Showing posts with label health policy. Show all posts
Showing posts with label health policy. Show all posts

The Truth About Obamacare Review

The Truth About Obamacare
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The Truth About Obamacare ReviewBest book out there on what is wrong with ObamaCare and why it has to be repealed. Every politician should read this - every TEA party member, Republican, Conservative, Libertarian,...anyone right of center or fiscally conservative should memorize the data in this book! I have been highlighting and writing notes in the margins on every page just to make certain I remember all the facts that Ms. Pipes lays out.
Easy to read, easy to understand, and above all - easy to retell to those people convinced that government is the answer to every problem. Excellent price too - buy a few, and hand them out.The Truth About Obamacare Overview

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Chaos and Organization in Health Care Review

Chaos and Organization in Health Care
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Chaos and Organization in Health Care ReviewThere have been a great number of books analyzing health care over the past year and one suspects that this wave will continue. The book by Lee and Mongan entitled Chaos and Organization in Health Care (MIT Press, 2009) is one of the more recent. The premise of the book appears to be that the delivery of health care has problems because it is in an organizational state of chaos and if order is restored by the means proposed by the authors then all things will improve.
On page xi they specifically state that "the solution is organization" and it is from this assertion that they continue to build their argument. On page xiii they assert their proposal that a "tightly structured delivery organization" is the ideal and they proceed to use several examples throughout the book. Before continuing, I would introduce an interesting historical observation. When I spent time in and around Longwood Avenue, the Harvard Medical School area, in the 1960s, I could actually park my VW in the lot in front of one of the hospitals. By the late 1980s I had to use a multi-story garage, for what I thought was a great fee of $8. Last week I used the gigantic subterranean parking edifice for $30. The authors seem to recommend that the patients come to them, where they are collected as a group, but the vignette on parking just is the tip of the exclusion iceberg. It is quite difficult to get patients to trek to a single location for intermittent or routine care, they are all too often difficult to get to, especially for a patient who would then have to take great time from an already pressured schedule. The answer has been the single or multi-practitioner practice.
On p xii the authors speak of team based solutions to treating Diabetes. If one looks at Type 2 Diabetes, then in the overwhelming majority of cases it is s self inflicted disorder due to obesity and diet. The disease can be cured by just losing weight, and there should be actions taken to make that happen, otherwise a cost should be applied to the patient's life style choices. Assuming that nothing can be done with such a patient is just wrong and places the costs on the rest of us who comply.
On pp 39-40 the authors begin their analysis with the data from Medicare showing that patients see multiple physicians each year. They have a chart which shows that for Diabetes the Medicare patient sees 9 different physicians 3 of which are primary care and 6 of which are specialists. One will accept the data but one must question it. If the patient has Type 2 Diabetes, then we know that there are kidney, cardiac, neurological, ophthalmological, and possible endocrine issues, but if the average Medicare patient with type 2 Diabetes sees all of this every year then this is clearly an overload on any system. The authors put this data out there without adequately explaining it and allow it to speak for itself. It does not do so well.
On p 47 the authors have a table which shows the tests that Internists no longer routinely perform. Let me address a few. First, the treadmill stress test is better performed by a cardiologists just in case a patient does suffer an MI while be tested. The general internist is not prepared to handle this and the insurance could skyrocket if it were taken on, as well as the insurance company may not reimburse it. There are many reasons why not. Now for a liver biopsy. No Internist would take the risk of performing an invasive surgical procedure in their office unless there was no possible alternative. Slicing an artery in the liver is a substantial risk.
Part II starting on p 55 is where the authors begin their proposal for organization. Their overall proposal is in Chapter 6 for a Tightly Structured Health Care Delivery Organization, on p 97 and they use the VA as an example. The essence of the proposal is that one can create a dense and tightly integrated delivery system and that one gets the patients to come to that system and because of the efficiencies in this delivery mechanism the units costs and thus total costs are reduced. This is the classic centralized architecture approach introduced into production in the 1800s. Yet one questions whether that is the sole paradigm for the delivery of health care.
In Chapter 10 on p 175 the authors detail many of the reasons for lack of change. They focus on the provider and carefully list the key barriers to any form of evolution. On p 184 they present an interesting chart, charts of this type one can find in almost any environment, that one physician in the ER ordered 40% more CAT scans then the second highest ordering physician. Rather than bemoan that statistic one should try to understand why, the devil is in the details.
On p 205 the authors appear to support the bundling of payments, a plan which has worked its way into the current health care bills (2009). Bundling is a natural outgrowth of institutionalizing health care delivery. However if one can argue for the permanence of a distributed health care delivery system, which is in proximate contact with the patients, then bundling would be just another word for institutional control and the reduction of physician autonomy and patient choice. It is a sticky issue and the authors do not do credit to both sides.
On p 229 in the final chapter the authors stress that organization of providers is essential for change. They also seem to promote the single payer system approach on p 237.
The problem is that there is no financial or business analysis of the proposals. There are many generalizations and many anecdotes but frankly not a single analysis and what would be obtained by defined actions. I return to the metric we used before, namely that for any specific disease we have the total costs being:
Total Costs=Population X Incidence X Procedures per Patient X Costs per Procedure
Thus we can look at costs as driven by the four elements above. We see a growing population and thus no influence there. We can reduce incidence. Smoking has been reduced by taxing cigarettes and thus we have seen a reduction in male lung cancer incidence. Yet on the other hand we see a massive explosion in obesity and the resulting Type 2 Diabetes. A great deal can be done on incidence. On procedures; for acute coronary syndrome and the like we now have many procedures we can do today that we could not do 40 years ago and we have reduced mortality 50% as a result. Is that good, should we perform those procedures.
Then finally the costs per procedure. The last element is what the authors seem to be speaking to. What are they and how do their proposals reduce the costs and by how much. The devil is in the details, and more importantly in the numbers. It is with the numbers that the authors come up very short. The book is much too anecdotal and way too lacking in details.
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Sick To Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life (California/Milbank Books on Health and the Public) Review

