This makes me forgive Larry Summers whatever he
said about women scientists.

Posted at July 2, 2008 3:26 PM in response to One Small Step For Equality

Pathman 25--

You're absolutely write. "Thinking medicine" or "cognitive medicine" is just a term that some
health policy people use to talk about medicine which involves talking to and listening to the patient---but not "acting" (i.e. operating or performing some other procedure).

Of course surgery requires an immense amount of thought. I think most people realize this--they look up to surgeons. (Hence, the phrase, "It's not brain surgery").

(And I agree--I can't think of a single area of medicine that doesn't require much thought.)

But I think many people may not realize how much thought is required to be a really good family doctor, pediatrician or palliative care specialist.

This is part of the reason why doctors in these areas are paid so much less. Of course in many cases, what they do doesn't require as many years of training and they don't have as many years of loans --so some salary differential makes sense.

But it's too wide--which is why we have a shortage of doctors in these areas. (I've written about average salaries in various specialties here http://www.healthbeatblog.org/2008/01/health-care-spe.html

Some med students who would like to go into these areas just don't feel they can afford to because they have $275,000 in loans. . .

Posted at July 2, 2008 3:21 PM in response to The Score: Physicians 355; Insurers 59: Blood on the Senate Floor

Thank you all for your comments.

John W.-- You've hit the nail on the head. We need to think about health care as a collective problem, not as an individual problem. That's what other countries do--and that's why they have health care that's affordable, universal and in many cases better.
I often say that the reason that the French have such a good healthcare system is that the French feel that nothing is too good for another Frenchman. Unfortunately, we do not feel that way about each other. I’ve written about this here: http://www.healthbeatblog.org/2008/03/obstacles-to--2.html

Tenaciousd and Marquis de SeaToShiningSea--
I agree with the Marquis. Most states have made a mess of Medicaid and SCHIP. Some just don't have the money to do it right.(Alabama) Others just don't care about taking care of their poor. (Florida and Texas).

Bluebell and Brook D. -I have to agree with you about the current Congress. Overall, an extraordinary disappointment. Timid. Cowardly. etc.
But we will have a new Congress soon. The question is whether the so-called liberals who come to Congress actually are progressives--and whether they have the spine to act. We need politicians who will lead, not politicians who hold focus groups and then try to please the people who have time to go to focus groups . . .

Ellen-- The House bill would give insurers two years to phase out "fee-for-service" Medicare Advantage plans which are a)costing us more than other Medicare Advantage plans and b) providing significantly poorer care. (MedPac has very good medical research showing this. I read their 400 page reports, which come out in March and June every year. Unfortunately, they don't get as much publicity as they should--for obvious reasons.)

The problem with Medicare Advantage plans that pay fee-for-service and don't build a network of doctors is that you wind up seeing 7 specialists who don't know each other, don't talk to each other, and, because they are paid “fee-for-service” have a financial incentive to "do more" (tests, procedures etc) whether or not "more" will be medically effective. Over-treatment is a huge problem because if the treatment is not necessary, a patient is, by definition, exposed to risk without benefit. In other words over-treatment isn't just a waste of money, it's hazardous to our health.

So seniors really won't be losing anything under the House bill.

You write: "Medicare Advantage is popular with seniors, especially young seniors, because it eliminates the need for Medigap insurance -- a savings of something near $1500-$2100 per year. Some may see insurers being paid "a huge premium" by the Medicare Advantage program; seniors may see it differently.”

You are right that with Medicare Advantage you don't have to buy Medigap. But, under Medicare Advantage, you often find that you don't have all of the benefits you had under traditional Medicare—and your co-pays may well be higher. . Of course you only find this out when you get sick. (It's very, very hard to read the policy and figure out what it will and won't cover. I’ve written about this on www.healthbeatblog.org. Let me quote from one post: “ in February the Government Accountability Office (GAO) reported that “19 percent of Medicare Advantage beneficiaries [are] in plans that projected higher cost-sharing for home health services, and 16 percent of beneficiaries [are] in plans that projected higher cost-sharing for inpatient services," meaning that a decent chunk of MA enrollees are actually going to see higher out-of-pocket costs and co-pays than they would under traditional Medicare.

