This BLOG picks up where the last one left off - discussion of all of us as "consumers of health care ". I started wondering what does being a "consumer" mean. I had heard the discussion about how we are becoming/have been a "consumerist culture". Then I started wondering if everybody is really a "consumer of health care" and if we should indeed approach the debate on health care that way. So of course I went to Dictionary.com and got a formal definition of "consume". Here it is:
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consume
c.1380, from L. consumere "to use up, eat, waste," from com- intensive prefix + sumere "to take," from sub- "under" + emere "to buy, take" (see exempt). Economic sense of consumer (opposite of producer) first recorded 1746. Consumerism is from 1944 in the sense of "protection of the consumer's interest;" modern sense of "consumption as an economic policy" is from 1960.
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I was struck by the base of the word is "to buy, take, use up" in an intense manner. When I go to the doctor, do I really "consume" his services? I feel intensely uncomfortable with that characterization. Consumer/customer is supposed to be the king. The goods and service providers aim to please the customers/consumers and give them what they want. Is that a correct model to adopt in health care setting? More importantly what is the role of the consumer/customer in determining the utility/effectiveness/value of the transaction? In most ordinary cases the utility/effectiveness/value is very largely if not completely determined by the producer or the entity delivering the service. The taste of the food, at the first level, does not depend on your actions. What is required on part of the consumer/customer are some basic actions - chew the food and swallow. Similarly in case of travel, it is completely incumbent upon the airline/railway/bus companies to ensure safety, comfort, timeliness of the journey.
In case of health care, the situation couldn't be more different. In most if not all cases, consumers/customers play a vital role in the outcome - restored health and functionality. The consumers/customers have a very significant role in determining the efficiency and cost effectiveness of the enterprise. So what does it mean in the case of health care that "consumer focused culture" or the health care industry that says "customer is always right"?
One specific case captures this issue: I heard a news report about Nexxium (the acrid reflux medicine). It is a powerful medicine (proton pump inhibitor that completely stops acid production in the stomach. The report talks about the severe side effects when the medicine is stopped. There are many lifestyle changes that are found to be quite effective in managing the acid reflux. However many people may find those "hard" and "not acceptable" especially when there is a pill they can take and their insurance pays for it and they can continue living as before without the pain and discomfort. Same things can be said about hyper tension, cholesterol, diabetes. It is clearly what the customer wants. Is that what the doctors and insurance companies should give? If we accept a certain model of transaction between health care providers and customers, then this is indeed what should happen and as a matter of fact is happening.
Some people may say I am talking about a paternalistic view of health care providers. May be that is what I have in mind when population at large continues to behave like juveniles! Another analog that I will expand on later is the education system. If the teacher considers a student to be the customer/consumer then it is clear that most of the customers/consumers want grades without homework and exams. Is that what the teachers should provide?
If one does not want a paternalistic health care system, then they should act like adults and accept consequences of their actions. A chain smoker who develops lung cancer or COPD should be (may be) given palliative medication to "take the edge off the pain somewhat" but should be allowed/required to face consequences of their actions. Same goes of obese people suffering from many maladies that come with their behavior, or for alcoholics who develop cirrhosis of liver.
Are we as a society ready to take these actions? If not, then we have no right to expect to demand a "consumer-oriented health care system"!
Wednesday, September 30, 2009
Saturday, September 19, 2009
Health- is not the same as Health Care- is not the same as Health Insurance
In any setting and in any assembly of people it is hard to avoid discussion of the current Health Care Reform debate. This weekend the five couple that forms our bridge group are on a “Bridge Retreat” in Lake Anna. In this beautiful and relaxed setting, we nonetheless did engage in strong and long debates on this issue. As a matter of fact I wrote this post from Lane Anna.
A couple of weeks back David Goldhill wrote a along article in Atlantic Magazine titled “How the Health care System Killed My Father”.
http://www.theatlantic.com/doc/200909/health-care
It is an intense article that proposes solutions that are radical and far outside the scope of current proposals across the political spectrum. I found the article thought provoking and insightful in many respects but also seriously deficient in a few. The scope is too broad so I don’t want to cram it in a single BLOG entry. Instead I will discuss it in separate BLOGS.
