost to the health care system?

Senators to be Pilloried

In the NY Times are two columns (link to a, link to b) suggesting that passing the Senate Health care Bill is worthwhile, despite its shortcomings. The shortcomings of the bill highlight the shortcomings of our political process.

In 'column a' David Brooks asks if the bill will "put us on a path toward the real reform, or does it head us down a valley in which real reform will be less likely"? He worries that "it will slow innovation. (Because) Government regulators don’t do well with disruptive new technologies ... (and) We’ll shovel more money into insurance companies". Yet his worries about the costs could easily be addressed (and the cost curve bent) if only the reformers would shovel less money to the insurance industry and instead give doctors the incentive to innovate - remember Gawande's accountable care organizations.

And we don't need new demonstration projects. Here in the downstate New York region, a hospital network clinically integrated (a huge hurdle were it a physician network) then emerged, to the consternation of the payers, as the low cost health care provider in its region!

In 'column b", Paul Krugman describes some Senators as "motivated largely by a desire to protect the interests of insurance companies."

Protection of the insurance companies is anti consumer - it is the enemy of physicians, patient interests and meaningful health care reform. Those Senators, and their bill should be pilloried.

Choice Worth Fighting For?

According to the WSJ, Aetna Inc. spent less money on patient care for some small businesses than it originally reported. The Senate Committee on Commerce, Science and Transportation said Aetna overstated by $4.9 billion the amount of money it spent on patient care for small businesses. Aetna said the error was a simple mistake.

Last month, the committee chastised Cigna Corp. for mislabelling $5 billion in premiums.

Sen Lieberman and the Health Insurance Industry

Mr. Lieberman now opposes both public option and early medicare buy-in, a change in position the senate majority leader has described as 'vexing'.

According to the WSJ, senate aides recalled a September interview with the Connecticut Post, in which Mr. Lieberman suggested giving people 55 and older "an option to buy into Medicare early."

The NY Times noted that Mr. Lieberman has taken more than $1 million from the industry over his Senate career. He ranked second in the Senate in contributions from the industry in 2006.

While he does seem to recall the industry contributions, what has become of his 'commitment' to health care reform?

Its Not Health Care Reform If the Doctor is Not In

Centrist senators raised concerns about a major new element of the (senate) legislation, ... (that to) expand Medicare to cover some people ages 55 to 64.

Senator Olympia J. Snowe, Republican of Maine, said Democrats were moving to expand Medicare “without really understanding the ramifications ... I just don’t think it’s a policy we should embrace.”

This comment from US Senator George LeMieux (R-FL), 'It's not health care reform if the doctor is not in' begs that most important question yet to be considered.

Oxford Expands Fee Schedule to Non-Par Physicians - 'Free' Market?

Oxford has notified several New York physicians of a change from 'charge-based' insurance reimbursement (including the fraudulent UCR) to 'fee-schedule' based out of network reimbursement.

According to the notification, out of network reimbursement will be limited to an amount of 140% of the published medicare reimbursement amount.

We first learned about the program, as applied to physicians, in an article which appeared in MSSNY News of New York, October 2009. In the article, Sanford P. Cohen, Chief Regional Medical Officer, UnitedHealthcare explained that the MNRP payment would be an option that could be elected by an employer. Cohen said that it 'will be based on 110% of the current year payments stipulated for Medicare patients by the Center for Medicare & Medicaid Services (CMS)'.

The schedule-based MNRP program was implemented in New Jersey in January 2009. At the time it applied to Hospitals (inpatient and outpatient), Free-standing ambulatory surgery centers, Free-standing radiology centers, and Free-standing laboratories.

Among the stated goals of the program is the promotion of provider participation and consumer choice. But this is a dangerous and anti-competitive precedent. If allowed, this program:

• Harms Physicians - it further reduces a plan's incentive to negotiate with participating physicians, as an insurer's exposure is limited, irrespective of whether a physician is in network or out of network.
• Harms Consumers/Patients - it strips much of the value from an out of network benefit, a benefit that 70% of insureds currently pay extra premium for.