“And if a senior becomes seriously ill, he may well discover that while he had been told that there was a $4,000 annual cap on out of pocket payments, certain very pricey items are excluded from the cap. In February, the Times revealed that 29 percent of MA plans that have caps don’t include the cost of some cancer drugs, 23 percent exclude the cost of some mental health services and 21 percent don’t include home health care expenses. These, of course, are the big ticket items that could bankrupt a senior—or force her to sell her home.

“Meanwhile, GAO says, the majority of Medicare Advantage policies offer no cap on how much a beneficiary may wind up spending out of pocket. In other words, the claim that MA is cheaper for Medicare beneficiaries has a big fat asterisk next to it. So too does another possible justification for the government’s investment in MA: that the money thrown into MA funds leads to better coverage .. .”
“Just how much is this costing us? Last year a CBO report noted that payments to private health plans in the Medicare Advantage program rose “from about $40 billion in 2004 to about $56 billion in 2006…[T]hose payments will increase to $75 billion in 2007 and $194 billion by 2017 and will total $1.5 trillion over the 2007–2017 period.” All in all, CBO notes, “the share of Medicare spending for...Medicare Advantage plans will increase from 17 percent in 2006 to 27 percent in 2017.”
Ellen, when you write that while “Some may see insurers being paid "a huge premium" by the Medicare Advantage program; seniors may see it differently,” the phrase “being paid” begs the question—Who is paying?

The answer: There is no free lunch. Seniors are paying higher co-pays and deductibles in regular Medicare as well as in Medicare Advantage to foot the bonus that we’re paying Medicare Advantage insurers. . If we continue to throw money at private insurers via Medicare Advantage, all workers will be paying the bill through higher FICA payroll taxes. Medicare is growing broke. Unless something is done, it will run out of money to pay hospital bills in eleven years. That’s why it’s talking about slashing doctors’ fees. But that’s not the answer. (Some doctors are paid too much; others, like primary care docs are paid too little. The fees need to be adjusted with a scalpel, not an axe).

Ellen--On the AARP siding with the doctors. AARP is also in the Medicare Advantage business, so that’s not why it’s siding with the doctors. The fact is that AARP realizes that “inflated payments to Medicare Advantage plans are unfair and fiscally irresponsible.” (an official statement.) AARP recognizes that the money paid to the insurers is coming at the expense of regular Medicare. AARP also realize that if doctors’ fees are slashed across the board, doctors who now make, say $120,000 to $150,000 a year may well stop taking Medicare patients or retire early. We now have a shortage of primary care docs, gerontologists, palliative care specialists, family doctors, etc—because they are paid so much less than the folks who cut you or radiate you. This will get worse.

RDF: you are certainly right about the recent history of public commissions. But I remember a time--before 1980, before the conservative movement took over the country.

I think many of us are ready for a pendulum swing back to a more progressive, more intelligent form of government. The people on the MedPac Commission (Medicare Payment Advisory Commissoin are really, really good. By and large they are not in anyone's pocket. Their reports are smart and filled with medical evidence. Now, if someone would appoint them to look into reforming Medicare . . . It will be very interesting to see who Obama appoints to head the FDA, CMS, . . ..

We are ready for a new "New Deal." Sometimes, things have to get really bad before they get better. They're really bad. . . .

Posted at July 2, 2008 1:05 PM in response to The Score: Physicians 355; Insurers 59: Blood on the Senate Floor

Getex--

Because the post was so long, I cut part of what I was going to say about "overtreatment."

Overtreatment is treatment that exposes the patient to risk without providing a medical benefits. We have more than two decades of research done by physicians examining Medicare records, looking at treatments and outcomes, and that work shows that about 1/3 of our health care dollars are wasted on treatments that put the patient at risk and do him no good.

