Health 'Reform' Gets a Failing Grade
Ubiquitous
As the dean of Harvard Medical School I am frequently asked to comment on the
health-reform debate. I'd give it a failing grade.
Instead of forthrightly dealing with the fundamental problems, discussion is
dominated by rival factions struggling to enact or defeat President Barack
Obama's agenda. The rhetoric on both sides is exaggerated and often deceptive.
Those of us for whom the central issue is health�not politics�have been left
in the lurch. And as controversy heads toward a conclusion in Washington, it
appears that the people who favor the legislation are engaged in collective
denial.
Our health-care system suffers from problems of cost, access and quality, and
needs major reform. Tax policy drives employment-based insurance; this begets
overinsurance and drives costs upward while creating inequities for the
unemployed and self-employed. A regulatory morass limits innovation. And deep
flaws in Medicare and Medicaid drive spending without optimizing care.
Speeches and news reports can lead you to believe that proposed congressional
legislation would tackle the problems of cost, access and quality. But that's
not true. The various bills do deal with access by expanding Medicaid and
mandating subsidized insurance at substantial cost�and thus addresses an
important social goal. However, there are no provisions to substantively
control the growth of costs or raise the quality of care. So the overall
effort will fail to qualify as reform.
In discussions with dozens of health-care leaders and economists, I find near
unanimity of opinion that, whatever its shape, the final legislation that will
emerge from Congress will markedly accelerate national health-care spending
rather than restrain it. Likewise, nearly all agree that the legislation would
do little or nothing to improve quality or change health-care's dysfunctional
delivery system. The system we have now promotes fragmented care and makes it
more difficult than it should be to assess outcomes and patient satisfaction.
The true costs of health care are disguised, competition based on price and
quality are almost impossible, and patients lose their ability to be the
ultimate judges of value.
Worse, currently proposed federal legislation would undermine any potential
for real innovation in insurance and the provision of care. It would do so by
overregulating the health-care system in the service of special interests such
as insurance companies, hospitals, professional organizations and
pharmaceutical companies, rather than the patients who should be our primary
concern.
In effect, while the legislation would enhance access to insurance, the
trade-off would be an accelerated crisis of health-care costs and perpetuation
of the current dysfunctional system�now with many more participants. This will
make an eventual solution even more difficult. Ultimately, our capacity to
innovate and develop new therapies would suffer most of all.
There are important lessons to be learned from recent experience with reform
in Massachusetts. Here, insurance mandates similar to those proposed in the
federal legislation succeeded in expanding coverage but�despite initial
predictions�increased total spending.
A "Special Commission on the Health Care Payment System" recently declared
that the Massachusetts health-care payment system must be changed over the
next five years, most likely to one involving "capitated" payments instead of
the traditional fee-for-service system. Capitation means that newly created
organizations of physicians and other health-care providers will be given
limited dollars per patient for all of their care, allowing for shared savings
if spending is below the targets. Unfortunately, the details of this massive
change�necessitated by skyrocketing costs and a desire to improve quality�are
completely unspecified by the commission, although a new Massachusetts state
bureaucracy clearly will be required.
Yet it's entirely unclear how such unspecified changes would impact physician
practices and compensation, hospital organizations and their capacity to
invest, and the ability of patients to receive the kind and quality of care
they desire. Similar challenges would eventually confront the entire country
on a more explosive scale if the current legislation becomes law.
Selling an uncertain and potentially unwelcome outcome such as this to the
public would be a challenging task. It is easier to assert, confidently but
disingenuously, that decreased costs and enhanced quality would result from
the current legislation.
So the majority of our representatives may congratulate themselves on reducing
the number of uninsured, while quietly understanding this can only be the
first step of a multiyear process to more drastically change the organization
and funding of health care in America. I have met many people for whom this
strategy is conscious and explicit.
We should not be making public policy in such a crucial area by keeping the
electorate ignorant of the actual road ahead.
| Dr. Flier is dean of the Harvard Medical School.
