He wants Senate Democrats to start all over, and use reconciliation to pass health care reform next year, because, he contends, without a public option or the Medicare buy-in replacement, the current bill isn’t worth passing.

Jane Hamsher (no surprise) seconds Dean. “From what we know about the bill, it is worse than passing nothing,” she says. So do Darcy Burner, a former House candidate, and so do pretty much all the health care reform activists as opposed to policy wonks. There has been a sharp difference of opinion for some time now between those on the left who felt the public option was more important than the overall bill, and those who took the view that the underlying legislation was more important. As Greg Sargent notes, the response among liberal bloggers to Howard Dean’s call to “kill the bill” is falling rather neatly along that same dividing line:

There鈥檚 a debate raging in the blogosphere about whether the Senate bill has been so watered down that it鈥檚 time to try to kill it, and one thing that鈥檚 interesting is how cleanly it breaks down as a disagreement between operatives and wonks.

The bloggers who are focused on political organizing and pulling Dems to the left mostly seem to want to kill the bill, while the wonkier types want to salvage it because they think it contains real reform and can act as a foundation for further achievements.

In the former camp are bloggers like Markos Moulitsas, former House candidate Darcy Burner, and the Firedoglake crew. They mostly deride the bill as a giveaway to the insurance companies that does nothing for consumers. A quick rundown of their opinions right here.

In the latter camp are wunder-wonk types like Ezra Klein, Jonathan Cohn, and Nate Silver. They all make expansive arguments that the current legislation contains real reform and indeed represents a fairly immense progressive achievement. A quick rundown of their opinions here.

I respect the activists’ passion and sincerity, but I do not agree with them at all — although at one time, I would have. I think the underlying policy is more important than whether we get everything we want in the first round. One of the reasons I feel that way is the length of time we’ve been trying to get health care reform: All my life. That’s since 1950, for who those who don’t know. I think activists are being very naive if they think we can start from scratch and get the best parts of this legislation — or any parts of it at all through reconciliation. If it dies now, it’s dead. Maybe not forever, but for another couple of decades for certain. And I’m not willing to see that happen.

More commentary here.

Kathy Kattenburg
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Copyright 2009 The Moderate Voice
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Leonidas
Guest

I might still disagree with you in general about many aspects of healthcare “reform” Kathy, but I respect the fact that you have matured out of the “activists” way of thinking that Dean suggests.

On another note: Howard Dean is pretty much advocating the kind of thing that you went after Joe Lieberamn for with your assumptions as to his motives, ie., being willing to engage is disingenious mens reconciliation) to achieve a political end.

You respect their ” passion and sincerity” when they make such a statement, but assume that Lieberman lacks it without such a bold declaration from him.

DaMav
Guest

It’s interesting that several major pieces of legislation passed under President Bush, including No Child Left Behind, Prescription Drugs for MediCare, and Tax Relief, to say nothing of the AUMF, Patriot Act, and funding for the Surge. He also got two USSC appointees through the confirmation process. Yet Bush had nowhere near the margins in the House and Senate that Obama has today. While the Republicans did control the Senate, it was at most with a 55-45 majority.

While I recall a great deal of grousing and complaining by Republicans, I don’t recall people loudly proclaiming the country to be “ungovernable”. Indeed, the legislative accomplishments noted above show that it was not.

No Child passed the Senate 87-10. It had almost as many Republicans vote against it as Democrats. http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=107&session=1&vote=00371

Prescription drugs for Medicare passed the Senate 76-21. Not even close to filibuster territory.

The most obvious explanations for the current polarizing stalemate are that the Democrats are less competent than the Republicans were at getting legislation passed, and/or that they have become so beholden to their far left base that they are alienating the center which should be providing enough votes to pass major legislation. I think it is a combination of the two. Major legislation under the Bush Administration was sufficiently moderate to attract large numbers of Democrats in support. Bush also played an active leadership role in shaping the agenda, oftentimes to the distress of members of his own party (Amnesty for example). But he got many of his major initiatives passed.