For example, we know that a large number of angioplasties are done on patients who will not benefit--research shows no reduction of mortalities for patients who fit that profile.

Do you remember when all children had tonsillectomies? Well today, there are still many "tonsillectomies"--procedures that are overdone on way too many patients.

AS for dying patients, what I cut was a section saying that too many dying patients receive aggressive, hi-tech care that they do not want. But once you're in the hospital, you may not feel you have many choices. You're simlply told: this is what we're going to do now.

What patients need is "palliative care." This is different from hospice care which means that you stop trying to cure the patient and simply treat his pain.

Palliative care specialists talk to the patient, explain his options--in detail, talking about risks and benefits--and let him make the decisons. (They also counsel the family). They continue giving the patient as much treatment as he wishes, while keeping him out of pain.

Posted at July 1, 2008 5:08 PM in response to The Score: Physicians 355; Insurers 59: Blood on the Senate Floor

Saroff writes:

"we both missed the 60s, and his conclusion is that there were 'excesses'.He does not understand those times, and does not understand that the backlash against them was driven almost entirely by racism, so he gets his political points from dissing an era that changed the nation for the better.

This is absolutely true. Too often, those who "missed the 1960s" buy into Reagan's revisionist and deeply racist view of that era. It is too bad that Obama seems to belong to that group.

I agree that Krugman saw this before many others were willing to acknowledge it.

Now, the centrist rhetoric is piling up--along with the pandering to the Christian Right. I dread the speech on Motherhood.

Those of us who are left of center need to speak out and keep reminding Obama that we are an important part of his base.

Posted at July 1, 2008 12:09 PM in response to Fake Left, Cut Right

This is why manufacturers should not be invited to "sit at the table" when making decisions about health care reform.

Posted at May 15, 2008 12:39 PM in response to Eli Lilly Edits Disclosure Bill

This is why manufacturers should not be invited to "sit at the table" when making decisions about health care reform.

Posted at May 15, 2008 12:39 PM in response to Eli Lilly Edits Disclosure Bill

If you read part 1 or 2, you'll see that
I'm not talking about a top-down mandate.

Ultimately, I'm talking about giving people
a choice between the healthcare they have
now, or some other private insurance, or
a public-sector plan.

But as the next post will explain (and as I indicated earlier) BEFORE
giving the entire nation that choice,
I suggest that we try to reform Medicare--
raising the quality and lowering the cost
by focusing on care that is effective.

Medicare is part of our broken system. If we
first try to fix Medicare, then we will
have a much better model for a rational
affordable, high quality public sector plan.

Posted at May 13, 2008 3:07 PM in response to The Third Obstacle to Health Care Reform: The Lobbyists

Matthew, you wrote:

"What if every new initiative the Chinese government unveiled was wrapped in rhetoric about how the point of it was to compete with the United States, rather than to raise Chinese living standards? Well, we'd be freaking out."

I agree completely. We would say that China was "trageting us."

When will we ever learn to think globally (in the best sense), and to understand that when economic conditions improve in other countries this is good for the world as a whole?

I'd disagree with destor23 in comparing the progress China and India are making today to Japan's seeming economic dominance in the 1980s.

Unfortunately, Japan's boom was based on a stock market bubble built on top of real estate that was hugely overvalued. Like our stock market bubble of the 1990s, it was bound to blow up.
At the time, Japan was a developed economy moving from success to excess.

China and India are developing countries that are trying to become developed countries. Along the way, there is the danger of excess--things will become overvalued, and after taking 3 steps forward, they'll have to take two steps back. Maybe 3 steps back.

But the Chinese govt, in particular, is trying to keep a lid on the economy so that it doesn't try to grow too quickly. At the same time, they have to create jobs for millions of people. And their environmental problems are huge.

