"Put patients back in control of their health care"

LOL. Redolent of Kahneman and Tversky.

Well, OK, then, here we go...

From a Republican House Speaker Paul Ryan tweet.

The axiomatic platitude now being parroted by the Republicans every day regarding repealing “Obamacare” (one that Trump HHS nominee GA Rep. Tom Price just repeated during his Senate confirmation hearing). They all say they are going to “put patients back in control of their health care." Okeee-dokeee, then. What does that even mean?

It was recently reported in a GAO study that fully half of Americans ages 55 and older have no money saved for retirement, and have a household net worth of less than $25,000. apropos, here's a short list of estimated "fair prices" (Healthcare Bluebook) for a number of fairly common acute medical events and procedures (mostly incurred as we age):

• CABG: Coronary artery bypass graft, $56k
• Aortic valve replacement with CABG, $67k
• Hip or knee replacement, $31k
• Partial mastectomy, $22k
• Prostatectomy, $17k
• Lung cancer lobe removal, $29k
• Kidney transplant, $48k
• Liver transplant, $78k
• Chemotherapy hospitalization episode, $12k
• Stroke hospitalization, $10k

Enjoy being "in control" (assuming you can cut the checks), in light of the likelihood of Republican "Repeal without Replacement," and given that such repeal means the insurance industry reverts to where it was prior to passage of the ACA — pre-existing conditions policy denials, policy cancellations ("recission"), exclusions, and lifetime coverage caps. You may become one of millions of newly uninusurable patients. A "full retail chargemaster self-payer" (30 days sent-to-Collections*) in your future?

My late Dad had a valve job w/CABG in 1996. My late Mom subsequently had a hip job.** That's roughly a hundred grand right there, based on the Bluebook current numbers. Unlike most Americans, were such to befall me (given that the family history fruit don't fall far from the tree), I now have it in the bank, in liquid, non-retirement accounts. So, I could unhappily weather those (or some of the others), worst case (cash payment). Not that it wouldn't be a significant dent in our retirement stash.

** I served a lengthy stint as next-of-kin caregiver for both of my parents, beginning in late 1996 and ending in late 2011 with my Mother's passing -- POA on my Ma and Legal Guardian to my dementia-addled Dad -- so I've been witness to EoB Hell. Pop was WWII combat disabled full-benefits VA (lost a leg in Europe), they both had UnitedHealthcare coverage that was part of his Bell Labs retirement package, Ma was eligible for military spouse Tricare For Life, and they were both on Medicare. Man! The paper-shuffling, the "coordination-of-benefits" madness.

Those scenarios are becoming increasingly rare.

* In 2010, I had an AMI false-positive ambulance trip to the ER. The ~$900 ambo bill was in my mailbox when I got home after discharge (I was admitted for tests), apprising me that it would be "referred to Collections" if not paid in full within 30 days. "We do not file insurance claims."

My wife and I are now Medicare benes, so maybe we're relatively "safe" from those sorts of financial calamities. Maybe. For now. The goal on the political right of turning all federal "entitlements" (including Social Security) into means-tested spend-down-to-poverty-for-eligibility welfare programs is hardly a secret.

What's the old joke?

Pardon the "vulgarity" (or, as Donald Trump would no doubt shrug and say, "mere locker-room" vocabulary). Crassness aside, the point is valid. Which goes to...

Another new read, just downloaded:

From the Amazon blurb:

Economic inequality is one of the most divisive issues of our time. Yet few would argue that inequality is a greater evil than poverty. The poor suffer because they don’t have enough, not because others have more, and some have far too much. So why do many people appear to be more distressed by the rich than by the poor?

In this provocative book, the #1 New York Times bestselling author of On Bullshit presents a compelling and unsettling response to those who believe that the goal of social justice should be economic equality or less inequality. Harry Frankfurt, one of the most influential moral philosophers in the world, argues that we are morally obligated to eliminate poverty—not achieve equality or reduce inequality. Our focus should be on making sure everyone has a sufficient amount to live a decent life. To focus instead on inequality is distracting and alienating.

At the same time, Frankfurt argues that the conjunction of vast wealth and poverty is offensive. If we dedicate ourselves to making sure everyone has enough, we may reduce inequality as a side effect. But it’s essential to see that the ultimate goal of justice is to end poverty, not inequality.

A serious challenge to cherished beliefs on both the political left and right, On Inequality promises to have a profound impact on one of the great debates of our time.