Link to Oxford Materials:

Freshman Amendment to Senate Bill - Draft

A group of freshman democrat senators have crafted a proposal to contain costs in the senate bill (PPACA). The proposal would allow an array of pilot projects aimed at cutting medical costs to be expanded more rapidly if there is evidence that they are successful in reducing expenses.

on administrative simplification they offer:

• "Health Care Fraud Enforcement: We direct HHS to utilize technology to prevent fraudulent, abusive or improper payments prior to payment of claims".

as a physician, the legislation seems abundant in its focus on preventing payments - i would seek something that might enable us to be paid.

• "Eliminating Legal Barriers to Care Improvement: We would require GAO to study current law and regulation to identify barriers that may impede providers’ ability to improve the quality of care and the ability to aggressively implement the innovative delivery system reforms PPACA makes possible".

this would be helpful, particularly if it results in relaxation of antitrust barriers to collaboration, accountable care organizations, and gainsharing. But shouldn't this be studied prior to health care reform?

Mostly, not unlike their senior colleagues, the freshmen have trouble unleashing the potential harnessed by the physicians.

Grand Bargain no Great Deal

Economist Paul Krugman describes health care reform as a 'Grand Bargain', "coverage for (almost) everyone, tied to an effort to ensure that health care dollars are well spent."

He continues that well respected economists "are seriously impressed by the cost-control measures in the Senate bill, which include efforts to improve incentives for cost-effective care, the use of medical research to guide doctors toward treatments that actually work, and more ... 'the best effort anyone has made'...”

If Krugman senses a bargain, he's no horse trader. While economists may be 'seriously impressed', physicians (Gawande, Jauhar) know that meaningful and sustainable cost containment can result only from innovation - physician driven, physician centered innovation.

The 'medicare commission' is inadequate for the task and the current antitrust environment presents a hurdle barely addressed in the proposed legislation.

"Share the Savings ... See Them Grow" - Sandeep Jauhar, MD

In a New York Times essay, Sandeep Jauhar, MD responds to the CMS plan to award bonuses to hospitals that lower readmission rates. He believes that, instead, some of that money should be shared with doctors.

"Current law prohibits hospitals from paying doctors for reducing hospital services, even if the goal is to provide more efficient care. But such “gainsharing” will align doctors’ incentives with broader cost-cutting goals.

Our system needs to provide inducements to decrease the amount of health care ... especially (to counter) ... the current incentives that encourage (un-coordinated care and) rampant over-utilization".

His conclusion could not be better stated, "Unless doctors view cost-cutting goals as their own, policy makers don’t stand a chance of achieving them".

Link to other Sandeep Jauhar, MD Articles

Link to Essay

Costs to Increase Under COBRA

7 million unemployed Americans, laid off or downsized between Sept. 1, 2008, and Dec. 31, 2009, get a federal subsidy to help them buy health insurance under legislation known as the Consolidated Omnibus Budget Reconciliation Act. The COBRA subsidy pays 65 percent of their job-based health insurance premiums for nine months.

According to the Kaiser Family Foundation job-based coverage averages $398 per month for families and $144 for individuals, with the subsidy. Without it, premiums average $1,137 for a family and $410 for an individual.

That subsidy expires Monday (11.30.09) for thousands who began receiving it in March, when it first became available as part of the American Recovery and Reinvestment Act.

Before the subsidy was offered, only about 9 percent of people who were eligible for coverage under COBRA took advantage of it because it was so expensive. An analysis found that COBRA enrollment had doubled since the subsidy became available.

But industries with large job losses showed greater increases. Enrollment among industrial manufacturing workers went from 7 percent to 59 percent, while enrollment tripled among construction, leisure and retail workers.

It remains unclear when or whether Congress will address the subsidy expiration with specific legislation or as part of a major jobs bill.

Obama's 4 Pillars - Can He Deal With a Tripod?

