In William Brody's first sentence, he nails the issue with healthcare in the U.S. "the escalating cost of care." He also identifies the biggest obstacle to fixing it: Congress. Lawmakers are much too vulnerable to lobbyists to make intelligent decisions. They value re-election above all else, and see campaign contributions as the key to that goal. I asked a Congressman directly last week if he would support price competition for healthcare services, as Medicare had tried to do for medical devices. He quickly pointed out that the previous effort by Medicare had disadvantaged a firm in his district, so he didn't want to try that again. Hard to tell a Congressman to do something that would cause him to lose both money and votes. That would require both leadership and courage. Next time you see those two traits together on Capital Hill, call me. Brody talks briefly about drug costs and how generic drugs would be cheaper, if only Congress would allow Medicare to promote their use. And also about how Medicare patients are falling behind the curve as healthcare costs rise faster than Medicare reimbursements. One result is that practitioners increasingly refuse to accept Medicare patients (or any other insurance, but that's another story). His remedy for this is, of course, to take Congress out of the decision-making arm. Let them appropriate money, but appoint another federal agency to make the tough decisions about how it is spent. He compares his idea to a Federal Reserve System for healthcare. Certainly, the failure of most city hospitals has come because the city fathers couldn't keep their hands off the tiller and out of the till. So, handing of management responsibility has some appeal. But somehow, I just don't see Congress agreeing to this. Not quite sure what the problem would be, but, you know, all that money, so close, . . . . And then some constituent would call to complain that they weren't getting enough reimbursement. Actually, Congress isn't all that good at appropriating money either. They still haven't passed a budget for the government this year, so things will run on a series of continuing resolutions for awhile. The more serious problem in the long run is that Congress would just cut the appropriations for healthcare as a way to save money. That's what the Canadian government does, and then leaves it to local governments to run the healthcare system. In the end, tho, he's absolutely right. "We must provide ways to effectively manage the costs of care." He might even be able to get wide agreement on that statement. Unfortunately, there is no agreement yet on how to bend that curve.

As the health reform debate moves to the final round, it's important to remain focused on the goal. There are numerous other issues seeking to divert our attention from the key goals of the effort. There were two:

1. Healthcare for the uninsured.

2. Reduce expenditures for healthcare in the U.S.

Clarifications:
1. Many decry the fact that there are uninsured people in this country. In our culture, healthcare equates to health insurance, so those without insurance have trouble getting care. With all that we have, surely we could provide healthcare/health insurance for everyone. So for a variety of reasons, one goal of health reform is healthcare (insurance) for everyone.

2. For a perspective on the expenditure problem, reference Peter Orzag's work, particularly his writing about Medicare. Given the current trajectory, Medicare will consume all of the discretionary spending of the federal government in the foreseeable future. Not good, so this is a worthy goal.

Unfortunately, there are many distractions on the way to reform. Some are peripheral issues that are indeed important but not related to the key goals, above. Some are created by opponents of any reform who seek to delay the process by offering distractions that divert attention from the key goals. Here is a partial list:

1. Abortion. Sorry, this was never on the agenda. It's a legal part of healthcare and doesn't consume large amounts of money. Forget it.

2. "Lies." Sorry, the current legislative proposals do contain wording to prevent reform money from being used to provide healthcare for illegals. Reasonable people might argue that there are no provisions for enforcement, but reasonable people don't shout insults in a public meeting. Besides, the rules for enforcement are typically written by the Secretary of the relevant bureau (in this case, HHS) after the legislation has passed. And that usually after a period for public comment. Besides, there are some compelling arguments that illegals should have healthcare. These are the folks who wash dishes in the restaurant where you ate last nite or drove the taxi you took from the airport. Don't you want to know if they have Tb?

3. Technology. viewed by some as a key to paying for reform. Buzzer! Last time I looked, IT cost money. Big money. Many advantages to electronic records, but if it were truly cost effective, everyone would be doing it already. Lots of clever and convenient tricks, but saving money is not one of them. My history with IT goes back to mainframes and Hollerith cards, and I love it. Don't oversell it.