The central theme of the article is contained in the title of this BLOG. He further adds “happiness” as another critical factor. Goldhill correctly points out that the current debate is almost exclusively focused on health insurance industry that administers and finances the health care industry. The discussion implicitly assumes that the fundamentals of current system are correct and we need to remove some distortions and inequalities to make the system work better. He takes strenuous objections to this central thesis. He sets up a parallel with auto insurance which all of us are required to get (mandate) if we wish to register and drive our car. In this BLOG I will summarize his arguments and then expand upon it.
Wikipedia definition of insurance: Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium, and can be thought of as a guaranteed and known small loss to prevent a large, possibly devastating loss. (For a very interesting article, see http://en.wikipedia.org/wiki/Insurance)
A couple of weeks back David Goldhill wrote a along article in Atlantic Magazine titled “How the Health care System Killed My Father”.
http://www.theatlantic.com/doc/200909/health-care
It is an intense article that proposes solutions that are radical and far outside the scope of current proposals across the political spectrum. I found the article thought provoking and insightful in many respects but also seriously deficient in a few. The scope is too broad so I don’t want to cram it in a single BLOG entry. Instead I will discuss it in separate BLOGS.
The central theme of the article is contained in the title of this BLOG. He further adds “happiness” as another critical factor. Goldhill correctly points out that the current debate is almost exclusively focused on health insurance industry that administers and finances the health care industry. The discussion implicitly assumes that the fundamentals of current system are correct and we need to remove some distortions and inequalities to make the system work better. He takes strenuous objections to this central thesis. He sets up a parallel with auto insurance which all of us are required to get (mandate) if we wish to register and drive our car. In this BLOG I will summarize his arguments and then expand upon it.
Wikipedia definition of insurance: Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium, and can be thought of as a guaranteed and known small loss to prevent a large, possibly devastating loss. (For a very interesting article, see http://en.wikipedia.org/wiki/Insurance)
In case of auto-insurance, we are insuring against accidents, thefts and other damage. All of these can be reasonably considered unpredictable and uncontrollable events. In addition to the “Collision and Comprehensive Insurance”, a car is also covered by “Manufacturer’s Warranty” that protects owner against unpredictable failures in major engine and drive-train components of the car. The owner also has an option of buying an extended and expanded coverage against such unpredictable and statistical events. Other items such as filling gas, oil changes, tire replacement, tune-ups and number of other “routine maintenance” are not covered since they are completely predictable and under owner’s control. As a matter of fact when a person purchases a car, these expenses and other owner responsibilities are made explicit in the “Owner’s Handbook”. Indeed manufacturer’s warranty (basic or extended) is contingent upon the owners fulfilling their obligations and documenting them by receipts.
This should be contrasted with the structure of Health Insurance as currently structured.
Routine and predictable expenses such as annual physicals and planned events such as child birth are expected to be covered by our “Insurance Policy”. This basically says that the so-called “Health Insurance” is really not insurance in the traditional sense but actually a benefit to employees (partially) covering their “health expenses”. In other countries like India, many companies also provide housing allowance and car with driver, also tax free.
Goldhill proposes separating these aspects of health care expenses. I am modifying on his ideas somewhat and proposing the following. Health care can be divided into three categories
- Routine, predictable and planned;
- Unexpected but “manageable” – short duration illnesses and minor injuries
- Unexpected and catastrophic – chronic conditions, severe injuries and fatal illnesses
It is clear that the boundary between these categories is not very sharp and they can very well morph into each other, upwards as well downwards. So any system evolved to deliver care and pay for expenses of these three different conditions have to be flexible and integrated. Yet this softness of boundaries should not be an excuse for the current state of affairs where there is no clear distinction in how these three categories are handled.
Then Goldhill proceeds to describe different approaches to a combination of government, personal and insurance companies paying for these three types of expenses. He also describes different institutions (store front clinics, hospitals, specialty hospitals). Then he talks about a "consumer-centric" health care system.
This is where I started having serious disagreements. Health care is NOT like buying a shirt or a hamburger and patients are NOT simple customers/consumers of a product. The quality of the outcome is dependent critically on what the patient/consumer/customer does or does not do.
Without considering the entire health care enterprise as a cooperative, collaborative affair, no amount of reform of any kind (left, right, center) is going to amount to anything.
In a classic American fashion, the adversarial system rules supreme. Current tort system goes a long way towards setting the tone for doctor-patient relation. Same thing can be said for patient-insurance company and doctor-insurance company interactions.