According to the NYTimes, "In a conference call with reporters Wednesday to highlight cost-containment provisions, the two senior presidential advisers, Peter R. Orszag, White House budget director, andNancy-Ann DeParle, director of health reform, cited a letter to Mr. Obama by a group of respected economists who strongly endorsed the (independent) Medicare commission ... which some House leaders view as encroachment on Congressional authority over Medicare."

Obama said of the commission, it "can help encourage the adoption of these common-sense best practices by doctors and medical professionals throughout the system — everything from reducing hospital infection rates to encouraging better coordination between teams of doctors.”

Physicianvoice asks, wouldn't anti trust relief, such as limiting the hurdles for clinical integration and accountable care groups encourage better coordination - only better?

The Boobs at the The U.S. Preventive Services Task Force

This week the The U.S. Preventive Services Task Force (USPSTF) released recommendations concerning breast cancer screening that seem stunning.

Among the recommendations is that against routine screening of those age 40-49. Your moderators are generally supportive of the concept of evidence based medicine, when the evidence considered is sufficiently broad. The task force recommendation is limited in that:

• it is based on mortality and longevity data alone, ignoring other positive medical outcomes
• it seems biased by the comparatively larger number of screens necessary to save a life, without considering the comparatively larger economic value of saving that younger life
• it is absolute in its recommendation. The panel could have, instead, recommended less frequent screens in the 40-49 year olds had they created a decision tree that considers the results of an initial screen (this would preserve the existence of a baseline exam, which itself may impact the survival data of those age 50 and up). This action could reduce the number of exams required, under age 50, yet still save the same number of lives as the current protocol does
• It ignores a wealth of unpublished clinical experience
• it fails to consider the recommendations of several specialty societies (themselves experts in the field)
• etc

The HHS Secretary Sebelius then made a statement reflecting her view that this report would not impact upon third party payment decisions. In doing so, she injected this action of the USPSTF into the health care reform discourse.

Basic Needs of Physicians Must Come First

Concerned physicians (both those who do and those who do not oppose the AMA strategy on Health Care Reform) have asked, "Is the AMA ready to 'walk away from the table' IF the 'onerous provisions' remain in the final Senate version?"

• AND IF the SGR is not eliminated without the substitution of another financial nightmare...
• AND IF tort reform remains a mere promise...
• AND IF collective negotiations remain a pipe dream?

PM writes "The basic needs of physicians MUST come first, (for only) then we can help those that desperately need our help to keep them well.

We are not public servants. We are healers that put our patients' welfare before our own personal needs. This time we must look out for us first. We cannot afford to settle for less (because it is politically correct) and hope to change 'onerous provisions' after the fact."

The Hypocrisy of Deficit Reduction & Health Care

Daniel Gross, in a recent Newsweek column, describes the hypocrisy of those who loathe " deficit spending for the purpose of funding social insurance, but love it when it's used to finance military actions abroad".

Too often, "deficit reduction is a form of defense—... a shield for policies ... (that legislators) don't like," according to Maya -MacGuineas, president of the bipartisan Committee for a Responsible Federal Budget.

Hospital Associations and State Medical Societies alike have attempted to quantify the economic impact of health care. But the chart above, from the Bureau of Labor Statistics, suggests the importance of the health care sector on employment. In these times of high unemployment and debate on health care reform, the importance of health care as an employer should not be underestimated.

Gross concludes, "Being obsessed with deficit reduction when the economy has suffered its largest setback since the Depression is like being obsessed with water conservation when your house is on fire."

Can't We Pick One from Column A and One From Column B?

The Republican bill leaves out a number of the key features of the Democrats' legislation (and thus does too little to alleviate the problem of the uninsured):

• It does not require employers to insure their employees
• It does not require nearly all Americans to purchase insurance
• It does not block insurers from denying coverage to people with pre-existinghealth conditions

Instead, the Republican plan

• increases incentives for people to use health savings accounts,
• caps non-economic jury awards in medical malpractice cases at $250,000,
• provides various incentives to states with the aim of driving down premium costs and
• allows health insurance to be sold across state lines.

