The American College of Physicians and Health Care

The ACP just released a position paper on health care access. It’s a comprehensive analysis of our system compared to those of other developed countries. It’s a fair and sober as long as you start from the view that what’s needed in the US is a single payer system.

It says it wants to learn from other health care systems in the developed world. It’s full of interesting data that anyone interested in the issue should peruse. This is its conclusion:

The main lesson of this article is that many countries have better functioning , lower cost health care systems that outperform the United States. We must learn from them.

What would you guess we should learn from them? How about establishing a top down national health care program? This report was prepared under the aegis of the leadership of ACP. How much input the college got from its membership is not known to me. I was not asked to comment, though I have had a minor leadership position in the organization. No one else I know who belongs to the college was asked for an opinion. I suspect, but cannot know for sure, that the leadership of the ACP is quite a distance from its rank and file and that its members had little input to the group that put the document together.

There are some things we can learn from other countries that are not in this report. To begin with, many of them have a rate of growth in their cost of medical care that exceeds ours. This is what health care engineers either ignore or gloss over with fantasies about impossible cost savings. The most important health issue is not access, but a cost growth that persistently exceeds that of national income. If you live in a house and your rent annually goes up faster than your income you’re going to have to move sooner or later. All the nations in the developed world are going to have to move (from their medical house) soon.

Another lesson that can be learned is that if the birth rate is less than replacement, you’re going to have to move out of your medical house even sooner than you thought. Every country in the developed world except the US has a birth far below replacement.

Isaiah Berlin wrote a famous essay, “The Pursuit of the Ideal.” In it he shows how the search for perfection always ends badly. Every issue that is important is seen differently by different people. If you have the “perfect” system the only way you’ll get it adopted is by force. Consider the ACP’s recommendations which are abstracted below.

Provide universal health insurance coverage to ensure that all people within the United States have equitable access to appropriate health care.
Federal and state governments should consider adopting one of the following pathways:
Single-payer systems, which generally have the advantage of being more equitable, with lower administrative costs than systems using
private health insurance, lower per capita health care expenditures, high levels of consumer/patient satisfaction, and high performance on
measures of quality and access. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.
Pluralistic systems, which can be designed to assure universal access while allowing individuals the freedom to purchase private supplemental coverage. Such systems are more likely to result in inequities in coverage and higher administrative costs.
Congress should encourage state innovation by providing dedicated federal funds to support state-based programs to cover all uninsured
persons within the state.
Cost-sharing provisions should encourag patient cost-consciousness without deterring patients from receiving needed and appropriate services.
Develop a national health care workforce policy for the education and training of an adequate supply of health professionals to meet the nation’s health care needs, including primary care physicians.
Redirect federal health care policy toward supporting patient-centered health care that builds upon the relationship between patients and their primary care physicians and the patient-centered medical home.
Support initiatives that provide financial incentives to physicians for the voluntary achievement of evidence-based performance standards, to encourage quality improvement and reduction of avoidable medical errors, and incentives for systems performance that encourage comprehensive and continuous care coordination and prudent stewardship of health care resources.
Support an interoperable health information technology infrastructure with federal funds to assist physicians in acquiring technology that will enhance delivery of evidence-based patient-centered care.
Reduce administrative and regulatory burdens, such as multiple and duplicative physician credentialing forms and multiplicity of types of insurance forms, and their attendant costs.
Encourage public and private investments in all kinds of medical research, including research on the comparative effectiveness of different treatments, to foster continued innovation and improvements in health care.

If you survived all this and are still here you’ll notice that these recommendation while they seem great at first reading are in practice impossible and in some cases mutually contradictory. They are utopian, full of either errors or unsupported assumptions, and seem disconnected from reality. Do its authors really think the single payer system they want will “reduce administrative and regulatory burdens”? They repeat the crazy belief the the federal government can run a medical system with less administrative costs than the private sector. See my post of Dec 4, 2007.

But this report is Socratic in comparison to the editorial that follows it. Written by the editor of the Annals of Internal Medicine its last paragraph reads thusly:

“Successful national health care systems have taken several routes to paying for health care, but they share one essential characteristic: The government guarantees that every citizen will have health insurance. They have solved a problem that grows worse every day in the United States. Why do Americans tolerate a system that leaves one sixth of its citizens with poor access to basic medical care? When will we elect leaders who will erase this stain on our national character? Perhaps the example of other countries will motivate Annals readers to join ACP in demanding decisive action on universal coverage.”