Sick To Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life (California/Milbank Books on Health and the Public)
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Sick To Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life (California/Milbank Books on Health and the Public) ReviewInsightful review of end-of-life care in US and policy perspectives on what needs to be accomplished. Especially sensitive to caregiver needs.Sick To Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life (California/Milbank Books on Health and the Public) Overview

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Conflicts of Interest and the Future of Medicine: The United States, France, and Japan Review

Conflicts of Interest and the Future of Medicine: The United States, France, and Japan
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Conflicts of Interest and the Future of Medicine: The United States, France, and Japan ReviewThis is the most compelling book exposing conflicts of interest, usurpation of a whole profession by money & a total disregard for the code of honor of medical professionals.The systems of Japan & France are also scrutinized. Medicine & the allied professions in the USA were bought off by industry long ago and what we have now is a mendacious medical industrial complex where whole systems no longer have the integrity they used to. Billions are spent on medical futility or therapeutic obstinacy on those past all cures, all remissions, all reprieves from advanced age or dementia. Sadly, just follow the money. The capitalistic model is only interested in the bottom line- even industry controls the message of the medical student to buy this brand or that brand. No wonder the system is bankrupt: financially, morally, ethically. The medical industrial complex has sown rewards for generations to come, rewards for itself. For this work of major importance I give Dr. Rodwin 5 stars. Damiano de Sano Iocovozzi MSN FNP CNS, CEO of the Thomas Edwin Walls Foundation (scholarship to medical, nursing, social work and respiratory care students who learn biomedical ethics, advocate for sooner hospice placements & learn the signs that a patient has less than 6 months of life)Conflicts of Interest and the Future of Medicine: The United States, France, and Japan Overview

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Understanding Global Health (LANGE Clinical Medicine) Review

Understanding Global Health (LANGE Clinical Medicine)
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Understanding Global Health (LANGE Clinical Medicine) ReviewI chose this book as a textbook for an undergraduate summer course on global and public health. The book is probably among the best available and I found it providing the level of information needed for a short course. The chapters are short enough to each be read in a couple of hours or so making them good homework assignments. The book covers the main areas of global health. Some chapters would have benefited from expansive discussion such as the environmental health chapter that focused on water quality and sanitation or infectious diseases chapter. Topics of tobacco or chronic diseases are not covered or missed from the book. But in all, this is a good book and written in an easy and understandalbe language even for the lay person and I would recommend it.Understanding Global Health (LANGE Clinical Medicine) Overview

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Inside National Health Reform (California/Milbank Books on Health and the Public) Review

