This chapter illustrates the unfortunately traditional tradeoff between efficiency and equity. While reading, I was continually struck by the perversion of patient care by the influx of possible profit. While I don't think that all consolidations are problematic and I understand the economics behind market-based health care, it remains disturbing to me that money has changed the way we provide care. The phrase "wallet biopsy" (page 436) is likely to haunt me forever. The government has worked strenuously to secure public health, first eradicating environmental reservoirs of disease, then acute individual conditions and now, individual chronic care conditions. While I agree that emergency rooms are often abused, transferring a patient to save money at the risk of the patient's life is unacceptable, for-profit hospital or not.
I also find it interesting to note that although a surplus has occurred, it has occurred unevenly. An article was recently released detailing the shortage of primary care physicians. As money was poured into specialties in the 1970s and 80s, a shortage of generalists slowly developed and persists today. Shortages also exist in certain communities. Unfortunately, market based tools are unlikely to adjust for these shortages.
Finally, the comment tying health care provision to a McDonald's hamburger is particularly revealing. On a macro level, we want health care that is effective and efficient. When it comes to health care for ourselves, our children or our parents, however, we want individualized health care, tailored carefully so as to address the individual needs of our loved ones. I am certainly guilty of this. I want health care that provides for all people, but when it comes to the needs of my sister, who is currently suffering from an enigmatic immune disorder, I want the best doctor available. One size fits all is simply not good enough for her. As we move forward and attempt to revitalize and redesign our system, we need to be pragmatic about stakeholder interests and realize that even individually, we hold conflicting values about what a health system should accomplish.
Monday, November 24, 2008
Sunday, November 16, 2008
Book Two, Chapter Four: End of Mandate
Crisis is a powerful motivator, whether a semantic conception or physical occurrence. As Chapter Four illustrates, the crisis of the 1970s surrounding healthcare led to an incredible amount of political activity, little of which can be argued to have moved us forward towards a better system. This is not to deny that there was an impending crisis, but merely to point out that from all the changes and new policies resulted little improvement.
I would argue that most of the crisis was political. While it was generally accepted that health care was an area government should be involved in, particularly because it doesn't get distributed equitably if only done on an ability to pay basis, by the 1970s, both conservatives and liberals were dissatisfied with the system. Costs were escalating far beyond that of inflation and yet, return on investment was flat. Health care, as we've discussed previously, had a significant case of the law of diminishing returns. In the early part of the 20th century, medicine had shifted from public health to acute individual disease care. Thus, improvements were readily observable. As we shifted to chronic care, however, improvements were less easily to observe because they were many improvements in quality of life. As Starr notes, life expectancy and death from chronic conditions were actually improving even in this time of acute criticism. However, people were so convinced of a low rate of return on investment that improvements were shrugged off.
Although I think the word crisis is often applied too soon, its effect is undeniable. I find it interesting that the plight of the uninsured and the poor persists today, along with the creeping sensation of a system in crisis. What will it take to enact true change? Why are the providers so resistant to lose profits? Does the Hippocratic oath not include cost and the barrier created by it as a source of harm? Why has the government resisted significant regulation on health care costs?
I would argue that most of the crisis was political. While it was generally accepted that health care was an area government should be involved in, particularly because it doesn't get distributed equitably if only done on an ability to pay basis, by the 1970s, both conservatives and liberals were dissatisfied with the system. Costs were escalating far beyond that of inflation and yet, return on investment was flat. Health care, as we've discussed previously, had a significant case of the law of diminishing returns. In the early part of the 20th century, medicine had shifted from public health to acute individual disease care. Thus, improvements were readily observable. As we shifted to chronic care, however, improvements were less easily to observe because they were many improvements in quality of life. As Starr notes, life expectancy and death from chronic conditions were actually improving even in this time of acute criticism. However, people were so convinced of a low rate of return on investment that improvements were shrugged off.
Although I think the word crisis is often applied too soon, its effect is undeniable. I find it interesting that the plight of the uninsured and the poor persists today, along with the creeping sensation of a system in crisis. What will it take to enact true change? Why are the providers so resistant to lose profits? Does the Hippocratic oath not include cost and the barrier created by it as a source of harm? Why has the government resisted significant regulation on health care costs?
Friday, November 14, 2008
Book Two, Chapter Three: The Liberal Years
This chapter begins to foreshadow many of the issues we still struggle with in health policy today and also shares some eerie similarities with today's political climate. What I found most interesting was the evolving federal role and the tie to leadership and the persistence of some inequities in health care provision that unfortunately persist today.