My question is - Is this basic approach sustainable? I think not! More on this topic, next week.
Sunday, September 13, 2009
DANGER: (Morally) Hazardous Road Ahead
My original plans was to write my next BLOG entry about the URL "non-principled-guy" and why I chose that name. But then I saw an article by James Glassman in Commentary Magazine on "Hazard of Moral Hazard".
http://www.commentarymagazine.com/viewarticle.cfm/the-hazard-of-moral-hazard-15220)
I found that article fascinating and also fitting into the theme of the BLOG title "The Buck Stops Here". So I thought I will write about it briefly.
Glassman's point is that the rescue of financial sectors, GM-Chrysler and various homeowners who took on sub-prime loans and and now find themselves facing foreclosure presents a certain "moral hazard". This concern has been raised by others as well that if all these institutions and individuals feel that when they will be saved from the consequences of their reckless behavior by the tax payers, what incentive do they have of behaving prudently? What about those people/institutions that DID behave prudently and as a result did not get the temporary boost in their financial rewards but also did not suffer the downside? Why should they have to pick up the tab? Krugman calls it "Privatization of Profits and Socialization of Losses". This seems to be the worst of pure capitalistic and pure communist systems!
President Obama gave the analogy about one row house catching fire due to careless owners. We still want to put out the fire to keep adjacent houses from going up in smoke. In that, we are protecting the innocent not necessarily condoning reckless behavior.
I started thinking about many other places where individual reckless behavior is involved without any broader social consequences. I will list them below without comment:
http://www.commentarymagazine.com/viewarticle.cfm/the-hazard-of-moral-hazard-15220)
I found that article fascinating and also fitting into the theme of the BLOG title "The Buck Stops Here". So I thought I will write about it briefly.
Glassman's point is that the rescue of financial sectors, GM-Chrysler and various homeowners who took on sub-prime loans and and now find themselves facing foreclosure presents a certain "moral hazard". This concern has been raised by others as well that if all these institutions and individuals feel that when they will be saved from the consequences of their reckless behavior by the tax payers, what incentive do they have of behaving prudently? What about those people/institutions that DID behave prudently and as a result did not get the temporary boost in their financial rewards but also did not suffer the downside? Why should they have to pick up the tab? Krugman calls it "Privatization of Profits and Socialization of Losses". This seems to be the worst of pure capitalistic and pure communist systems!
President Obama gave the analogy about one row house catching fire due to careless owners. We still want to put out the fire to keep adjacent houses from going up in smoke. In that, we are protecting the innocent not necessarily condoning reckless behavior.
I started thinking about many other places where individual reckless behavior is involved without any broader social consequences. I will list them below without comment:
- A two-pack-a-day smoker in his 50's requires a lung transplant or develops a lung cancer. Being in 50's, the danger of smoking was well identified and publicized. Various tools to help quitting have also been widely available.
- A blizzard is predicted and warning for not going skiing have been issued. Some skiers go out nonetheless to get the extra thrill. They get trapped and require heroic and dangerous efforts by rescue teams.
- (This is a true story) A young foreign graduate student does not get health insurance to save money and gets into a serious accident. The local community starts taking collection for paying the medical bills.
In the age of unlimited resources, there is no question that the society should protect the individuals from the worst consequences of their own action in the name of being a compassionate society. But we cannot even pretend to have unlimited resources. So when the society pays for cancer treatment for a smokers, it is probably cutting down on prenatal care for a poor woman or cutting arts classes from local schools.
What is the correct course of action in that case? Is there a way for these reckless institutions/people to somehow pay? Here are some ideas I heard about:
- In California some idiots went in a kayak down California river when it was flooded and had to be rescued. The park service or whatever did that, but sent them the bill.
- I understand there are proposals for the federal government to get a significant part of capital gain (if any) through taxes for home owners that were helped.
- Extra insurance premiums smokers etc as is done now except may be extending those even for people who are obese.
Everything said and done, it is still deeply disturbing that reckless behavior many times pays in short term and if things go really down, then there is a safety net there.
Am I missing something here? I am not sure. May be things are not this bad!