Link to Boehner Bill (Med Mal pp 150-169)

Universal Coverage and Life Expectancy

From Nicholas Kristof in the NYTimes:

"The United States ranks 31st in life expectancy (tied with Kuwait and Chile), according to the latest World Health Organization figures .... (but) there is one American health statistic that is strikingly above average: life expectancy for Americans who have already reached the age of 65.

At that point, they can expect to live longer than the average in industrialized countries. That’s because Americans above age 65 actually have universal health care coverage: Medicare".

Enough Talk About Deficits, Will I be able to Afford the Premium?

Health Care Reform has become a debate politicized well beyond, in your administrators view, the overriding objectives of

• health care for all and
• the sustainability of the system

The CBO has prepared estimates of the costs to the nation of health care reform under various congressional proposals, and has even estimated the further savings that can be achieved by including provisions such as liability reform into these proposals.

But there seems to be considerably less consideration paid to the affordability of premium. This is despite the fact that the ranks of the uninsured are populated by people simply unable to afford insurance. A mandate alone will not make the premium any less of an individual hardship.

Even if premium (and the proposed subsidy) is 'affordable', there is concern that pending legislation offers insufficient protection against the high payments required to meet deductibles, co-payments, and other out-of-pocket charges.

There is concern that some families would have to strain to pay their premiums and would probably have to cut back on such items as clothing, various household expenses, meals eaten out, and other activities. Additionally, their plight could worsen in coming years as premium would rise faster than wages.

It would be shameful that if due to poor planning and poor politics the under-insured became the under-clothed and the under-nourished as well.

'Consumer Option' to have Negotiated Rates

According to the NYTimes, Speaker Nancy Pelosi has decided to propose a government-run insurance plan that would negotiate rates with doctors and hospitals, rather than using prices set by the government.

Ms. Pelosi said the public plan, which she prefers to call a “consumer option,” would compete with private insurers.

Members of the House Democratic leadership team offered these details of their bill, to be unveiled on Thursday.

• It would provide coverage to 35 million or 36 million people.
• The 10-year cost of expanding coverage would be less than the $900 billion ceiling suggested by President Obama.
• The cost would be offset by new taxes and by cutbacks in Medicare, so would not increase the federal budget deficit in the next 10 years or in the decade after that.
• The new bill retains a surtax on high-income people, but increases the thresholds to hit married couples with adjusted gross incomes exceeding $1 million a year and individuals over $500,000

Link to article

Small Business Premiums Double Last Years Increases!

Insurance brokers and benefits consultants say their small business clients are seeing premiums go up an average of about 15 percent for the coming year — double the rate of last year’s increases. That would mean an annual premium that was $4,500 per employee in 2008 and $4,800 this year would rise to $5,500 in 2010.

Some experts ... think the insurance industry, under pressure from Wall Street, is raising premiums to get ahead of any legislative changes that might reduce their profits... Small businesses ... employ about 40 percent of the private labor force.

Owners of small companies say the lack of options is why they have been paying increasingly higher premiums for less and less coverage — this year perhaps more than ever.

NYTimes Article

Ingenix Replacement Announced - Unfair (Insurance Company) Practice Reversed

New York State Attorney General Andrew Cuomo announced the establishment of an independent database for consumer health care reimbursement and a consumer website. Cuomo said that, previously, industry data was skewed to show lower health care costs so insurers could underpay for out-of-network services.

Mr. Cuomo, acting upon concerns raised by the AMA and MSSNY, achieved settlements with the major insurers to replace the flawed Ingenix database with a new database. This will be developed by Fair Health Inc. and an upstate research network headquartered at Syracuse University. Funding is from the Cuomo settlements.

Cuomo stated that this will bring much needed transparency, accountability and fairness ... to a broken system. According to the Cuomo press release, this announcement arises from a wide-ranging investigation which uncovered 'a fraudulent and conflict of interest ridden system'.