Starr notes, on page 349, that the Hill-Burton law "carefully limited political, particularly federal, discretion." This limitation of top-down authority is a trend we still observe today. For example, many economic development projects focus on similar geographic areas to the Hill-Burton act (at least in intent). Policy makers seem fervent that these projects should be bottom up efforts, or at the least, state to local, rather than federal-local. While some aspects of a centralized government are necessary in democracy, more than almost any other country, America has rejected the idea of paternalism from the federal government. In this light, it is particularly interesting to note the positive role the federal government has in driving the research agenda. It will be interesting to observe the changes, for example, in research with the Obama administration, as well as a Democratic Congress. Like the U.S. Congress of the liberal years, research grants are expected to rise.
I found it particularly of note that the inequities we struggle with today have been perpetual struggles, through various iterations of our health care system. Even with the best of intentions, the rural areas still end up with the fewest resources, the lowest paid (which likely translates into the least talented) staff and the most basic health care. Similarly, rural health centers face health problems far more complex than suburban health care institutions. Like the center in Mississippi, before providers could deal with sickness, they had to deal with the basic need of food. It is things like this that make working in a rural health center incredibly challenging and explains the high level of burnout.
Finally, the statement about Kennedy being a harbinger of change brings hope. Although we will never know what he would have done had he not been assassinated, his words ring remarkably close to that of President-elect Obama. The words of journalist Godfrey Hodgson offer a warning, however, that Americans "wanted change, but they did not want to be changed". (364) Thus, it is with that warning that we look forward to what Obama might change in health care.
Starr notes, on page 349, that the Hill-Burton law "carefully limited political, particularly federal, discretion." This limitation of top-down authority is a trend we still observe today. For example, many economic development projects focus on similar geographic areas to the Hill-Burton act (at least in intent). Policy makers seem fervent that these projects should be bottom up efforts, or at the least, state to local, rather than federal-local. While some aspects of a centralized government are necessary in democracy, more than almost any other country, America has rejected the idea of paternalism from the federal government. In this light, it is particularly interesting to note the positive role the federal government has in driving the research agenda. It will be interesting to observe the changes, for example, in research with the Obama administration, as well as a Democratic Congress. Like the U.S. Congress of the liberal years, research grants are expected to rise.
I found it particularly of note that the inequities we struggle with today have been perpetual struggles, through various iterations of our health care system. Even with the best of intentions, the rural areas still end up with the fewest resources, the lowest paid (which likely translates into the least talented) staff and the most basic health care. Similarly, rural health centers face health problems far more complex than suburban health care institutions. Like the center in Mississippi, before providers could deal with sickness, they had to deal with the basic need of food. It is things like this that make working in a rural health center incredibly challenging and explains the high level of burnout.
Finally, the statement about Kennedy being a harbinger of change brings hope. Although we will never know what he would have done had he not been assassinated, his words ring remarkably close to that of President-elect Obama. The words of journalist Godfrey Hodgson offer a warning, however, that Americans "wanted change, but they did not want to be changed". (364) Thus, it is with that warning that we look forward to what Obama might change in health care.
Saturday, November 8, 2008
Book Two, Chapter Two: The Triumph of Accommodation
Since many of our conversations on the discussion forum have focused on the elements required to enact healthcare reform, this chapter was particularly interesting as it provides some history on what societal context gave rise to previous healthcare reforms. Starr talks about how the Great Depression was a huge impetus for the rise of insurance, particularly the rise of Blue Cross and Blue Shield, as well as a variety of indemnity plans. While we are not in a true Depression, we are in a recession and fears about the future are high. I wonder if the combination of economic insecurity and new leadership might be key ingredients to true reform.
I have also been struck throughout the book with the characterization of the AMA. While Starr fairly explains their intent, the effect of their policies seems to do harm, rather than avoid it. To claim total control over medicine is not only impractical, it fails to recognize the complex requirements of a healthcare system. While the relationships between the AMA and rest of the healthcare system appear to be less antagonistic now, traces of this former rift are still apparent. Healthcare providers complain that administrators don’t understand that of the floor staff while administrators hold that providers miss the big picture. If we seek to move towards reform, it is necessary that we move beyond turf battles to collaboration.
Finally, I thought it was interesting how the UMWA created an issue that John Kingdon would call “in-waiting” for a window of opportunity. Lewis carefully build stakeholder support and used various agenda setting opportunities to achieve his goal of insurance for miners. While he initially met opposition, he used the window of opportunity created by the 1947 Interior report to activate the miner’s funds. It is interesting to consider that many of our health policy issues are like the miner’s funds; they are formed and just floating along, waiting for the right opportunity.