The dismissive way Obama (“I won”) has treated the opposition, and the far left wing tilt of the party base (“dump Lieberman”) may have resulted in an historic act of self-immolation. The question is whether Health Care Reform serves as a learning experience for the party in power, or further raises the sense of outrage and entitlement voiced by the Howard Dean left wing of the party.

Personally, I think the Democrats have made such a hash of health care reform that I hope that this horrible piece of legislation does not pass. Which puts me on the same side as Dean, but for obviously different reasons.

Anna
Guest

DaMav said:
“Major legislation under the Bush Administration was sufficiently moderate to attract large numbers of Democrats in support.”

That’s because Bush figured he could bypass anything “moderate” in the legislation with a signing statement and do as he pleased. /snark

superdestroyer
Guest

At least the Democrats are being honest. Unless the health insurance reform bill kills the health insurance industry and unless it creates a massive new entitlement that will be funded by borrowing money, then the Democrats are not really interested in suppport it.

I guess until all of the U.S. has the problem of Detroit, Los Angeles, or Baltimore, the Democrats will not be content.

Don Quijote
Guest

I guess until all of the U.S. has the problem of Detroit, Los Angeles, or Baltimore, the Democrats will not be content.

I guess until all of the U.S. has the successes of Mississippi, Alabama, or Louisiana, the Republicans will not be content.

CStanley
Guest

Can you describe, Kathy, what components of the current bill you believe will have positive effects?

I heard one pundit last night say that Dems should pass it because it will achieve two goals- near universal coverage and an end to the practice of denying insurance coverage for preexisting conditions.

Are these the main features that you see in the bill?

If so, why spend nearly a trillion dollars to accomplish this? Both of those things are done through mandate and regulation, which doesn’t necessitate that kind of spending (presumably there will be some spending to pay for the mandated coverage for the working poor though.)

I think what some Dems are failing to consider is the backlash. Once this amount of money is committed to ‘reform’, if real reform isn’t accomplished then I doubt the public is going to support more and more spending in the hopes that they eventually get it right. We’re already seeing backlash because of ARRA, and the lackluster effects of such massive spending.

So although I am not a fan of purism of the type being displayed by some on the far left, and I don’t agree with what they think should be in the bill, I have to agree with them that this bill needs to be put out of its misery. I think it’s completely misguided to think that passing this could represent a good ‘first step’.

HemmD
Guest

CS
“If so, why spend nearly a trillion dollars to accomplish this? Both of those things are done through mandate and regulation, which doesn’t necessitate that kind of spending (presumably there will be some spending to pay for the mandated coverage for the working poor though.)”

Though you and I have disagreements concerning health care coverage, I totally agree with your sentiments here. I also saw that the right to import drugs back into the US at great savings also has been removed from the bill. Just another example of cost savings neatly being snipped from the current bill.

let it die, and let 51 votes decide this. Prior to 1917, that was how Congress worked.

tidbits
Guest

While I probably would not agree with what Howard Dean would propose, and certainly don’t agree with reconcilliation as a means of passing critical legislation that will have a permanent impact, I agree with him to the extent that the legislation currently working its way through congress is so deeply flawed that a new beginning is in order. In saying that, we should also recognize that both sides of the aisle, as well as a host of special interests, are responsible for this mishmash.On a broader perspective, there seems to be a theme developing within the Obama administration. They appear eager to bring special interests to table for buy-in, but in the process lose sight of the mainstreet objective, ala bank bailouts, auto bailouts, stimulus bill and now healthcare reform.

SteveK
Member

tidbits wrote: “I agree with him to the extent that the legislation currently working its way through congress is so deeply flawed that a new beginning is in order.”

Absolutely tidbits, If the current bill passes it will look, taste, and smell like Part D Medicare… A fiscal disaster that benefited only the industry.A disaster that will: a) appear to be exclusively the fault of the Democrats (and it might well be!) and b) be so damaging to the average Americans belief in our governments ability to do anything about the health care problems that any future attempt to actually “reform” health care will be impossible.Let them eat cake!.. a cake with a big red “R” on it.