4. Insurance. A complex issue here. Insurance reform will be part of any solution, but it is NOT the problem. Yes, insurance executives do some pretty egregious things (I hear they can't shave in front of a mirror), but insurance, per se, tends to mimic costs of healthcare. And that's the problem. Healthcare costs too much. Bring down the cost of individual healthcare services, and you should see the costs of insurance fall, particularly if we allow competition across state lines.

5. Prevention. Nice idea. I'm all for it, but it doesn't save money. Some still think it might in the long run. Maybe. One current idea is targeted surveillance--only do the tests in high-risk groups. Anyone for genetic testing here? With a family history of colon cancer, you may rate a colonoscopy. Otherwise, fecal occult blood will do. Yes, we'll miss a few, but that's statistics for you. From a population health standpoint, it doesn't pay to test everyone. However, if you have enough money, you may want a colonoscopy every 10 years and be willing to pay for it yourself.

6. Bundled care. Your views on the package deal approach depend on where you where you sit. Those in closed panel HMO's (like Mayo or Kaiser) love the idea. They are better able to take advantage of it, since they own the whole production line. Otherwise, it's a hard sell. Will it save money? Not clear. Mayo and Kaiser will try to make sure that doesn't happen. Possibly a partial solution in some local areas, but not an easy fix for the system.

7. Disparities. The idea here is to take the Dartmouth atlas and make every community look like the low cost areas they have identified. What they don't say is that the unit cost of healthcare services doesn't vary that much. Some areas just provide more care than others. Gawande's article drew attention to McAllen, TX as a high cost area, and yes, the cost per resident is very high. But the utilization is also very high. The unit cost is reasonable; they just do a lot more healthcare in McAllen, TX. Reducing the amount of healthcare provided would certainly reduce the total expenditures. That's what rationing is all about. This is what HMO's did in their early years. Certificate of Need laws were based on this philosophy--rationing resources. They didn't work and have been abandoned in most places. CON laws are anti-competitive and thus subject to graft and corruption. Some countries limit the number of providers. A U.S. physician can't just move to another country and set up practice. We might try closing a few medical schools or limiting the number of residency slots in surgical specialties. Those would be popular ideas.

8. Disease management. Another in the list of promising ideas that sounds as if it should work. I was sold. The thought is to teach patients how to manage their own chronic disease (diabetes, asthma) and do this with low cost providers. The needs for expensive healthcare services would thus be minimized and costs would go down. But they didn't. Maybe we're just doing it wrong. At any rate, it's not a magic bullet.

There are others, and I may revise this posting from time to time.

Looks like nothing works! What can we do! Well, if I were King, . . . . no, you wouldn't like it. No one would. That's what makes reform difficult.

Gotta do it. The President's speech was the most significant event in the health reform debate and the most talked about event in town for the past quarter. (The Triathlon didn't even make the sports page.)

Whatever your politics, you've got to admit President Obama is a great orator. You may not agree with his ideas, but even critics admit they are well organized and well presented.

In case anyone missed it, here is a link to a transcript of the speech, so you can check out exactly what he did say. This is necessary, because there are various opinions about what he said. "Selective hearing" is a good term. In fact, one columnist stated that polarized positions were not changed. Perhaps the intent was really to solidify his team and convince them to support the existing bills. Someone described the speech as "aggressively pragmatic."

Many have criticized the talk for not providing sufficient details, chiefly on payment. He declared again that the reform plan must be self-financing but didn't say how that would be done. There were vague references to savings from eliminating fraud and abuse (standard political rhetoric) and more from prevention (clearly shown NOT to produce any savings). Medicare Advantage plans would take a well deserved hit, and there's still talk about taxing overly generous health insurance benefits. All of this will not be enough, and no one has mentioned promoting greater efficiency in healthcare services.