We'll see. Our newly-empowered social darwinist righties will no doubt disagree.

I have Dr. Frankfurt's other books. Cited "On Bullshit" here. You might also be interested in my review of Peter Frase's book "Four Futures" as it goes to the implications of relative economic abundance and scarcity going forward. Unhappily, I see a "Quadrant IV" coming. I would love to be wrong.

NEW FROM ATUL GAWANDE

A long read, well worth your time. From The New Yorker:

Annals of Medicine
THE HEROISM OF INCREMENTAL CARE
We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more. 

...Our ability to use information to understand and reshape the future is accelerating in multiple ways. We have at least four kinds of information that matter to your health and well-being over time: information about the state of your internal systems (from your imaging and lab-test results, your genome sequencing); the state of your living conditions (your housing, community, economic, and environmental circumstances); the state of the care you receive (what your practitioners have done and how well they did it, what medications and other treatments they have provided); and the state of your behaviors (your patterns of sleep, exercise, stress, eating, sexual activity, adherence to treatments). The potential of this information is so enormous it is almost scary.

Instead of once-a-year checkups, in which people are like bridges undergoing annual inspection, we will increasingly be able to use smartphones and wearables to continuously monitor our heart rhythm, breathing, sleep, and activity, registering signs of illness as well as the effectiveness and the side effects of treatments. Engineers have proposed bathtub scanners that could track your internal organs for minute changes over time. We can decode our entire genome for less than the cost of an iPad and, increasingly, tune our care to the exact makeup we were born with.

Our health-care system is not designed for this future—or, indeed, for this present. We built it at a time when such capabilities were virtually nonexistent. When illness was experienced as a random catastrophe, and medical discoveries focussed on rescue, insurance for unanticipated, episodic needs was what we needed. Hospitals and heroic interventions got the large investments; incrementalists were scanted. After all, in the nineteen-fifties and sixties, they had little to offer that made a major difference in people’s lives. But the more capacity we develop to monitor the body and the brain for signs of future breakdown and to correct course along the way—to deliver “precision medicine,” as the lingo goes—the greater the difference health care can make in people’s lives, as well as in reducing future costs.

This potential for incremental medicine to improve and save lives, however, is dramatically at odds with our system’s allocation of rewards. According to a 2016 compensation survey, the five highest-paid specialties in American medicine are orthopedics, cardiology, dermatology, gastroenterology, and radiology. Practitioners in these fields have an average income of four hundred thousand dollars a year. All are interventionists: they make most of their income on defined, minutes- to hours-long procedures—replacing hips, excising basal-cell carcinomas, doing endoscopies, conducting and reading MRIs—and then move on. (One clear indicator: the starting income for cardiologists who perform invasive procedures is twice that of cardiologists who mainly provide preventive, longitudinal care.)

Here are the lowest-paid specialties: pediatrics, endocrinology, family medicine, H.I.V./infectious disease, allergy/immunology, internal medicine, psychiatry, and rheumatology. The average income for these practitioners is about two hundred thousand dollars a year. Almost certainly at the bottom, too, but not evaluated in the compensation survey: geriatricians, palliative-care physicians, and headache specialists. All are incrementalists—they produce value by improving people’s lives over extended periods of time, typically months to years.

This hundred-per-cent difference in incomes actually understates the degree to which our policies and payment systems have given short shrift to incremental care. As an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse...

"According to a 2016 compensation survey, the five highest-paid specialties in American medicine are orthopedics, cardiology, dermatology, gastroenterology, and radiology."

HHS nominee Congressman Tom Price, MD (R-GA) is an orthopedic surgeon. I have to say, having watched much of his confirmation hearing testimony, Dr. Price is a forceful, articulate, and unequivocal advocate for his views. I continue to dislike him, but I have to admit to a grudging new respect for his fiesty, adept-on-his-feet combativeness. Not sure his alleged insider-trading medical stock purchase conflict-on-interest problems are a show-stopper.

There's a lot at stake. From a new Atlantic article:

Georgia Representative Tom Price is a wealthy man. A successful orthopedic surgeon in Atlanta before his tenure in the U.S. House, Price amassed a net worth of millions in private practice before entering public service. Since then, he’s managed his wealth via investments in a diverse portfolio. His net worth places him somewhere comfortably in Congress’s upper tier of wealth.