Silhouette
Guest

As much as the nation needs healthcare now, this may be the most prudent and meaningful path after all. Dean comes up with good ideas now and then.

mikkel
Guest

I had these criticisms even when there was a toothless “public option” involved. If they really want to work on the foundations then they should pass a bill very limited in scope that would target preconditions, drug imports and allow interstate competition/nonprofit collectives. That wouldn’t cost very much money at all and do far more to reduce healthcare inflation than this plan (in any of its forms). As I’ve noted before, the uninsured problem should be tackled completely differently. Oh and I have been convinced that some sort of tort reform is necessary too, not because of the actual level of money currently spent, but because of the effect it has on delivering care. Also I can say conclusively that well over 50% of the problems in health care are due to doctors, administrators and internal culture that no bill can affect, and until that is addressed then things will continue to spiral out of control.

dduck
Member

Now that Dean has jumped on the “to lousy to pass” bandwagon, I guess we see a little break in the fog.
I was never a fan of Dean, but what I thought was goofiness, was probably passion.
It’s ironic, that starting from two different viewpoints, that Dean and Joe wind up at the the same junction.

JSpencer
Member

dd, it is ironic indeed, particularly since Joe doesn’t seem to care about much except himself, whereas Dean has always advocated for the people who tend to be disenfranchised.Kathy, I appreciate your POV on this situation and while I’d rather see incremental progress than no progress, I am deeply disappointed in this devolution. Anyone who looks at the big picture (objectively) realizes the failure of worthwhile healthcare reform must be laid at the feet of the GOP (except when Nixon was actually trying to do something about it), but I still am disgusted with the rather gutless performance of the democrats and would rather see Dean’s scenario be realized. That said, how hard would it be to get traction at this point?

dduck
Member

My fault, I was trying to subtly say that they both could have good motives.
So, I guess you just want it to be, Joe= bad, Dean= good. Fair enough.

JSpencer
Member

I guess you just want it to be, Joe= bad, Dean= good.

It has nothing to do with what I “want it to be” (if only 馃槈 … but with what it is.

dduck
Member

I can’t resist this one. “It depends on what is is.” http://www.youtube.com/watch?v=SaZBm-d5Yqs

ProfElwood
Guest

Maybe after trying all the wrong ways, and committing so hard to doing “something” this year, they’ll have painted themselves so far into the corner, that their only remaining option will be to tackle all the special interests. Joe (yes, you’ve all made it quite clear how popular he is with you) said [something like] there would be no way to do real reform because the special interests are making it politically impossible — the Democrats could get their real revenge by proving him wrong.

DaMav
Guest

America is of course a Constitutional Republic, not a Democracy. But in the context of ObamaCare those appealing to our democracy by bemoaning the filibuster and praising Dean for speaking for the “disenfranchised” ought to consider that a long string of polls has demonstrated that most American voters oppose the passage of this bill. While most favor health reform in general, they do not favor the passage of bills currently before Congress.

If we were following the “Principles of Democracy” the current legislation would have been scrapped months ago.

If any group has been disenfranchised in the process, it is the majority of Americans who oppose the bill. Not only might it be passed over our objections, but we are not even allowed to know what it contains or how the latest version has been scored economically. Our elected representatives have demanded rushed decisions, held the language secret, and cut deal after deal behind closed doors without our consent or at times even our knowledge. That track record of secrecy and deceit puts the lie to attempts to appeal to lofty rhetoric.

Oh, and $ 300,000,000 in tax payer dollars to buy one vote? What ‘democratic principle’ does that rest on? At least Lieberman didn’t sell his vote to the highest bidder and brag about how much he got for it.

dduck
Member

Meantime, the Reps. (McCain, Cantwell) have proposed what the Dems, including Dean, should have proposed earlier: Glass-Steagall redux.
http://www.bloomberg.com/apps/news?pid=20601103&sid=aQfRyxBZs5uc
Walk the walk.

ksb43
Guest

Note to Democratic Congress:

1. Get your asses in gear and pass the bill you want, through reconciliation.

2.. Kick Joe Lieberman’s ass so far out of the party that he’ll need a pick axe and helmet-light to find his way back to Washington. Not only does he not caucus with the Dems, but he loses all committee chairs and seniority. Stop kidding yourselves–HE’S NOT ON YOUR SIDE!

