From: Walter Miles <waltmiles at comcast.net>
To: WSFA members <WSFAlist at KeithLynch.net>
Date: Thu, 10 Oct 2013 17:16:20 -0500
Subject: [WSFA] Re: A point of information about the government shutdown
Reply-To: WSFA members <WSFAlist at KeithLynch.net>

Hello Mike

WM>> Healthcare reform *could* have been the key to U.S. budget stability,

MB> One of the points we agree on.  Healthcare is one of the more likely
MB> things leading to bankruptcy for the country.  The problem is that
MB> demanding that everyone get health insurance isn't the right starting

Well, I'd be inclined to demand that everyone RECEIVE health insurance.
As Mark pointed out, Sen. Baucus (and others, many also Democrats) made
that more difficult.

MB> point.  The right starting point is figuring out why health care costs
MB> so much here (and I think that health insurance is a prime suspect).

Well, it's tough.  First some not-very-insurancy aspects:

*End of life care*

My wife sees (and sometimes must give) care that she believes *reduces*
the quality of life of patients, and is unlikely to increase the length
of life.  Mostly this is near the end, of course.  This is happening in
an institution (the VA) that is working hard on palliative medicine, and
on improving outcomes/reducing costs.  There are many causes:  families
that can't let go of loved ones, or whose religious beliefs won't let
them, a few that are trying to keep benefits, some that don't want the
patient at home, a good number that really can't take care of them there.
Ignorance about all aspects of medicine is a very important factor--not
just for poor people.  Talk of "death panels" sure didn't help.  It may
have caused real torment to be inflicted on some patients.  My impression
is that very few people, if they think about that stage of life, really
want "heroic" efforts to be made.  Everybody wants to be cured of a
temporary malady, though.  It takes care and attention on the part of
medical professionals, and education of patients and family (all of us,
really) to make those judgments.

(Note:  I've emphasized patient/family issues, but there are still doctors
who never want to give up and hope that they can cure anything (whether
it's compassion or ego).  I think we *are* learning to deal with that.)

Better understanding of patients by doctors, and medicine by laymen, will
help costs come down.  New lifesaving treatments will continue to appear,
which will always make it difficult to know when it is right to treat a
patient aggressively.  There will be dreadful goofs, and more money spent
than is mathematically optimal, but some cost will come out.  Note that
I've said nothing about limiting treatments for sicker patients:  it may
happen, but I don't think there's a big savings there compared to having
patients be informed and doctors better able to communicate
----------------------

*Fee For Service (kind of insurancoid)*

We have a friend who works the part of the Pew Charitable Trust that does
public health research and advocacy.  We were talking about government
provided care (Alaskan Native Health Service, in his case), and I said
that only the rich would get better care from a private fee for service
system.  He said no, not even them, and gave an example:  ANHS patients
with leg injuries would be required to have rest, or physical therapy,
etc. for months before surgery was scheduled.  Often, they improved so
much that NO operation was needed.  If money is no object, or an FFS
service regime is in place, doctors are biased (not always by greed, but
by attitudes inculcated during training, and by the standard practice of
those around them) towards immediate surgical procedures that pay them
directly.  The outcomes are slightly worse overall.  I don't know if that
operates in every area of medicine, but he believed it was pervasive
problem, that the FFS incentive fought against "evidence based medicine."
Eliminating FFS, if we can find a good formula for paying for maintaining
health, will help cost somewhat as well.

(Another note:  evidence based medicine is sometimes pushed so hard that
it seems that one size *must* fit all.  An insightful physician may find
it difficult to deviate from standard practice, even in cases where its
efficacy is unclear.  I suspect this will be worked out slowly).
-----------------------------

*Malpractice vs. quality control*

I *do* believe the reports that malpractice insurance cost rose early in
the 2000s because of diminished financial market returns rather than
increased jury awards.  But that *ain't* where it's at.  The worst thing
about the malpractice law system is not the money, it's capriciousness.
A patient that doesn't know to sue, or won', may let a physician get away
with a terrible act, but a doc in an unlucky outcome may get nailed for
no good reason.  Multi-disciplinary review boards (including us ordinary
folks?) looking at many cases will probably find more problems that need
to be corrected, than lawyers very familiar with legal outcomes, but not
with medical ones.  Malpractice law *IS* better than nothing, but why does
the alternative have to be *nothing*?

The (generally academic, sometimes governmental) medical establishment is
working on quality, and on requiring training for people who make mistakes
instead of (generally financial) punishment as the only solution.  Costs
are huge for one malpractice incident, substantial in insurance terms for
practitioners, but I suspect they are *very* small compared to the cost of
all avoidable mistakes.  Better documentation of cases, automatic checking
of prescriptions etc., really dumb checklists for procedures, good old
evidence based medicine, and so on, and on, will help.  Computers are huge
in this.

The "Blame Free Environment" is important in encouraging self-reporting,
and will focus attention on common practices that need to be improved.
However, a few weeks ago, Sholey detected some NON-"blame free" behavior
by nurses (not deadly, not a firing offense, but they sure shoulda known
better), and got resistence to her report from supervisory nurses.  It's
a real trick.  How do you balance problem detection and solving with the
need to eliminate real negligence?  This will probably also be worked out
slowly with painful hiccups.  The public beheading crowd will resist this.

The problem of paying for people who have bad outcomes must be separated
from that of correcting bad medical behavior.  Patients who suffer when
doctors perform flawlessly need to be taken care of too.  There is a place
for legal or financial sanction, but it can't start with the lawyers.
Unfortunately, neither they nor the tort-reform advocates generally pay
much attention to that.  I wonder if malpractice law will just fade into
the background if outcomes and "internal discipline" improve?

I think there will be a sizeable payoff from better quality control.  This
will be true for other advanced nations as well, so it won't catch us up
to them at all.  I don't think they are *that* far ahead of us in this
area.  Yet?

What a flood of verbal diarrhoea!  (Note the "o").  Maybe I'll get around
to the insurance side before the country is dissolved (nawww).  I do think
that's bigger (health insurance, not the End Times).

Walter