Sunday, September 6, 2009
Why the name "Buck Stops here"
President Harry Truman had a sign on his desk that read "The Buck Stops Here". He displayed it prominently to send a message that he will stand up and be accountable for his actions and will not "pass the buck" to somebody else since he was elected as the President of United States to take action and not point fingers. Indeed while he was much maligned during his presidency, he was respected in more recent years for his character for taking hard but unpopular decisions, such as firing the WWII hero, General MacArthur.
An unintended consequence of that sign may have been to send a message to the rest of us that "It is OK to pass on the buck, point fingers at others and not be held responsible for our actions or their consequences". Lately I have started wondering if we (that definitely includes myself) have become a society of "buck passers". In any debate or discussion (sub prime mortgage, global warming, education, health care...) any and every group argues vehemently as to how it is "the mortgage brokers, Wall Street financiers, Chinese/Indians, Teacher's Union, greedy insurance companies and big pharmaceutical companies...." that are screwing it up for them, the poor innocent victims of these evil forces. They conveniently forget the common dictum "When you are pointing one finger at somebody, three fingers are pointed at you".
Hence the title of my BLOG!
I started wondering:
"What if we as a society and I as an individual started wearing a button that said The Buck Stops Here and started taking personal responsibility for every action and engagement in our day-to-day life?"
I know, everybody will say that I am being naive and that I am suggesting something that is against fundamental human nature. May be so. But I will end the inaugural BLOG entry with a story.
PFC Jessica Ellis joined the army as a medic out of community college. Her mother Linda was Chanda's best friend during their gruelling two-year MS Nursing course in 1996. So we knew Jessica as a young girl. In 2007, she was posted in Iraq. Sometime in early May 2008, the convoy that she was travelling with was hit by a road side bomb. Fortunately nobody was hurt badly and Jessica escaped with some cuts and bruises. Two weeks later her unit was going out on a patrol again and her CO told her that she did not have to go but can work in the clinic at the base that day. Jessica said "I can't let my buddies go without their medic". On that patrol the Buffalo (a heavily armored vehicle) that she was riding in was hit by a particularly vicious road side bomb. Jessica was the only person in the vehicle who was killed on that Mother's Day in 2008. She was 24 years old.
I can only speculate that Jessica was not motivated by "Bringing Freedom and Democracy to Iraq" not was she driven by the "adrenalin rush caused by action". She simply refused to duck her responsibilities and chose to stand by her buddies and her commitment.
An unintended consequence of that sign may have been to send a message to the rest of us that "It is OK to pass on the buck, point fingers at others and not be held responsible for our actions or their consequences". Lately I have started wondering if we (that definitely includes myself) have become a society of "buck passers". In any debate or discussion (sub prime mortgage, global warming, education, health care...) any and every group argues vehemently as to how it is "the mortgage brokers, Wall Street financiers, Chinese/Indians, Teacher's Union, greedy insurance companies and big pharmaceutical companies...." that are screwing it up for them, the poor innocent victims of these evil forces. They conveniently forget the common dictum "When you are pointing one finger at somebody, three fingers are pointed at you".
Hence the title of my BLOG!
I started wondering:
"What if we as a society and I as an individual started wearing a button that said The Buck Stops Here and started taking personal responsibility for every action and engagement in our day-to-day life?"
I know, everybody will say that I am being naive and that I am suggesting something that is against fundamental human nature. May be so. But I will end the inaugural BLOG entry with a story.
PFC Jessica Ellis joined the army as a medic out of community college. Her mother Linda was Chanda's best friend during their gruelling two-year MS Nursing course in 1996. So we knew Jessica as a young girl. In 2007, she was posted in Iraq. Sometime in early May 2008, the convoy that she was travelling with was hit by a road side bomb. Fortunately nobody was hurt badly and Jessica escaped with some cuts and bruises. Two weeks later her unit was going out on a patrol again and her CO told her that she did not have to go but can work in the clinic at the base that day. Jessica said "I can't let my buddies go without their medic". On that patrol the Buffalo (a heavily armored vehicle) that she was riding in was hit by a particularly vicious road side bomb. Jessica was the only person in the vehicle who was killed on that Mother's Day in 2008. She was 24 years old.
I can only speculate that Jessica was not motivated by "Bringing Freedom and Democracy to Iraq" not was she driven by the "adrenalin rush caused by action". She simply refused to duck her responsibilities and chose to stand by her buddies and her commitment.
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