3. Next time, let the Reps filibuster. A REAL, honest to goodness, bring-in-the-cots-filibuster. Preferrably over Christmas, where all of America can see just who has their best interests at heart.

4. Historically, you’re going to lose seats in 2010. Deal with it. Pass the legislation you want to pass, that you think is the best thing for the country and take the hit like adults. Nobody likes the dithering, it’s probably losing you more support than just passing the bills.

CStanley
Guest

Get your asses in gear and pass the bill you want, through reconciliation.

This presumes that there’s a bill that all of the factions of the Dem Congress ‘want’, which is not the case.

ksb43
Guest

But there is a bill that the majority of both houses can agree on. It’s the obstructionist sideshow that’s watered it down to what it is today. It is a handful of people that have precipitated the changes we’ve seen over the last few months. They have now negotiated themselves into obscurity, as far as I’m concerned.

Lieberman, in particular, has not been negotiating in good faith.

DaMav
Guest

People I disagree with are all the time negotiating in bad faith. Go figure. It’s almost like its settled science.

Mary Landrieu, who voted for the measure getting 300,000,000 in taxpayer dollars and bragging about it, now that’s “good faith” negotiating right? And yet she has the same number of votes in this as that awful Joe Liebermann!

And how about Harry Reid? Has he demonstrated good faith by holding the language of the bill as an Official State Secret? Is that good faith negotiating? Or the White House cutting a secret deal with Pharma, and denying they did what they later admitted that they did. Good faith again?

Seems there is plenty of bad faith to go around. Or maybe it’s just sausage being made to specs, as usual.

ksb43
Guest

When these folks start moving the goalposts every time everyone *else* thinks there’s a deal in place, get back to me.

dduck
Member

Yup.

CStanley
Guest

A razor thin majority of both houses, perhaps- which is to say that you’re advocating the 50+1 strategy for legislation that will make sweeping changes to our entire healthcare system and economy. I’d also say that the slight majority who would vote to pass the current bill would do so out of partisanship, elbow twisting, and bribery, rather than conviction that the bill represents actual reform.

ksb43
Guest

Works for me.

ksb43
Guest

Dems, it’s time to start acting like Republicans. Enough being nice, enough compromise. Get the f**king bill passed, by whatever means necessary. You can always go back and fix it later.

mikkel
Guest

I fail to understand what you even like about this bill.

dduck
Member

Wrong. Listen to Dean. Don’t pass a faulty compromise, it lowers your party considerably. We need you guys to balance out the crazy reps. out there.

DaMav
Guest

So since there is a deal in place on the Stupak Amendment that passed the House, we won’t be moving the goalposts on that one, right?

ksb43
Guest

Stupak is a distraction, at best. Throw the anti-choicers a bone. They’re probably sincere. End of story.

Be like sharks, keep moving forward.

Tadly
Guest

This Congress does not have our “best interest’s ” in mind for the coming year.

Maybe we should throw all the bums out and start over.
Dean is right. This fiasco needs to be started over. Transparency as promised, CSPAN debates and actual bi partisan work toward a fair health plan that includes everyone.

AND I HAVE SOME OCEAN FRONT PROPERTY IN ARIZONA TO SELL YOU.

$199537
Guest

In the United States Senate, the Senate rules permit a senator, or a series of senators, to speak for as long as they wish and on any topic they choose, unless a 3/5ths of the Senate (60 out of 100 Senators elected and sworn), brings debate to a close by invoking cloture.

AR we can argue over the different shadings and changes over the years but I read this as the original intent being to allow Senators to speak as long as they wish, not to delay a vote without actually speaking. Indeed your post notes that no longer requiring continuous floor speeches represents a change. I do enjoy your posts and agree with you more often than not.

