Monday, January 24, 2011

Post-ideological health care

Haves and have-nots

In A Tale of Two Moralities (13 Jan 2011, NY Times) Paul Krugman describes a fundamental divide among Americans about "what constitutes justice." In a couple of sound bytes, Krugman categorizes Americans into two groups: those who believe it's right "for the affluent to help the less fortunate," and those who believe "people have a right to keep what they earn." It's a compelling opinion by a thoughtful essayist, and worth reading.

Needless to say, not everyone will agree with Krugman's ontology. Some of the 763 comments to his op-ed point out that people can help others without the government playing the role of broker or enforcer; or that the federal government can step back and let state governments do the brokering. And, yes, both of those are possible in some bravely imagined universe. But stretch that brave imagination a little further.

Those who believe it's right for those who have more to support those who have less consider such support a moral imperative -- something we're all obligated to do, not something people can do if and when they feel like it.

Those who believe they have a moral right to direct how much of their wealth gets shared with those who have less, and which of those who have less, and under what idiosyncratic conditions, do not believe that moral imperative applies. In diametric opposition, they insist on a moral right to disburse their wealth as they see fit, if they see fit.

Individual rights. Social obligations. The tension is not a new one. (Which leads one to wonder whether the advocates for each of these have changed political 'brands' since Isaiah Berlin's time. I'm not sure John Boehner would take kindly to be lumped in with the liberals, but he and his buddies do love to call the Prez a Marxist. Puzzling.)

Krugman wrote, "In future columns I will no doubt spend a lot of time pointing out the hypocrisy and logical fallacies of the 'I earned it and I have the right to keep it' crowd. And I’ll also have a lot to say about how far we really are from being a society of equal opportunity, in which success depends solely on one’s own efforts." I'll look forward to that (and will circle back to the next of Krugman's NYT op-eds in a few paragraphs).

For a moment, though, let's set aside moral rights and imperatives. Let's consider dollars and cents.

Investment in health care reduces health care costs

Atul Gawande is a surgeon, a professor of health policy management at Harvard, a 2006 recipient of the MacArthur Award (a.k.a. the "genius grant"), and a staff writer for The New Yorker. His latest article in today's issue of that magazine is The Hot Spotters (24 Jan 2011). The article describes provision of extra care dispensed to a fraction of the very small percentage of people (1%) whose medical care costs a lion's share (30%) of what Camden, New Jersey spends delivering medical services .

These super-consumers of health care resources turn out to be some of the poorest, least organized, most drug-addled people in Camden's population. They're often not the sort that your average taxpayer, worried about how much of an uncertain paycheck the government is going to appropriate, would naturally bump to the front of the Let's Help This Person line. Often they look like they can't be helped. Some aren't willing to be helped. In some healthier people's view, individual agency -- real or imagined -- in the degree to which a complex illness has devolved actually disqualifies a human being from 'eligibility' for social assistance. Go figure.

And yet, through the efforts of a doctor named Jeffrey Brenner, engaging activist providers -- and social workers or "health coaches" to aggressively manage care and give follow-up support such as encouraging patients to take prescribed medicines, keep doctor appointments, cook nutritious meals, and so forth -- dramatically reduced the cost to the government of the net services used by those receiving the "resources and brainpower," as Gawande puts it, directed their way.

The raw reduction in costs? In Camden, 56% in bills for hospitalization. True, the net savings will be lower after taking account of a complex basket of medical costs and what-if outcomes in addition to reduction in hospital bills. But Gawande characterizes the health savings in Camden as "revolutionary" (uh-oh, does that make him a Marxist too?). Other examples described in his article (some summarized below) suggest these savings are not a fluke.

And if the government saves money, that means taxpayers do too. We are, after all, funding the operation.

In fact, identifying patients whose medical expenses are bloated not because of their conditions per se, but because their conditions aren't well-managed is big business for a company outside Boston. The company is called Verisk, and it analyzes data about delivered care to help employers reduce their health benefit spending. According to Gawande's article, a medical doctor named Nathan Gunn, Verisk's head of research: "uses his company's medical intelligence software program to zero in on [...] patient[s] who are sick and getting in adequate care. 'That's really the sweet spot for preventative care, Gunn said.'"

Systemically speaking: "The critical flaw in our health care system [...] is that it was never designed for the patients who incur the highest costs."

Is there hope that our behemoth system can be redesigned? Maybe.

A program you might have heard of -- Medicare, in which the federal government acts as a single-payer insurer for 80% of medical expenses for people over 65 years old -- is running programs to incent the kind of care management practiced by Dr. Brenner in Camden and encouraged by Dr. Gunn of Verisk. It's working at Massachussets General, to the tune of a 15% reduction in emergency room visits, and the program is just coming into its stride.

A radically-redesigned practice in Atlantic City, New Jersey that adds social work and "health coaches" to the medical care mix reduced emergency room visits and hospitalizations by 40%. In a small preliminary study comparing this practice's patients with a group managed more traditionally, a 25% reduction in overall costs was realized.

The common denominator here? Investment in additional care, targeting prevention and health maintenance to reduce need for emergency intervention. Note the first word of that last sentence: investment.

(To read The New Yorker's article in full requires a subscription, or a trip to your local bookstore or public library; but Gawande's interview of 19 Jan on the radio program Fresh Air can be heard on-line. Visit Lowering Medical Costs By Providing Better Care for the article and podcast. The good doctor is as articulate and engaging when he speaks as he is in print.)

Lies about federal health care reform

Back to Krugman, who did not win a genius grant ... but was awarded the Nobel Prize in Economics in 2008.

In his NY Times piece of 16 Jan 2011, The War on Logic, Krugman enumerates a slew of lies and misdirection that Speaker of the House John Boehner (R-Ohio) and his party are employing to build an illusion that their interest in rolling back health care reform enacted in March of last year has to do with deficit reduction. I won't repeat the facts he cites; read Krugman in his own words, The War on Logic is short and clearly focused.

As Krugman summarizes his argument, "The key to understanding the G.O.P. analysis of health reform is that the party’s leaders are not, in fact, opposed to reform because they believe it will increase the deficit. [...] They’re against reform because it would cover the uninsured -- and that’s something they just don’t want to do."

Maybe so. While that seems pretty illogical to me, the "reasons" Boehner and company advocate for scuttling health care reform are pretty illogical too. So maybe we've got a syllogism here? That's the power of ideological opposition to health care reform.

Go back a few paragraphs. To the part of this post explaining how recent studies demonstrate that by providing health care, health management, and social support to the least fortunate among us, society as a whole can reduce health care costs.

Is that an idea worth pursuing? I sure think so.

Is that where President Obama's health care reform is headed? Well, actually, yes.

What does the Party of No propose as an alternative to reducing costs? Are we to barricade public hospitals to people who don't have health insurance, like Camden's 1%?

That would be cheaper even than the rational sorts of health care described by Gawande in The New Yorker and on NPR. If such people -- it's human beings we're talking about -- were left to die in the gutters, society could save a fortune in medical care costs.

Maybe that's what Rep. Boehner has in mind when he spews tricksy lies about health care reform and deficit reduction? A sort of right-wing homecoming to Social Darwinism, where if you can't disprove evolution you employ it to wipe out poor people?

Me, I'll take post-ideological health care any day of the week. Starting last week.

Thanks to AmericanLibraries for the image of Dr. Atul Gawande published on Flickr.

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