I have also been struck throughout the book with the characterization of the AMA. While Starr fairly explains their intent, the effect of their policies seems to do harm, rather than avoid it. To claim total control over medicine is not only impractical, it fails to recognize the complex requirements of a healthcare system. While the relationships between the AMA and rest of the healthcare system appear to be less antagonistic now, traces of this former rift are still apparent. Healthcare providers complain that administrators don’t understand that of the floor staff while administrators hold that providers miss the big picture. If we seek to move towards reform, it is necessary that we move beyond turf battles to collaboration.
Finally, I thought it was interesting how the UMWA created an issue that John Kingdon would call “in-waiting” for a window of opportunity. Lewis carefully build stakeholder support and used various agenda setting opportunities to achieve his goal of insurance for miners. While he initially met opposition, he used the window of opportunity created by the 1947 Interior report to activate the miner’s funds. It is interesting to consider that many of our health policy issues are like the miner’s funds; they are formed and just floating along, waiting for the right opportunity.
Sunday, October 26, 2008
The Mirage of Reform
This chapter is eerily similar to the headlines in the paper this week. As McCain and Obama make their final pushes for the White House, we have heard socialism thrown around as an insult. We have heard about privatizing health care, about establishing national health insurance. It leaves one to wonder whether the efforts of either President-elect will come to fruition, or flounder like the efforts before them.
It seems that the greatest barriers to success are interest group politics and division of efforts. It is interesting to note that incrementalism, in this view, served to stratify and distract from a larger effort. As specialty hospitals weighed their options, they chose to go off individually and focus on their own agenda, rather than a group agenda. This is an oft-observed phenomenon. Tiny factional groups will work on their own piece of an issue, not because they are unable to see the larger picture, but because the resources required for collaboration, the high likelihood of failure and the sheer challenge of coordinating a large agenda overwhelm collective efforts. In local government, we are starting to use the term "collaborative governance." This replaces thirty vogue terms before it, but captures the challenge of change in an environment of significantly limited resources. We all have goals, individually and collectively and many of these goals actually have a high level of overlap. Collaborating in way that facilitates the achievement of these goals for more than the individual, however, requires sacrifices from all participants. In a group setting, sacrifice is political. Those who feel compelled to sacrifice sense a loss of power.
As we move towards election day and more importantly, into a new presidency, it will be interesting to observe the efforts towards health care and track them against this chapter and indeed this book. To watch? Interest groups, political compromise and scaling back of goals from the lofty to the achievable.
It seems that the greatest barriers to success are interest group politics and division of efforts. It is interesting to note that incrementalism, in this view, served to stratify and distract from a larger effort. As specialty hospitals weighed their options, they chose to go off individually and focus on their own agenda, rather than a group agenda. This is an oft-observed phenomenon. Tiny factional groups will work on their own piece of an issue, not because they are unable to see the larger picture, but because the resources required for collaboration, the high likelihood of failure and the sheer challenge of coordinating a large agenda overwhelm collective efforts. In local government, we are starting to use the term "collaborative governance." This replaces thirty vogue terms before it, but captures the challenge of change in an environment of significantly limited resources. We all have goals, individually and collectively and many of these goals actually have a high level of overlap. Collaborating in way that facilitates the achievement of these goals for more than the individual, however, requires sacrifices from all participants. In a group setting, sacrifice is political. Those who feel compelled to sacrifice sense a loss of power.
As we move towards election day and more importantly, into a new presidency, it will be interesting to observe the efforts towards health care and track them against this chapter and indeed this book. To watch? Interest groups, political compromise and scaling back of goals from the lofty to the achievable.
Friday, October 3, 2008
Chapter 6: Escape from the Corporation
Chapter 6 hints at struggles within the medical profession that pervade today. Even within the elevated rank of physician are strata that separate the "regular" doctor from the specialist. Some of this is attributable to popular television, which is an information source for many people. On shows such as Grey's Anatomy, House or E.R., the doctors who get the most attention are not the General Practitioners, but the specialists, the renowned plastic surgeon or neurosurgeon or the doctor who only takes the most complicated cases. This is further propagated by the online informational sites that many people consult daily to supplant the need for a doctor for every ache and pain. Often, these sites contain a recommendation to seek further help from a doctor specializing in the field. While a specialist is certainly an expert, general practitioners are also highly knowledgeable and in many cases, can treat a variety of common afflictions.