CStanley
Guest

It’s too bad the discussion keeps getting sidetracked because I’d like to hear from the couple of people here who still support the Senate bill (or at least what little we know about it’s current form) a response to our question- what is it that you still feel is worth supporting here?

Dr J
Guest

what is it that you still feel is worth supporting here?I thought Atul Gawande, in one of his reliably lucid New Yorker articles, presented a good case for it. He identifies runaway costs as the fundamental problem and likens it to the runaway food costs we were facing in the early 20th century. Then, as now, we had many theories about how to improve efficiency, but no one knew which to trust or how to re-engineer a whole culture around it. We ultimately solved the food crisis, more dramatically than anyone might have dreamed at the time. Mr. Gawande credits the USDA for turning the problem around by sponsoring experimentation in great variety and at large scale. He’s bullish on the Senate bill precisely because it’s a big hodge-podge of government-sponsored experiments.

CStanley
Guest

We ultimately solved the food crisis, more dramatically than anyone might have dreamed at the time. Mr. Gawande credits the USDA for turning the problem around by sponsoring experimentation in great variety and at large scale. He’s bullish on the Senate bill precisely because it’s a big hodge-podge of government-sponsored experiments.

Yeah, I saw that article and some blog discussion about it. I found in unconvincing, mainly because the two things (agriculture and medicine) are too dissimilar. I don’t think there are the same kinds of efficiencies to be found in the practice of medicine that existed in farming. To the extent that some efficiencies can be found, or incentives realigned to reduce costs, I’m all for it of course (and I have to say, it’s a shame that we haven’t heard more about all of these supposed pilot programs that this author describes in the current bills, and I can only take his word on it that they’re there at all because the proponents of the bills attempt to sell them without describing any of the ways that the bills might attempt to actually reign in costs of the medical care itself- instead it’s all about cutting insurance costs by setting mandates.)

Dr J
Guest

I’d wager there are similar factor-of-ten kinds of efficiency improvements to be had in medicine that we saw in agriculture. And some similar challenges achieving them. Medicine, like farming, often comes down to how individual practitioners do their jobs, and they do it the way they’ve been doing it for 30 years. You can’t get a whole culture to change by fiat.

CStanley
Guest

I doubt it. I agree there’s a lot of room for improvement in medicine, but not in similar ways to agriculture. And that’s a function of what we expect from medical care- it has to be provided locally, so you can’t have economies of scale like we now have in farming. It has to be duplicated in every single community, with all kinds of specialists (this would be analogous to having ALL varieties of crops grown locally, everywhere). We expect the quality to continue improving, and we want everyone to have access to the highest quality regardless of their ability to pay (the equivalent would be organic arugala and free range, high quality meats for all at the price of iceberg lettuce and cheap hamburger.)Even some of the experiments that the author described which do make sense (looking at models like Mayo, for instance) are fraught with potential reasons that they may not work on a larger scale. Mayo is unique because it attracts the highest quality doctors, who in part are attracted by the prestige and the opportunity to work in such an environment. By definition, you can’t duplicate the top end of the bell curve across the board. Also, Mayo hospitals exist in large population centers so that they can have their own economy of scale to support a full variety of specialists who can work together symbiotically- but that too can’t be duplicated in rural areas.

At any rate, I don’t mean to push back so hard against that article because the points he makes does have validity even if they’re arguable. My biggest objection remains that the bulk of the bills, and the bulk of their costs, are for things that make no sense. In the farm bills that the author compares, there’s no similar policy which mandated and subsidized people buying ‘food insurance’. So, the rest of his points should be considered separately- if there are good ideas for experimentation toward efficiency and real cost reduction in the bills, then strip out the costly garbage and try to work at cost reduction first. If he’s right about some of those ideas working, then we probably won’t need to do the rest.

Dr J
Guest

Those are interesting assumptions to poke at, CS. How much care really does have to be provided locally? Sure, the dude with the tongue depressor needs to be local, but specialists can and sometimes do render opinions from far away. What is a specialist, anyway, but someone with a wealth of knowledge about one subject? The notion that knowledge must be local looks rather quaint in the information age. Hospitals certainly need not be local for many treatments; once you’re talking about a $10K hospital bill, a $500 plane ticket looks pretty cheap.