Inside National Health Reform (California/Milbank Books on Health and the Public)
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Inside National Health Reform (California/Milbank Books on Health and the Public) ReviewInside National Health Reform offers an uncommon combination of both the political process and policy substance of the Affordable Care Act. From his unique perspective, John McDonough provides a first-hand, thoughtful account of the politics surrounding health reform, and supplies the context for how our health care system, and its many problems, came to be. Further, McDonough's thorough and balanced description of the provisions included in the ACA go far to educate readers on the substance and potential implications of the new law, written in both an entertaining and accessible way. The book revives much-needed optimism about the future of our health care system at a time when we are too quick to forget the historic accomplish and sweeping benefits the ACA.Inside National Health Reform (California/Milbank Books on Health and the Public) Overview

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Health Policy Issues: An Economic Perspective Review

Health Policy Issues: An Economic Perspective
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Health Policy Issues: An Economic Perspective ReviewThis is an excellent book that provides the reader with a great overview of relevant issues in HealthCare. The format is extremely user-friendly, and the content is superior. This book was required for my Health Policy class, and it will be a keeper. Regardless of your opinions on the status of healthcare in this country, you can find useful information to defend any perspective, as well as information that will be eye-opening, possibly changing your perspective on certain issues. I thought I knew it all until I read this book. It's one of the best I've ever read. By the way, did I say how READABLE it is? As a busy physician, I hardly have time to read anything; but this was well-worth it! This updated version even covers Medicare, Part D.Health Policy Issues: An Economic Perspective Overview

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The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream Review