Link to WSJ

Link to LIBN

Link to Attny General Cuomo's statement

United Health's Better Than Expected 3Q Earnings

Mr. Hemsley, the United CEO, said, ... that ... Ingenix -- a health-care data and consulting operation (and home of the fraudulent database) -- will be the company's widest-margin business in 2010.

Link to WSJ Article

SGR is not a Problem of the Uninsured

On a NY Times blog was this entry regarding the politics of S 1776:

'(Providing an SGR fix), ... in legislation separate from the big health care overhaul, is raising uncomfortable questions for President Obama and for Democratic leaders in Congress ...

(This is so, because they) promised that revamping the health care system would not add to the nation’s deficits.'

Physicians recognize that the flawed SGR, and Congress's repeated 'patches' over the years, are essentially a 'loan'. Repayment of this loan, which itself derives from flawed budget legislation from 1997, does not in any way redress the current health care system problems of the uninsured and of expanding access. It would thus be illogical to consider this cost in the same breath as true Health System Reform.

Senate Bill on SGR

Repealing the SGR is one policy objective that is a common goal of all physicians. The Stabenow bill, S. 1776, the “Medicare Physicians Fairness Act of 2009,” creates the pathway to achieve that goal. Call (888) 434-6200 toll free to leave a message for your senator.

S. 1776 will:

1. serve as the Senate legislative vehicle for eliminating Medicare’s sustainable growth rate (SGR) formula and
2. lays the foundation for establishing a new Medicare physician payment update system.

The procedural path for passing S. 1776 will be complicated, requiring the support of 60 Senators on several procedural motions over the next few days.

S. 1776 will be the subject of a cloture vote on late Monday afternoon (Oct 19). 60 votes are needed to invoke cloture to allow formal consideration of the bill.

A vote on final passage is expected to occur next Thursday (Oct 22) or Friday ( Oct 23).

Harry Reid, the Senate Majority Leader, Sen. Baucus, Chairman of the Senate Finance Committee, and Sen. Chris Dodd, along with President Obama all strongly support passage of S. 1776.

Again, call (888) 434-6200 toll free to leave a message for your senator. Keep the momentum going.

Health Plans Strike Back

America's Health Insurance Plans engaged PricewaterhouseCoopers to examine the impact of four components of the health reform bill being proposed by the Senate Finance Committee. The report, on behalf of the insurers, will assert that under four of the provisions of the senate finance bill, health premiums will rise faster than they would under the current system.

According to the PricewaterhouseCoopers report, there are four provisions included in the Senate Finance Committee proposal that could increase private health insurance premiums above the levels projected under current law:

o Insurance market reforms coupled with a weak coverage requirement,

o A new tax on high-cost health care plans,

o Cost-shifting as a result of cuts to Medicare, and

o New taxes on several health care sectors.

The flaw in this analysis results from the failure to consider the impact of each of the four provisions independently. For example, the 'weak coverage requirement' of the senate bill alone is identified as promoting adverse selection for the health plans. This is the basis of much of the bill's impact upon premium. The report fails to project the impact upon premium should this 'weakness' be eliminated.

Additionally, the report is limited in that it examined just the four provisions considered likely to increase costs. No consideration is given to the beneficial effect on premiums of other provisions of the bill such as health exchanges or the public option (not contained in the senate bill) that would likely result in premium reduction.

The States and Health Care Reform

A new compromise proposal by Sen. Tom Carper would spell out how to boost competition in the private market by enacting government-run plans at the state level.

Under the proposal, in its current form, each state would have the option to:

1) Participate as grantees in the CO-OP program and apply for seed funding.

2) Open up that state’s employee benefits plan to all citizens.

3) Create a state administered health insurance plan (public option) with the opportunity of banding together with other states to create a regional insurance compact.

"Conceptually, having the states take responsibility makes a great deal of sense," said Nebraska Sen. Ben Nelson, a key voice for moderate Democrats ... states are already in the health-insurance business because they administer Medicaid and other federal-state programs.

One key Republican in the debate, Maine Sen. Olympia Snowe, cast doubt on the Carper idea. She favors the so called 'trigger' should private insurers fail to provide affordable coverage.