Your assumptions about the highest quality doctors remind me of another new yorker article on the rise of caesarian sections, which ultimately raised the question about whether medicine is an industry or a craft. To a large extent it is still a craft today, just like farming was a century ago–it’s practiced by individuals, locally, at their own discretion, based on their own experience, and outcomes hinge tremendously on doctors’ personal skills. Best practices are so non-standardized that it’s meaningful to talk about the “highest quality doctors” the way we talk about basketball stars. That all sounds overdue for a change.

mikkel
Guest

I recently went to a conference of research physicians and one presentation literally said that the craft of being a doctor hadn’t changed at all since the bloodlettings days. They strongly believed that all advances were primarily by either accident or a few individuals clearly showing that the best practice was completely wrong.

That turning out to be a widely held belief amongst research physicians and say that the current culture has nearly no tolerance for systemic approaches.

CStanley
Guest

I think there’s plenty of room for improvement and systemic changes, and I agree with Mikkel that there’s resistance to that- but I also don’t think it’s quite as bad as the two of you are alleging. In specialty practice there are meaningful ‘best practices’ which become standard and disseminated through conferences, peer reviewed journals, and associations of specialists…and practitioners do abide by them. The problem as I see it is that such best practices are developed in an environment that’s highly influenced by pharmaceutical companies and others with financial interests, without pushback from any group that would be on the cost efficient side. Add to that the tort situation, so that a nonconventional approach becomes risky and so the recommendations of the AHA or other such groups becomes sacrosanct.

A good example is coronary artery disease, where the current standards are to implant drug eluting stents in most cases. This has come about after initially the standard was balloon angioplasty to expand blocked arteries, and then bypass where arterial grafts were used, and then metal stents, and then when those were becoming reblocked (because the metal scaffolding stimulates fibrous tissue to implant and form a new blockage), the next evolutionary step was to drug eluting stents which help prevent reblockage.

All of this is considered as standard practice to ‘prevent’ heart attacks, but obviously involves very expensive surgical procedures and prosthetic devices. Meanwhile, some cardiologists noted that the standard approach and focus on screening for blockages (sometimes called the ‘plumbing approach’) was missing a fair number of people who would then have heart attacks. That’s because many times an artery goes from zero blockage to 100% occlusion very suddenly when plaque and clots break free. A much better approach then, which would likely be a cheaper prevention mode and would prevent more heart attacks, is to treat CAD as an inflammatory disease instead of a plumbing disease- which means prevention through much more aggressive use of statins and dietary therapy, and screening for overall levels of plaque via specialized CT scans. There are a small number of preventative cardiologists who take this approach, but they’re few and far between and fighting an uphill battle against the powers that be in the AHA. I imagine this sort of thing is duplicated in most specialties, too (particularly when it comes to potential preventative or treatment options based on nutrition or nutraceuticals, or lifestyle improvements, because there’s not enough financial interest in researching or pushing for those types of interventions.)

mikkel
Guest

The vast majority of “best practices” have never actually been shown to be more effective on the population level. The researchers at this conference hammered over and over again that most quantitative assessment is through randomized blind trials that have very specific population groups and that there is no methodology in place to figure out population efficacy except through anecdote. Their issue isn’t that the practitioners don’t abide by the standard practices, but that they don’t critically assess the pluses and minuses of a particular approach, and so it’s difficult to figure out what’s going on.

I wish I could get some of the graphs they showed. It demonstrated that mortality rates and cost for several conditions varied by 6-7x (and there was nearly no correlation between expenditure and outcome). But they really have no idea why there is that discrepancy.

There was widespread agreement that trying to do comparative effectiveness research was so hard because there are so many proponents that want to push more intervention and the newest stuff…even though most of the time there is little evidence in many cases.