The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream
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The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream ReviewIn his ethnography (PDF) of Grover Norquist's weekly breakfast meetings, Thomas Medved tells us how Newt Gingrich sold reluctant conservatives attending the meeting on Medicare reform.
The debate up to this point functioned largely as a prologue for the day's special guest, former Speaker of the House Newt Gingrich. Here to mediate between the fiscal conservatives who disliked the bill and the free-market conservatives who saw in it the seeds of health care privatization, Gingrich spoke out in favor of the Medicare reform act. His primary message to the group was that they must start "thinking like a majority" by accepting the logic of incremental progress. That's how the welfare state was built, he said, and that is how it must be dismantled. Citing his own efforts to "stop Hillary-care" and promote the Contract With America as examples of incremental progress, Gingrich said Medicare reform is a step toward a more conservative country because it "moves you toward choice." Gingrich saw other benefits in the legislation as well. He cited in particular a major "shift in plate tectonics" now that the American Association of Retired Persons (AARP), the largest voluntary organization in America, was on the Republican side of an issue and against the Democrats. And there was yet another hidden advantage: Gingrich predicted that the bill's passage would "break up the collectivist language" of union members because when employers adopt the strategy of giving Health Savings Accounts to their non-union employees, the unions would start fighting for them. In general, Gingrich said, we can "migrate Medicare" rather than destroy it by creating choices that baby boomers will take advantage of.
"Creating choices" is an interestingly ambiguous term. As discussed in Jacob Hacker's book, people who have signed up to Health Savings Accounts (which were around before the Medicare legislation) seem to be much less happy than those who have traditional coverage; they presumably wouldn't `choose' them if there were better options on the table. Nonetheless, the number of Health Savings Accounts is growing. Over a quarter of large employers said that they would offer them in 2006, and larger employers such as Walmart are increasingly trying to move away from traditional plans to HSAs, which discourage workers with health problems from staying with the firm, and hence save them money. The choice offered here is to accept a worse deal from your employer, or quit and hope that you'll somehow find something better somewhere else. Not much of a choice. Yet nonetheless, when the mantra of `choice' is invoked by the right, it often refers exactly to choices of this kind. There's something weird going on.
Jacob Hacker wants to unravel this weirdness. He's a political scientist - his major empirical contribution in the last few years has been to describe the mechanisms through which Gingrich and others have deliberately sought to undermine welfare state institutions, inch by inch. In writing about this, Hacker has enlarged our understanding of how institutional change takes place. But this book isn't an exercise in descriptive social science. It does help explain how the right's renewed emphasis on `personal responsibility' is less an exercise in increasing choice, and more a means of transferring risk away from large collective actors (such as governments or firms) to individuals, who typically have far fewer resources to deal with disaster when it happens. But Hacker is trying to change the political debate, to push back against current ways of framing these issues, and in so doing, to redefine the intellectual terrain. This is why the book was attacked so vigorously (and incoherently) before it was published, by people like Brink Lindsay and Glenn Reynolds . If Hacker's framing of politics succeeds in taking hold, it will make it much more difficult to chisel away the foundations of the American welfare state than it has been in the past, and correspondingly make it easier to expand welfare state principles to new areas.
Hacker's account is twofold. First, he looks at the various ways in which risk has increased over the last few decades. Jobs: Hacker discusses how expectations of stable employment have nearly disappeared, how part time and temporary work have increased, and so on. He argues, as others have argued, that `flexible' jobs don't necessarily increase choice for employees, because these work arrangements are typically set up "for the convenience of employers, not workers." Part time work may in principle be a boon for mothers with young children - but not when the firm changes your schedule according to its week-to-week needs, and fires you if you can't make it in. Families: having a family increases your risk of going bankrupt, and involves massive, and increasingly risky investments in housing and education. Old age: as defined benefit pension plans become vanishingly rare, individuals take on more and more risk through defined contribution plans, which will do well if the stock market does well, and do badly if it doesn't. Health: health care has become ever more expensive, posing greater risk both to the uninsured and the insured (and people move back and forth between these groups far more often than most people realize).
At least some of this increase in risk is secular - it's hard to trace it back to specific decisions made by particular people or groups. But what isn't hard to trace back are the decisions made by policy makers to exacerbate these risks by aiding and abetting the transfer of risks to individuals rather than countering it. This is the second prong of Hacker's argument. We know that policy makers could have done differently - they have done differently in other countries. But in the US, thanks to Gingrich and others like him, government has sought to increase individuals' exposure to risk rather than to decrease it, typically under the mantra of increasing `choice' or `freedom.' Thus, for example, the abovementioned individual Health Savings Accounts. Thus too, the effort to tear down Social Security, and replace it with a system of `private' or `personalized' (depending on which buzzword works better with focus groups) accounts, regardless of the enormous switchover costs. Instead of trying to mitigate risk, government under conservatives has sought to pile ever more risk on individuals, even if the fiscal consequences are horrendous.
Hacker argues that not only are these policies ideologically loaded - they transfer risk from corporations to the middle and working classes - but they don't make any sense in their own terms. High degrees of personal risk are a hindrance rather than a spur to beneficial economic activity. If people perceive that their jobs are risky, they're likely to underinvest in specialized training (here, there is a well established literature in political economy which suggests that an extensive welfare state goes hand-in-hand with the development of specialized skills). Personal investments in education are less attractive if the rewards from education are highly uncertain. In the book's conclusion, Hacker briefly describes a variety of policies that might help mitigate personal risks, including his own proposal for Medicare Plus.
Despite this short discussion of policy options, The Great Risk Shift isn't really a book that is aimed at the professionals who write about health care, pensions etc, or at scholars, although it relies extensively on findings by both policy wonks and academics. It isn't intended to contribute to specific policy debates, but to transform very broad public arguments. To my eyes at least, it seems very clearly intended to claw back territory from what Hacker describes as the Personal Responsibility Crusade by making policy makers deal with the problems of risk, and by making ordinary people realize that the economic risks that they face haven't descended from the skies. In large part, those risks are the result of conscious, deliberate choices made by conservative policy makers (and sometimes by centrist Democrats) both indirectly to help pave the way for the transfer of risk to individuals, and not to intervene when government could play an important role in mitigating risk.
Which is all to say that this book is going to succeed or fail to the extent that it changes wider public debates. As an unreconstructed social democrat, I wholeheartedly hope that it succeeds; while there are bits of Hacker's argument (such as his explicit discounting of the issue of economic inequality) that I disagree with, on the whole, I think that this is a highly valuable, and indeed potentially explosive book. This is a good, smart, polemical book. It deserves a wide readership, so that next time a Newtoid starts talking about this or that appalling piece of legislation `increasing choice' or `personal responsibility,' he or she will be called on it. Even if George Lakoff and others' arguments about political framing are rather reductive, political debate is shaped profoundly by the language that it is conducted in and the concepts that it invokes. This is a fiercely and tightly argued effort to change those concepts. I hope it succeeds.The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream Overview

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