It’s hard to be so emotional and get so many thing wrong in so few words. I don’t know what problem the editorialist thinks foreign countries have solved. It’s certainly not cost. Just before writing this I was in the hospital providing the best care I can to patients without health insurance including dialysis to undocumented foreign nationals. I guess I am a collaborator in staining the national honor. Not having medical insurance is not the same as not having medical care and anybody who writes about this issue and purports not to know this is disingenuous at the Olympic level. “A stain on our national character.” This sophomoric and melodramatic outburst trivializes a serious issue. The demand for medical care is endless. The cost of this care can only be contained by rationing by delay or rationing by price. If you want the former go for the single payer system. If you’re for the latter you won’t get elected. Or we can ignore the whole enterprise and sink under the weight of ever increasing costs.

Also note the position of moral superiority from which the editorial is proclaimed. Anyone who is not for universal coverage is not only wrong but is tainted the stain on our national character and must be a very bad person indeed. When you have the key to the truth you can brook no opposition.

The perfect being the enemy of the good it makes sense to try to fix one thing at a time. The ACP sets no priorities they want everything now. If you have a list of goals and meet just one of them you’ve done a great job. Medical care in the US for all it’s strengths could be a lot better. It will only get better if we realistically analyze its problems and set goals that are not overwhelming or utopian. The ACPs recommendations fail both these criteria.

For some interesting view of medical care to or north see here and here. Also see the video below. The US is a safety valve for the poor to our south and the affluent to the north. The Academy Award winning movie The Barbarian Invasions (largely set in a Montreal hospital) depicts hospital administrators and unions as corrupt, the physical plant to be decrepit, and physicians as ignorant of their patients problems and their names. I don’t know how accurate this portrayal is, but presumably the French-Canadians who made it have some experience with their medical system.

5 Responses to The American College of Physicians and Health Care

  1. Apurv Khanna says:

    Congratulations to Dr. Kurtzman on a very interesting blog. I must, however, take issue with his contention that a single payer system is not the answer to the U.S. healthcare crisis. I will use the Canadian single payer system for comparison.

    The number of uninsured in the U.S. not just 47 million, it is over 89 million if one includes those that were uninsured for at least a portion of that year (Families USA, 2007). Health insurance in this country may just be a fleeting benefit.

    Commenting on rationing by delay or by price, while Canadians do wait longer for elective procedures than do insured people in the U.S. they do not wait longer than the 89 million mentioned above, or putting it another way, they do not wait longer than that one-third of the U.S. population. On the other hand, vital operations such as kidney and bone marrow transplants are performed in a more timely fashion than for even the insured in the U.S. Also, only a tiny number of Canadians seek care in the U.S. (Katz, Health Affairs, 2002). Canadians, in fact, see physicians more often than people in the U.S. (Welch JAMA, 1996) Of course, one can argue whether that is a good thing or not!

    Administrative costs in the U.S. are 300% those in Canada. As for the hypothesis that armies of coders would be needed, I would submit that if there was a single system, things would be simpler and one would not need so many people to learn all the different systems currently required.

    So, initial cost control need not be “painful” to the patient in terms of care provided. Rather, it would be “painless” to the patient by reducing the 31 cents to the dollar of health care spending that goes for things such as insurance marketing, billing and claims processing and utilization review (Woolhandler, N Engl J Med 2003) For course, down the road, (and even now) rationing based on a more critical and educated review of new technology will be needed. But by then hopefully, the incentive for direct to the consumer marketing by pharmaceuticals, hospitals and health care providers would have been reduced, reducing the demand for expensive, high tech but questionable procedures and medications.