Many people complained about the resistance from most doctors to a methodical approach, even going so far as to say they were “ostracized” for suggesting it. One physician was a former engineer and said that he changed how his unit was setup and saw a 30% decrease in deaths, but eventually left that hospital because there was such resistance to adopting it.

CStanley
Guest

I don’t think what we’re each saying is very far off from one another. You may be more correct having talked to insiders who are observing the phenomena, while I’m looking at it as an outsider and doing some comparison between how I see the human medical field operating as compared to my own field. In vet medicine, there’s far more of the art of the individual practitioner making individual decisions (which seemed to be what Dr. J sees in human medicine and I don’t think there’s all that much of that.) There’s also far less concern about litigation, which accounts for a lot of the freewheeling. And while that’s not always great for best outcomes (it puts so much of the outcome resting on the abilities and judgment of the practitioner), there’s also a big difference in our field economically because we do bear the market forces of cost to the consumer. So, in terms of cost effectiveness our model ‘works’ better even though it’s highly individualized instead of based on widely held best practices based on empirical evidence.

mikkel
Guest

The doctors envision “best practices” as being highly individualized. They want to start collecting massive amounts of data to figure out what why some treatments work on some people and not on others and then characterize their own patients accordingly. They say that people need to start looking at individuals as their own “ecosystem” where the interventions that are made are dependent on what the healthy state looks like.

So while they are very much for largescale mining and empirical evidence and want that mindset to become standard, they also want to start pushing the message that there is really no such thing as the “average” patient.

CStanley
Guest

Well, that makes sense if you basically conceptualize a three tier hierarchy or evolutionary scale.

Lowest order is almost completely intuitive, based on the art of medicine, with certain individual practitioners having ability to ‘guess’ at the best approach for each patient. Dr. J’s comment seemed to suggest that modern medicine still pretty much operates that way, which I don’t believe is accurate.

Second order is where I believe we are now- ‘best practices’ have been developed and disseminated, but these are at best based on statistical averages and sometimes don’t even have that level of evidentiary support (largely because of research promoted by those with a financial interest, which distorts the level of certainty to imply that a therapy is ‘best’ even though that’s far from proven by the amount of research that’s been done.) This removes a lot of the physicians’ individual judgment, which perhaps raises the quality of care for those patients being treated at the lower end of the bell curve but reduces the quality for those whose doctors might be able to provide even better individualized care if they were free to think outside the box.

What I think you are saying these doctors want is to raise the level of evidence so that the rising tide will lift all boats- allowing practitioners who may not be as skilled or intuitive to have a basis for finding the best possible care for each patient, instead of relying on generic recommendations that might (again, at best) be good on a population level but not an individual one.

ksb43
Guest

CStanley and mikkel, my head is hurting from your discussion–in a good way. Rather than dispute the salient points you have both made, may I just suggest that the problem that I see, on the ground level, is that *people don’t care how much health care costs* because they aren’t paying the bills!

Bascially, people are greedy. There, I have said it. They want what they want, and they want someone else to pay for it. And far too often, the doctors have an incentive to give them that unnecessary test, that fantastically expensive life prolonging drug (even if it only prolongs life for a few days), that questionable procedure, all at enormous cost to you and me, the taxpayers.

The behavior and attitudes of the American people must change, to truly contain health care costs! How do we accomplish *this*?

CStanley
Guest

Totally agree, Vera. That’s exactly why I don’t agree with the liberal approaches to reform, because I feel they do nothing to even attempt to realign the incentives or put market pressure where it needs to be.

Unfortunately I have to run now- because I anticipate you might ask how a conservative approach might do what I’m suggesting. At some point I’ll either have to rewrite bullet points I’ve listed in previous comments here, or search the archives and copy and paste them. Other conservative commenters like Dr. J, DaGoat, and Casualobserver have discussed some of the ideas as well.

ksb43
Guest

On one hand, I want reform. People should not be forced into bankruptcy due to medical bills. Everyone deserves basic care.

But what everyone does not deserve is a banquet of health care options that they can endlessly gorge themselves upon, at others expense.

How can we reconcile these two positions?

