HCR -- Saturday Morning Curmudgeon

By John Ballard

Trudging along the health care reform trail with due diligence as a layman, I came across yet another sandbox of folks playing at the game of What's Gonna Happen Next?

A very smart post at The Health Care Blog by Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, points to the Massachusetts model as bellwether indicator for the rest of the country now having (nearly-)universal health care, his state having been first in the country to adopt the idea before all the others. As push comes to shove financially, the matter of insurance rates looms large in the public's perception of whether or not health care reform is "working." That's not the same as "Is universal health care resulting in better health care for more people?" Instead it is code language for "Can we afford it?"

The closing two paragraphs are revealing.

It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in.

That is what we is happening right now in Massachusetts. Watch us closely, other 49! Do we go the route of short-term political expediency and bad regulatory policy, or do we show the wisdom and maturity to put in place directionally appropriate policies? There is an old legal expression: Hard cases make bad law. As things founder in the judicial and executive realms, brava to Senator Murray for having the courage to step in.

I fear he's in for a rude awakening if he imagines anyone picked from the political class will speak the hard truth but I say that hoping to be wrong. It is possible that "Senate President Therese Murray will step into the breach when she speaks to the Greater Boston Chamber of Commerce Wednesday, unveiling a proposal she hopes will resolve the great health care standoff." But I'm not optimistic.  Too much of what needs to be said, not only in Massachusetts but all over the country, will call for tougher language than politicians are capable of using. (Witness Bart Stupak. I rest my case.)

Readers can go and read a muddled comments thread for details. Comments left at that blog are from all across the political and professional landscape, so keep your salt shaker handy. Finding no coherent line of thinking, this is what I left...

As a layman who has followed the health care reform debate going on two years now I am still waiting for clarification of a few basic realities.

1. PROFESSIONAL COMPENSATION IS NOT THE SAME AS PROFITS. What doctors are paid is different from what corporations report as profits. Unfortunately, the corporate view is that professional compensation is an "expense" (and a drain on profits) but for doctors the same amounts are how they earn a living.

2. HEALTH CARE IS FURNISHED BY MEDICAL PROFESSIONALS, NOT INSURANCE COMPANIES. Most people wrongly believe that health care is provided by insurance but the mission of insurance is to manage the costs of medicine, not medical efficacy.

3. TWO KINDS OF RISK MANAGEMENT ARE CONSTANTLY BEING CONFLATED: MEDICAL risks (expertise of medical pros) and FINANCIAL risk (expertise of actuaries working as insurance pros).

Universal health care should mean the end of cherry-picking for medical pros and insurance companies. It won't, of course, because we live in a free country and will always have boutique doctors and insurance policies in the same way that we have high-end retail shops, private clubs, gated communities and chauffeur-driven transportation. The sooner the shakeout, the sooner the dust will settle.

Meantime, professionals, both medical and insurance, need to get over thinking they have the whole market to themselves. Insurance companies and medical providers are now in the position of the Allies after WWI and WWII. It's time to divide the spoils and get on with what comes next. It's sundown time for cherry-picking.

And patients (remember them?) need to understand there is a limit to what medicine can and cannot do. But those limits are two-fold: medical (what is scientifically feasible) and financial (what can you afford?).

And the tough part is this: it's up to BOTH MEDICAL AND INSURANCE PROFESSIONALS TOGETHER to speak these hard truths to their patients/clients. Those who imagine that political types will do so are living in a fool's paradise.

As an addendum, "medical professionals" includes everyone from the highest-compensated specialists or GP all the way down to technicians, housekeepers and food service people. There is plenty of room in America for everyone and no one should be paid less than whatever the market can bear.

Until the Sixties all hospitals were "not for profit" but when the profit-driven hospital business model came into existence, along with physician-owned clinics and group practices, a "moral hazard" came along at the same time. A fee-for-service billing model plus referrals to for-profit institutions became the engine of health care inflation guaranteeing that over time parasites would eat their hosts. Sure enough, that's where we went.

Somewhere along the way the notion of healing sick people (which leads to a smaller revenue stream) got lost. I read somewhere that in Sweden hospitals are paid for empty beds as well as those in use. That notion is based on the quaint idea that the mission of hospitals is keeping the community healthy, so empty beds means that goal is being reached. I don't anticipate such a crazy idea will ever come to pass in this country, but the thought is worth contemplating.

Please excuse the ramblings of an old Saturday morning curmudgeon. I'll try not to trouble you again.

Beth Israel Deaconess Medical Center is where Dr. Halamka is Chief Information Officer. My occasional links to his blog have appeared here, and this week's item for "Cool Technology of the Week" is another fun toy, a hand-held windmill!
Go check it out.