That net worth and just how Price maintains it have become the subjects of scrutiny this week after a CNN report found that Price—a member of the Ways and Means Subcommittee on Health and a leading author of health-policy legislation—disclosed a number of investments in pharmaceutical and medical-products companies that lobbied for rules that Price endorsed or introduced. Democrats claim that Price’s holdings and actions while in Congress could violate federal law, but even if they don’t, they also could bring conflicts of interest if he is confirmed as Secretary of Health and Human Services. Those potential conflicts were one of the central sources of partisan tension in his confirmation hearing on Wednesday...

UPDATE: See Paul Keckley's THCB take on the Price hearing here.

Price stated that universal access to affordable insurance coverage is the aim and regulatory relief for insurers in the individual and small group insurance markets as keys. Dem’s probed the distinction between access and actual coverage, noting that last week’s Congressional Budget Office’ report estimated a spike in the numbers who will go without coverage in coming years if “replace” doesn’t achieve current levels of coverage...

"Universal access." Another of my favorite evasive cliches. As I've cracked elsewhere, "y'know, much in the same way that I already have 'universal access' to walk off the street into any Mazerati dealership in the nation."

"It its majestic equality, the law forbids rich and poor alike to sleep under bridges, beg in the streets and steal loaves of bread." - Anatoly France

Probably worth reposting some observations I proffered in my prior post.

BTW: The policy debate has been fairly raging over at THCB these days. I mostly stay out of the comments of late. Let these (mostly untraceable screen name) know-it-alls have their respective contending says.

To me, health care policy arguments ignore a couple of fundamental things. First, there's the "Ich/Du/Sie" PoV problem:

• I deserve full, affordable first-dollar indemnity coverage for my medical misfortunes;
• You need to have significant "skin the the game" to inhibit you from overutilization, which drives up my costs;
• He is a mooching parasite, a free-rider driving up my costs.

Then there's the ideologically glossed-over actuarial reality:

Health care UTIL risk is roughly, speaking of only adults in E-Z round numbers, a 60-year proposition tightly coupled in the aggregate with age (in sort of "hockey stick" fashion). We have long known this. Yet we continue to insist on selling "coverage" (much of which is 3rd party-intermediated "pre-payment," not "insurance") in one-year chunks (wherein everyone thinks they're getting screwed on both the insuree and insuror sides). None of the ensuing administrative paper-shuffling going to deductibles, co-pays, coinsurance, and other fine-print policy babble adds any value to actual care delivery (notwithstanding its profitability to the intermediaries).

Of course, the alternative would be the "social insurance" model now decidely out of favor with the GOP.

Agggh...

JOE FLOWER AT THCB

...Congressional Republicans are up a different creek right now: What they are attempting is mathematically impossible. The things they and President Trump have promised do not add up. Literally. Their problem is arithmetic. Getting more people covered, with better coverage, with lower deductibles and out-of-pocket costs — all that will cost more money, lots of it. Getting rid of the tax penalties for not having insurance (the “individual mandate” that is the most-hated part of Obamacare) and the taxes built into Obamacare on wealthy people and on segments of the healthcare industry — all these will cost the government revenue, the very revenue it would need to pay for the better coverage of more people. All this while they aim to cut taxes and lower the deficit. And of course they have on every Holy Book within reach that they will repeal Obamacare, so they can’t just leave it in place. This means it is highly unpredictable what they will come up with, or that they will come up with anything at all.

They are indeed in a place of chaos. But it’s not, as Skiff would have it, the usual chaos of constructing complex legislation. This is unusual, special chaos. In a class all it’s own. Really amazing chaos, chaos like you wouldn’t believe... 

ERRATUM

Interesting tweet about the Tom Price HHS confirmation hearing.

Oh, the lovely Irony-Free Zone. In 2013 the Federal Reserve Board did a study that found that roughly half of Americans would have trouble coming up with merely $400 to deal with an emergency (medical, auto, etc). But, hey, they'll all have amply-stocked HSA accounts, right?

Oh, wait! No spare discretionary funds, no problem! I know! We'll give people tax credits for funding their HSA's. What? They don't earn enough to pay FIT? We'll give them each $1,000 subsidies, that'll do it! Coupled with private market "premium support," problem solved. Now, quit griping and go get your CABG px.

Under the Federal Employees Health Benefits Program (FEHB), insurees pay only 30% of their premiums, with their respective federal agencies picking up the other 70%. Sweet.
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More to come...