The chapter also hints at the division between physician and other medical professions, one which also persists today. Indeed, although they often work together seamlessly, the division between nurses and physicians is not only significantly separated by gender, but by authority as well. Like the specialists of the early 20th century who were highly qualified for X-ray or radiology, the level of training for associated medical professionals seems to be continually on the rise, no doubt in an attempt to secure some of the authority physicians fought for in the early decades of organized medicine. Physical therapists, for example, are now required to have a PhD to practice. Although the PTs who were certified when it was a B.S. or M.S., the continued rising bar to practice is becoming a barrier to entry for some people. Similarly, nurse practitioners currently require only a masters. However, people within the industry estimate that within a decade, NPs will be required to hold a PhD. The legitimacy we associate with education is forcing many specialists, who are highly qualified with current qualifications, to receive higher and higher degrees to remain competitive and ensure authority.
The chapter also hints at the division between physician and other medical professions, one which also persists today. Indeed, although they often work together seamlessly, the division between nurses and physicians is not only significantly separated by gender, but by authority as well. Like the specialists of the early 20th century who were highly qualified for X-ray or radiology, the level of training for associated medical professionals seems to be continually on the rise, no doubt in an attempt to secure some of the authority physicians fought for in the early decades of organized medicine. Physical therapists, for example, are now required to have a PhD to practice. Although the PTs who were certified when it was a B.S. or M.S., the continued rising bar to practice is becoming a barrier to entry for some people. Similarly, nurse practitioners currently require only a masters. However, people within the industry estimate that within a decade, NPs will be required to hold a PhD. The legitimacy we associate with education is forcing many specialists, who are highly qualified with current qualifications, to receive higher and higher degrees to remain competitive and ensure authority.
Chapter 5: The Boundaries of Public Health
Much like public health at the turn of the 20th century, public health at the turn of the 21st retains much of the negative publicity of a century ago. While the practice of public health is becoming “cool” again, at least according to a New York Times article last week, the idea of the County Public Health Department is wrought with stereotype. Be it the commonly served population, who is often poor or minority, or the basic buildings in which care is provided, most people would rather not use public health, given the choice.
However, after our discussions about how to fix health care in this country for the 47 million uninsured, it occurs to me that public health might be the cure. Public health cannot provide everything for everyone. It can provide, however, the basic care that we as a group agreed should be a right. Vaccines to prevent the diseases we thought formerly eradicated, basic check-ups, neonatal care for poor mothers, eye and ear screens for children (although schools continue this practice, early detection is largely held as key to resolving and dealing with these issues), and nutrition information can all be disseminated by a public health department. Furthermore, for many people, the services provided by government are a mystery. For example, people know that food stamps are available, but the process of applying for them seems too laborious. Public health departments can also serve as a hub for more general community health.
But of course the question emerges, how do we pay for this? We pay for this the same way we provide a free, basic education for everyone- through taxes and grants and some in-kind donations. Paying for public health will cost money, but in many ways, we are already paying it. People who use Emergency Room services who have the ability to pay are already absorbing some of the costs of those who cannot pay. People who are not healthy enough to go to work impact our workforce and our productivity. Children who do not have adequate healthcare spread illness to children who do. There are so many discriminatory elements of life in this country, particularly along socio-economic lines. Although paying for public health may have a more direct cost, I believe a full cost-benefit analysis would reveal that the benefits outweigh the costs.
However, after our discussions about how to fix health care in this country for the 47 million uninsured, it occurs to me that public health might be the cure. Public health cannot provide everything for everyone. It can provide, however, the basic care that we as a group agreed should be a right. Vaccines to prevent the diseases we thought formerly eradicated, basic check-ups, neonatal care for poor mothers, eye and ear screens for children (although schools continue this practice, early detection is largely held as key to resolving and dealing with these issues), and nutrition information can all be disseminated by a public health department. Furthermore, for many people, the services provided by government are a mystery. For example, people know that food stamps are available, but the process of applying for them seems too laborious. Public health departments can also serve as a hub for more general community health.
But of course the question emerges, how do we pay for this? We pay for this the same way we provide a free, basic education for everyone- through taxes and grants and some in-kind donations. Paying for public health will cost money, but in many ways, we are already paying it. People who use Emergency Room services who have the ability to pay are already absorbing some of the costs of those who cannot pay. People who are not healthy enough to go to work impact our workforce and our productivity. Children who do not have adequate healthcare spread illness to children who do. There are so many discriminatory elements of life in this country, particularly along socio-economic lines. Although paying for public health may have a more direct cost, I believe a full cost-benefit analysis would reveal that the benefits outweigh the costs.
Subscribe to:
Posts (Atom)
