Tuesday, December 30, 2008

Too much moral purity, eh? Ooooh kaaaaay.

But more on that later. Meanwhile...

The problem with equating our private insurance companies with European private insurance companies, is that ours are investor-owned and profit-driven, while theirs are non-profit and, in essence, not much more than private companies that are hired to administer what is in most cases a de facto government-run single-payer system. The government tells them what they will cover and what they will charge people for that coverage, and most of that coverage is paid for with taxes.

The private "insurers" that Maggie Mahar admires here, Group Health Cooperative and Kaiser Permanente, are non-profit, true HMOs and are basically miniature versions of the National Health Systems of Spain and the UK, where the government [the taxpayers!] owns the hospitals and clinics and employs the doctors and nurses and so forth. We have that here in the US: the VA system [and no, Walter Reed is an Army hospital, not a VA hospital].

The much-admired Cleveland Clinic and Mayo Clinic also operate this way, non-profits that own their own facilities and hire their personnel on salary.

All of which argues that the very best way to deliver superb care *and* contain costs is to just nationalize the whole damned system, where the taxpayers own the hospitals and employ all the nurses and doctors.

After a lot of study, this has become *my* preferred solution: open up the VA system to everybody in the country [we'd probably have to rename it though]. The VA even has a working electronic health records system already in place, for those of you who are turned on by that sort of thing.

Not everybody is up for that radical a change, and besides, I'm all for promoting small and medium-sized businesses, so I'm willing to compromise here.

Nationalizing the whole system [payers, providers, and facilities] is one far end of the spectrum of methods for providing health care [for convenience, we'll call it the left].

What we have right now is almost all the way at the other far end of the spectrum: totally privatized [we'll call this the right]. We've essentially established Medicare as our national high-risk pool, covering the elderly and disabled, as both are rather expensive groups that the private insurers don't want to have to pay for, but beyond that [and a few other imperfect safety nets such as Medicaid, state high-risk pools, etc], it's pretty much market-driven competition.

And this is where Barack Obama's plan, Max Baucus' plan, Jacob Hacker's plan, Ron Wyden's plan, Bill Clinton's plan, Hillary Clinton's plan, John Edwards' plan, [I could go on] fall down. The assumption in all these plans is that providers [doctors, dentists, hospitals, pharmacies, etc] are competing with each other for customers [patients] and that payers [insurance companies, and "a new public plan like Medicare"] will all be competing with each other for customers [individuals, employers].

The reality is that intra-group competition doesn't happen all that much. Your employer dictates who your insurer is, your insurer limits your choice of doctors / hospitals / pharmacies, and people generally pick the closest doctor from that list and go to whichever specialist or hospital that doctor sends them to.

Really, payers are in competition with providers, employers are in competition with payers, individuals are in competition with each other [for jobs] and with their employers [over who pays how much of the premium], and individuals who lack employer-sponsored coverage are in competition with payers.

To help various entities in this multi-sided argument compete with various other entities, we have:

- benefits managers [hired by employers to negotiate with insurance companies, and to explain benefits to employees]

- pharmacy benefits managers [to negotiate three-way with insurance companies, pharmacies, and drug companies]

- radiation benefits managers [presumably they do the same thing as PBMs but with imaging centers instead of pharmacies and drug companies]

- denial management companies [to help providers argue with payers]

- patient advocates [to help individuals argue with payers]

- utilization review and utilization management companies [iirc, they're hired by payers to check up on providers and patients both]

Plus, you can hire auditors to check up on all of the above. It's a terrific system for employing lots and lots of people and shoveling lots of $$$$$ throughout the economy, but it sucks at delivering health CARE.

Single payer and European-style multi-payer are right smack dab in the middle: nationalized insurance and private providers. Single payer [fully-nationalized insurance] is a bit to the left of center, and European style [mostly-nationalized insurance] is a bit to the right of center.

Getting back to the moral purity argument... neither of these centrist positions is one of moral purity, but moving to one or the other of them is going to be essential for our survival.

Single payer has several advantages over European style:

- less administrative complexity means lower costs [or more money available to be spent on actual care]

- the US is a big country with a mobile population, and one plan with every provider "in network" means fewer hassles for travelers

- why would anybody want to choose among *plans* and *payers* when we could all have the same plan and payer and just choose our *providers*?

As for losing groups like the Cleveland Clinic, the Mayo Clinic, Kaiser Permanente, and the Group Health Cooperative if we go to single payer, it's my understanding that under HR 676, such non-profit provider groups would still exist. I haven't called John Conyers' office and asked him about it though, so I could be wrong. Any volunteers?

/rant

6 comments:

Mahakal / מהכאל said...

I'm happy with Kaiser Permanente. I think a system like open enrollment Medicare for all would be best, and as you suggest the VA system could also be made open to non-veterans, though I think they may specialize a bit in certain things. Non-profits like KP can (and I think do) take both members or Medicare patients. Payments to for-profits would have to be limited and that could hurt their business model further without per se putting them out of business.

Sometimes Saintly Nick said...

Happy New Year! May many blessings and joys be yours in 2009!

hipparchia said...

happy new year and blessings to you and alex, nick!

hipparchia said...

heya, mahakal!

hr 676 has provisions to convert all the for-profit hospitals and clinics to non-profits over a span of 15 years, with funding for buying out the investors. there's also wording in there about those providers that are already operating as non-profits being allowed to continue in their present mode, which i've always taken to mean that groups like kaiser permanente wouldn't really be affected [though that's something i've never verified].

i've read, in my jaunts through the blogosphere, that some people have complaints about kp, but everyone i've ever talked to directly [and i include commenting on blogs in talked to directly] that has actually had kaiser permanente has told me they're happy with it. friends who have been to the mayo clinic tell me it's wonderful, and i've read mostly glowing praise for the cleveland clinic. it would be a shame to dismantle groups like this if they're anywhere near as good as their press suggests they are. i'll have to look into this more closely.

expanding either the va system or medicare to the general population would require some tweaking, but we're adaptable creatures, we can do this. probably the switch to a fully-nationalized system [expanding the va] would be a bumpier transition than expanding just medicare, and the public payer / private providers model works really well, so i'd be happy with either one.

i'd even be happy with our present system if all these many layers were actually providing exquisite care to every single person who finds themselves inside the borders of this country, legally or illegally. it's an expensive and inefficient model, but people gotta have jobs, and those jobs might as well be delivering health care.

i refuse, however, to countenance keeping all these jobs around to deny care.

BadTux said...

Note that K-P is non-profit. They're run by the Kaiser Foundation, a not-for-profit foundation. This is actually how virtually all hospitals were run until deregulation started in the mid 1970's. When my mother entered nursing, for-profit hospitals were actually *illegal* in my state. That got overridden by federal laws during the mid 70's...

- Badtux the Healthcare Penguin

hipparchia said...

thanks for the timeframe info, badtux. like monkeyfister i didn't really start noticing the effects on my community until the 1980s.