CStanley
Guest

My quick and dirty response to that is to establish what we’d consider ‘the basics’ and use social welfare programs to make sure that everyone has access to that level- and then as much as possible, make people more directly responsible for costs for those higher levels of service. That’s the concept that the GOP was starting to move toward with establishment of HSAs and catastrophic health insurance, and subsidization of the same for people who couldn’t fund such things on their own.

Dr J
Guest

‘best practices’ have been developed and disseminated

I think you’re using a narrow definition of “best practices” that looks only at treatment choices. These are important, but they’re just one aspect of the choices practitioners make.

The New Yorker article gave a great example of another choice: the $1000 worth of sterile supplies the surgical team opened and didn’t use. I’m going to venture to guess that’s not a “best” practice at all. But august specialists will not be discussing it at conferences because it’s blindingly obvious to anyone who’s paying any attention to what things are costing. And they’re not.

CStanley
Guest

I think you’re using a narrow definition of “best practices” that looks only at treatment choices.

Yes, because that’s the way it’s defined currently by the industry. Medical journals and professional associations publish ‘best practices’ which are all about treatment protocols, and nothing to do with cost efficiency.

Dr J
Guest

‘best practices’ which are all about treatment protocols, and nothing to do with cost efficiency.

Yep. Hence my bold predictions that there are factors of 10 in efficiency waiting to be had.

CStanley
Guest

Ha…OK, touche. I’ll readily concede that physicians generally don’t think about cost when planning treatment protocols- but I still doubt the ‘factor of 10′ as well as the ability of those experiments that were proposed to get to much more efficiency (because I think the core issue is mainly the separation of the two people on each end of the transaction from the monetary considerations, and I don’t see that most of the suggested reforms would change that dynamic.)

mikkel
Guest

I also agree that legal issues are a problem. They were talking about this one procedure that had been standard for a long time and seen as immoral not to do, but eventually someone was convinced to let it go through a study and the study concluded that it actually was harmful to the patients…a finding that was supported through larger adoption.

Obviously the administrators that let them do that were really really sticking their necks out since if it hadn’t worked out they could have been in serious trouble.

CStanley
Guest

I just want to point out again that although I am critiquing the article based on my own opinions of how much efficiency we really might be able to squeeze out in medical practice, I really don’t object at all to his basic thesis that these kinds of experiments are positive (even if I were to be proven right that some of that wouldn’t work.)

Again, my main objection to his article is that he overlooks the elephant in the room. No matter how many ‘pages’ of the bills are devoted to these kinds of cost reduction seeking measures, the huge expenditures in the bills come from the attempts at insurance reform, not healthcare delivery reform- and that itself is a reason to oppose the bills. Strip out everything EXCEPT the policy experiments he’s talking about and then the analogy to the ag policy experiments will be more apt and I’d be more agreeable.

casualobserver
Member

Sooooo….how ’bout them climate change meetings?

ProfElwood
Guest

Dr J and Kathy, if I may intrude, I like to add another point that I’ve brought up before.First my current experience with the poor. My boss is both a landlord of cheap apartments and uses a lot of minimum wage and cash workers, so I get to see a variety of people that are solidly poor. I’ve met people who can’t be helped because they are simply too lazy. I know people who have run into unexpected disasters that just need temporary help to get through the recovery. I know people who have persistent problems (promiscuity, excessive violence, and relying on borrowing are common ones) that keep them from ever recovering. I know people who have messed up their lives (I was just talking to a guy who got caught years ago with a meth lab), but are sincerely doing everything they can to recover. Those that are recovering are the easiest to help. Those that are happy being poor, or prefer their problem to the solution, can’t be helped.My big problem with the current state of public (and many private) assistance programs, is that they treat only symptoms, but not causes. Those that can’t or won’t take care of kids that they produce need to be separated from the opposite sex. Those that make enough money, but borrow too much, need budget counseling. And, yes, there is a place for counseling, especially marriage and family counseling, and treatments, as any clergy or shelter can tell you. But right now, there’s no coordinated approach to assistance programs, and no clear path back to independence.

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