If, rather than competing with China, or fearing China, we tried collaborating--particularly on environmental issues which are important to all of us, that would make much more sense.

It's not about being No. 1 anymore.

Posted at May 5, 2008 12:42 PM in response to The Other Side of the Glass

Thanks for all of your comments.

I’m sorry I didn’t come back yesterday, but my laptop broke down. Today,
it magically, inexplicably ,began to work again. I have absolutely no idea how or why.

I haven’t been contributing to TPM café in recent months because I’ve been snowed under with my own new blog for The Century Foundation—(www.healthbeatblog.org)

But it’s good to be back, and to hear some familiar voices. Now that I’ve gotten my blog more
or less under control, I do plan to get back into the habit of posting here, on TPM.

Below responses to individual comments, beginning from the top.

Art Appraisor—It’s very good to hear from you again.

You write: “A final point I might add: consider what happens if, instead of raising general taxes to pay for increased Medicare costs, Congress starts raising the monthly premiums the retired already have to pay for Medicare, and/or co-pays, deductibles, etc. When everyone is hearing complaints from elderly relatives about that, it will be easier for conservatives to make people afraid of changing to more government involvement.”

You are right: if we let Medicare co-pays and deductibles continue to rise, people who greatly admired Medicare six years ago will see it as a failed project.

This, I’m afraid is what many conservatives want. They would liketo get rid of Medicare by privatizing it. (See my most recent post on www.healthbeat.blog. It's about privatized Medicare--Medicare Anvantage.)

And this is why we need to reform Medicare as soon as possible—cutting out the hazardous waste, raising the quality of care, and making it more affordable.

Thanks very much for the kind words about the posts..

Ellen & Wigmarx—

Wigmarx, I absolutely agree about getting rid of the TV ads.

But when it comes to obesity and smoking, it’s very important to understand that both
are linked to poverty. And while medical science has found a way to deal with one of these problems, it is helpless in the face of the other.

Begin with obesity and poverty. Poor people eat more foods high in carbs and fats
because they are much cheaper—and filling. Go to a grocery store in a low-income neighborhood and try to find fresh fish, fruits, vegetables, good meat . . If you find them at all, the prices will be very, very high.

Poor people also don’t have the same opportunities to exercise. They don’t belong to gyms.

And they’re not likely to go jogging early in the morning or in the evening after they comehome for work—too dangerous in the neighborhoods where they live.

Ghd public schools that their children go to don’t have playyards, may not have a gymnasium, regular gym periods, or a gym teacher (particularly in elementary schools.)

Finally, if you are poor, you are likely to be both depressed and quite anxious. You have a
lot to worry about: your kids getting hurt in the neighborhood; losing your job; getting a job;
your sister, who is an addict; your mother who is diabetic . . .etc. etc.

People who are very depressed or anxious tend to self-medicate: eating, smoking, and drinking in
excess are ways to feel better, and calm your nerves . . . You can’t afford a shrink. Or the medication a shrink might prescribe.

Finally when it comes to smoking, doctors have figured out how to help people quit smoking. Good
smoking cessation clinics are very successful. But we have far too few. Why? Because helping poor
people stop smoking is not very profitable. This is an area where the government needs to step in.

When it comes to obesity, this turns out to be a much more complicated problem. It’s a combination of the genes you inherited, environmental factors and psychological factors.

We just don’t’ understand obesity very well. Physicians who specialize it his area can help
patients lose weight—but they can’t Help Them Keep It Off. We don’t know why. The most conscientious patients who desperately want to lose weight follow their doctor’s instructions--and still regain the weight

So when you are tempted to blame obese people for being obese, you need to remember that

a) You are blaming them for being poor and
b) even physicians don’t know how to help them lose the weight long-term.

I’m afraid I have to break off now—other work to do. But I hope you all keep the thread going, and
I’ll come back to respond to the rest of the comments tomorrow.

Posted at April 13, 2008 8:21 PM in response to The Politics of Health Care Reform – Part 2