--
It's now time for healing, and for fixing the damage the Democrats did
to America.
snakehawk
> By JEFFREY S. FLIER
>
> As the dean of Harvard Medical School I am frequently asked to comment on the
> health-reform debate. I'd give it a failing grade.
But . . . but Dean--they probably wanted an intelligent comment. If
this crap is any indication of the quality of thought coming out of
Harvard, you people should consider adding carpentry and welding
classes to the curriculum.
>
> Instead of forthrightly dealing with the fundamental problems, discussion is
> dominated by rival factions struggling to enact or defeat President Barack
> Obama's agenda. The rhetoric on both sides is exaggerated and often deceptive.
> Those of us for whom the central issue is health—not politics—have been left
> in the lurch. And as controversy heads toward a conclusion in Washington, it
> appears that the people who favor the legislation are engaged in collective
> denial.
>
> Our health-care system suffers from problems of cost, access and quality, and
> needs major reform. Tax policy drives employment-based insurance; this begets
> overinsurance and drives costs upward while creating inequities for the
> unemployed and self-employed. A regulatory morass limits innovation. And deep
> flaws in Medicare and Medicaid drive spending without optimizing care.
>
> Speeches and news reports can lead you to believe that proposed congressional
> legislation would tackle the problems of cost, access and quality. But that's
> not true. The various bills do deal with access by expanding Medicaid and
> mandating subsidized insurance at substantial cost—and thus addresses an
> important social goal. However, there are no provisions to substantively
> control the growth of costs or raise the quality of care. So the overall
> effort will fail to qualify as reform.
Now Doc, costs and quality of care are matters almost exclusively
within the domain of the healthcare providers--principally, the
doctors. The healthcare legislation is aimed at providing access to
healthcare, access by the unemployed, the underemployed, the ill, the
elderly, children, students, and to the millions who will soon be
priced out of healthcare insurance. Get it now?
The idea, Doc, is to get everyone covered by some kind of insurance so
that when one of them has to pay the doctors, nurses, technicians, and
hospitals, they will have the funds available. The proposed
legislation is not trying to reform healthcare, it's trying to reform
healthcare insurance.
The proposed healthcare legislation does not mandate that doctors,
nurses, technicians and hospitals lower their fees. The law does not
propose to dictate to doctors how many visits to schedule, which tests
to conduct, or which medicines to prescribe. The law does not infringe
on medical decisions; the law simply aims to getting funds to patients
to pay for it all.
>
> In discussions with dozens of health-care leaders and economists, I find near
> unanimity of opinion that, whatever its shape, the final legislation that will
> emerge from Congress will markedly accelerate national health-care spending
> rather than restrain it.
Well, duuh. Adding over 40 million Americans to the ranks of people
with funds to obtain reasonable healthcare services is bound to
increase overall spending by the general public. But it will reduce
the number of people who receive publicly subsidized healthcare and
therefore reduce the amount of government spending. Think of it this
way: if everyone had private insurance, there would be no need for the
government to pay for any healthcare. All the homeless, the
destitute, the unemployed, and the minimum-wage laborers crowding
those public emergency rooms would disappear. Everyone would have
access to their own doctors and their local facilities--just like rich
people.
The idea is not to restrain "overall" spending on healthcare; the idea
is to spread the cost out among all the population so that those
unfortunates who actually need expensive healthcare are not driven
into bankruptcy and homelessness just so their child can get an
appendectomy. Oh sure, everyone (except doctors) would like to see the
cost of actual healthcare lowered by law, but that could only be
achieved through Socialized Medicine, where the doctors and nurses
would be public employees and the hospitals would be government-owned
facilities.
Likewise, nearly all agree that the legislation would
> do little or nothing to improve quality or change health-care's dysfunctional
> delivery system. The system we have now promotes fragmented care and makes it
> more difficult than it should be to assess outcomes and patient satisfaction.
> The true costs of health care are disguised, competition based on price and
> quality are almost impossible, and patients lose their ability to be the
> ultimate judges of value.
Are you the dean of the Medical School or the School of Economics?