But, when it comes to the twin objectives of lowering costs and providing coverage to all, the experience of state-by-state systems hasn't been a happy one. The vicissitudes of the business cycle make stable funding problematic. Unable to run budget deficits in lean years, recession-strapped state governments invariably must cut benefits, beneficiaries or even their programs altogether.

Most Republicans remain opposed to the president's plans. Yet recent census data suggest that those Americans lacking health insurance now are far more likely to live in states that usually vote Republican — the very states with senators and representatives least likely to support a law to extend coverage.

Opposition to health care reform thus presents a double quandary for the Republican leadership in Congress and in the states. It is their residents that need health care reform most, and as it turns out, the funding in part would come from blue state (northeast and midwest) taxpayers. Health care reform spending would be little different from the overall pattern of red state socialism (chart).

Retard Innovation

David Brooks, in the New York Times, supports the Wyden approach to health care reform, which he says infuses a combination of universal coverage and (consumer) choice. Brooks favors a more transparent system, in which people see the consequences of their choices.

Brooks points out the many weaknesses of The Baucus approach. "It entrenches a flawed system. It creates greater uniformity and rigidity ... It squeezes people into a Rube Goldberg complex of bureaucracies ...

The biggest problem is that it will retard innovation. Top-down systems just don’t innovate well, no matter how many Innovation Centers you put in ... The bill will retard innovation"

The problem with individual consumer choice is that, while desirable (and transparent), it alone is insufficient to overcome such powerful forces such as insurers, employers, pharm, government, and even the complexities of illness itself. Neither the pending bills, nor Brooks himself, defines an important role for the physician. Physician driven innovation will be needed to define and to sustain true reform.

Baby Steps

According to the CBO, "the bill would reduce deficits by a total of $81 billion in the decade starting next year ... the analysis “demonstrates that we can expand coverage and improve quality while being fiscally responsible ... (but) 25 million people — about one-third of them illegal immigrants — would still be uninsured in 2019"

Link

Get the Profit Motive out of Health Care Financing

In a Letter to the New York Times, Burton C. D’Lugoff & James Hawthorne note that "The United States is the only developed country that allows for-profit companies to eat up 20 cents of every premium dollar to provide insurance for basic health care." Favoring no specific solution, they instead urge, " The important thing is to get the profit motive out of health care (financing)."

Thus far, Congress has balked at health care reform due to the projected costs, about $1 trillion over the next ten years. In contrast, the Fed has been most aggressive in supporting the market for mortgage-backed securities ... purchasing about $905 billion worth of government-guaranteed mortgage-backed securities through mid-September (about 80 to 85 percent of the market).

Referring to these purchases, George Miller, executive director for the American Securitization Forum declared, “This is public support ... the mortgage risk is held by the taxpayer.”

Viewed solely on the basis of its cost, health care reform does seem expensive. But, when viewed relative to other initiatives of similar cost (and less certain benefit) the investment in health care reform is good value.

Waste and the Big Doctors’ Salaries that Go With it

Cohen's piece strikes a cord:

'In America ... There is endless worry that one’s neighbor may be getting more than his or her “fair” share.” ... (Americans) mythologize their rugged (always rugged) individualism as the bulwark against initiative-sapping entitlements.'

Cohen points out that, 'We’re not talking about health here. We’re talking about national narratives and mythologies — as well as money. These are things not much susceptible to logic.'

But he strays from his point, and loses my support when he provides as the second reason to support a public option; '... to provide competition to private insurers and so force waste, excess and cozy arrangements out of the American system. Behind all the socialized medicine babble lurks a hard-headed calculation about money — all the profits skimmed from that waste and the big doctors’ salaries that go with it.'

So, despite a decent appraisal of how the cultural differences between europeans and americans are shaping the discourse on health care, Cohen's (incorrect) assumptions about doctor's salaries, and their relation to waste and skimmed profits reinforce the important viewpoint of those skeptics within our profession.