Kaiser Health News assembled opinions from several "experts" (whatever that means). Beth Kilbreth saw the speech as an attempt to "reestablish debate as political discourse rather than mud wrestling" and an attempt to "defuse the anti-reform campaign based on falsehoods and inuendos." Subsequent events suggest that he failed on both counts.

Interestingly, the most commonly quoted phrase of the evening was uttered not by Mr. Obama but by Congressman Wilson from SC when he interrupted the President by shouting, "You lie!" Wilson, widely regarded as a jerk both before and after his remark, was unrepentant. He made the perfunctory phone apology to the White House press secretary but put a video on his web site saying essentially, "If you agree with me, send money." And many did.

The most cogent assessment of Wilson's outburst came from Gail Collins of the NY Times: "it is not a good plan to heckle the president of the United States when he's making a speech about replacing acrimony with civility." The Republicans were caught in a tough spot-not wanting to endorse his behavior but not wanting to deny it either. So they did nothing.

But what about the issue? Wilson challenged the President's statement that illegal aliens would not be eligible for healthcare. Facts say otherwise. There is text in both bills that clearly state that no money will be used to pay for healthcare for those who are in this country illegally. Period. So, he was wrong in his behavior and wrong in his facts, but that didn't stop many from endorsing him. Oh well.

Consensus is that it was a good speech, maybe the best he has made since the campaign. Those who are against everything were not moved. Reasonable people may have been convinced to think about the larger goals of caring for the uninsured and reducing the costs of healthcare. That's what leadership is all about: "Here's where we're going. You can come along and help or you can be left behind."

There is more talk about money these days. Harold Miller talks about the financial issues in health reform on the Health Affairs blog, but he fails to propose an effective strategy. Like many, he relies on prevention to produce cost savings. At the very least, it takes a long time (maybe forever) for the savings from prevention to offset the cost of prevention. Lori Montgomery of the Washington Post discusses the "mixed esults on cost savings" in part of the Post's series on Healthcare reform 2009. One approach to wringing more value from prevention is targeting, as we do with screening for colon cancer. Screening is more intense (more expensive) if you have risk factors for developing colon cancer. And not every woman needs a PAP smear every year. As we learn more about genetic predispositions, there may be a role for genetics in deciding which screening tools are most appropriate. All this works, of course, on a population basis but not for individuals. There will still be people who want a colonscopy, even without any serious risk factors. Sort of like getting a PSA every year, even tho the "experts" don't think it's cost-effective for the population. Miller also talks about improving the quality of healthcare, forgetting that we already have pretty good care. We just need cheaper care. Still good, but cheaper. Before you laugh, remember that other industries have done this. Competition does this. AT&T is a classic example of a benevolent monopoly but I suspect if they still owned the phone networks, your cell phone would have wire you had to plug in to use it. If GM were the only care maker, we'd all think SUVs were the only way to travel. Think also about banking. When's the last time you spoke to a teller? I bank online and don't think my bank employs any tellers, but my transactions are better--faster--cheaper than ever. In a 9 Sep editorial, the Washington Post declares it crucial for Congress to "pay for reform without gimmicks and structure structure reform so health-care costs stop rising." The NY Times documents efforts by various components of the healthcare industry to modify parts of health reform that they feel might impact their profits. In other words, almost everyone is working for the status quo. There's a line from Machiavelli about those who advocate a new order but find no friends among those who benefit from the old system. In actual fact, it's change we fear. True, not all change means improvement, but any improvement will require change. And of course, no mention of costs in healthcare would be complete without mention of Atul Gawande's New Yorker article, "The Cost Conundrum" about the free market approach gone amuk in McAllen, TX. If nothing else, this study demonstrates again that the potential market for healthcare is infinite when someone else is paying for it. In that setting, there was no limit on the amount of healthcare any citizen could receive, and all providers were paid at standard rates for whatever they provided. This erases any economic disincentive for a new provider to enter the market. And the taxpayers paid. This article received a lot of attention, tho the many used it to support their point of view without analyzing the causes. Many would be more receptive to reform if more credible ways were found to pay for it.