Competition? Since when do people shop around for doctors and
negotiate the price for surgery? Ever heard of a heart attack patient
walking out of the emergency room because the price was too high? In
real life, patients are the slaves of the doctor, doing what the
doctor says and paying what he demands.
Competition must take place before the patient needs healthcare--when
the patient is shopping for healthcare insurance. Unfortunately,
there is not much more competition between insurers than there is
between doctors. Most states have only one or two insuance companies
writing policies, and the companies are immune from antitrust laws and
can do pretty much as they please. In all the rate hearings in all
the states, no one has ever heard of insurance companies lowering
their rates. Why should they?
>
> Worse, currently proposed federal legislation would undermine any potential
> for real innovation in insurance and the provision of care. It would do so by
> overregulating the health-care system in the service of special interests such
> as insurance companies, hospitals, professional organizations and
> pharmaceutical companies, rather than the patients who should be our primary
> concern.
Overregulating insurance companies? The federal government doesn't
regulate insurance companies at all. Insurance companies are
regulated by state governments, and state ratings commissions are
virtual prisoners to the demands of the insurance companies. Immune
from antitrust laws, the insurance companies can set their prices and
threaten state governments with withdrawal of all business in the
state unless their demands are met.
It is more than passing strange that a Harvard man would ignore the
well-known explosion of healthcare insurance premiums and blythely
bypass the insurance crisis by lamenting that insurance companies
might be overregulated.
Incidentally, how do you feel about a public option where a government
managed program would offer an alternative to paying those hefty
private insurance company premiums?
>
> In effect, while the legislation would enhance access to insurance, the
> trade-off would be an accelerated crisis of health-care costs and perpetuation
> of the current dysfunctional system—now with many more participants. This will
> make an eventual solution even more difficult. Ultimately, our capacity to
> innovate and develop new therapies would suffer most of all.
>
> There are important lessons to be learned from recent experience with reform
> in Massachusetts. Here, insurance mandates similar to those proposed in the
> federal legislation succeeded in expanding coverage but—despite initial
> predictions—increased total spending.
>
> A "Special Commission on the Health Care Payment System" recently declared
> that the Massachusetts health-care payment system must be changed over the
> next five years, most likely to one involving "capitated" payments instead of
> the traditional fee-for-service system. Capitation means that newly created
> organizations of physicians and other health-care providers will be given
> limited dollars per patient for all of their care, allowing for shared savings
> if spending is below the targets. Unfortunately, the details of this massive
> change—necessitated by skyrocketing costs and a desire to improve quality—are
> completely unspecified by the commission, although a new Massachusetts state
> bureaucracy clearly will be required.
Are doctors in Massachusetts paid that much more than in other
states? Or is the skyrocketing costs associated with burgeoning
Insurance company profits? Does Massachusetts have a public option?
Do Insurance companies compete in Massachusetts? Comparing the
attempts by one state to rein in healthcare costs with a national plan
to spread the costs among the population is comparing apples and
oranges. C'mon Dean, you can do better than that.
>
> Yet it's entirely unclear how such unspecified changes would impact physician
> practices and compensation, hospital organizations and their capacity to
> invest, and the ability of patients to receive the kind and quality of care
> they desire. Similar challenges would eventually confront the entire country
> on a more explosive scale if the current legislation becomes law.
>
> Selling an uncertain and potentially unwelcome outcome such as this to the
> public would be a challenging task. It is easier to assert, confidently but
> disingenuously, that decreased costs and enhanced quality would result from
> the current legislation.
>
> So the majority of our representatives may congratulate themselves on reducing
> the number of uninsured, while quietly understanding this can only be the
> first step of a multiyear process to more drastically change the organization
> and funding of health care in America. I have met many people for whom this
> strategy is conscious and explicit.
>
> We should not be making public policy in such a crucial area by keeping the
> electorate ignorant of the actual road ahead.
>
> Dr. Flier is dean of the Harvard Medical School.
Next time I go to a doctor, I'm going to check his credentials--if
he's from Harvard, I'm outta there.