  2. Neil Kurtzman says:

    Thanks for your thoughtful comments. I appreciate the feed back. I have the following responses.
    1.The number of 89 million people without health insurance contains several logical errors. It’s like saying the number of people alive now should include those who were alive earlier in the year but are now dead. If you are going to add these people to those without insurance you have to subtract from the number of people without insurance those who had it earlier in the year.
    2.The 47 million people (not 89 million) without insurance include 19 million between the ages of 18 and 34, 10 million who are not citizens, and 9 million from households with incomes of more than $75,000 a year.
    3. And I seem not able to repeat this often enough – they still get care without insurance and even if they can’t pay for it.
    4.Only a tiny number of people seek health care in the US because only a small number can afford it. How many would come here if they had the money?
    5.Governments have no idea what their administrative costs are. These costs are either farmed out or put off the books. Governments use accounting methods which would put them in jail if they were used by private businesses. Insurance companies on the other hand have to comply with the laws mandating standard accounting practice.
    6.The idea that an army of coders would not be needed ignores why they are needed to begin with. It’s to comply with Medicare’s regulations. Medicare is a single payer system. Its rule book is 1200 pages long and weighs 5.2 pounds. The department in which I work has one coder for every two physicians. They spend almost all their time dealing with Medicare. In addition we have another army of coders in an undisclosed secure location also dealing with Medicare’s rules and regulation. The insurance companies don’t make me spend hours taking compliance tests, Medicare does.
    7.Technology raises costs only in medicine. Everywhere else it lowers costs. This anomaly is because there is no price competition in medicine.
    8.The pressing issue is not health insurance; it’s how to control costs that everywhere are rising faster than national income. No system anywhere has figured out how to contain medical costs in a democracy.
    9. How many people would elect to have the state provided medical care if they could afford to get it on their own in any way they chose?

  3. Apurv Khanna says:

    1. I think the figure of 89 million still stands. Regarding the group of 89-47=42 million who lost coverage for part of the current year, they may have had the same happen to them the previous year. Even if they did have coverage the previous year, there would have been another group of people who may have had coverage for only part of the previous year.
    2. Regarding the 19 million aged 19 to 34, why does that exclude them from the need for medical care? They can get sick too. The 10 million who are not citizens includes permanent residents and legal temporary visitors who pay taxes into the U.S. system. Though this is another debate, even illegals pay taxes as sales tax and some pay other taxes too. Also, being illegal certainly does not diminish their humanity.
    3. As far as getting care without insurance, that is only glossing over the reality. Care to the uninsured is not the same as care to the insured. The uninsured only get emergent care when it is a life or death situation, not other care. And the care provided is just a band-aid to get them out of the hospital.
    4. To say that more Canadians would seek care in the U.S. if they could afford it, is to ignore the facts. Canada beats the U.S. on pretty much all health outcome measures.
    5. Armies of coders would not be needed as providers would be paid through a global capitation system. The only administrative costs would be in assessing how many patients are enrolled with a provider. At the same time, patients would be free to change providers, giving a financial incentive to providers to work hard.
    6. Lack of coverage is the main issue rather than cost control. That is not to say that the latter is not important. The fundamental issue is how can a country which welcomes “the tired, the poor, the huddled masses yearning to breathe free, the wretched refuse, the homeless and the tempest-tost” continue to deny care to 89 million vulnerable humans living within its borders.

  4. Neil Kurtzman says:

    1. By this reasoning the number should be 300,000 million. Almost everyone has had a period when they didn’t have health insurance.
    2. People 19-34 are making a good economic bet if they choose not to buy health insurance. They’re not likely to need it. You want to force them to buy insurance
    even if they don’t want to. Note the word “free” in Emma Lazarus’ sonnet. Forcing young people to buy health insurance would be yet another income transfer from the young to the old. Everyone is human. We can’t provide for the entire world.
    3. This is simply false. Every clinic in every large teaching medical center is full of patients with scheduled appointments who get regular care whether they can pay for it or not. They also get a full menu of social services and prescription drugs. In our institution they get a “blue’ card which gets them any drug they need. America is so rich that it is the first country is history where obesity is a major problem among the poor.
    4. Rent “The Barbarian Invasions” and then revisit this issue. Health outcomes have little to do with medical care in the developed world. Every one of these 21 countries has passed the point where medical care makes much of a difference. What I mean is that they have so much of it that a little more or less is inconsequential. More medical care makes a difference in Africa and the like.
    5. You don’t want a single payer system, you want a national HMO. Will you let people opt out of the system? Even under a capitated system the federal government will write thousands of pages of rules. Every special interest group will successfully petition the government into sweetheart deals. Bureaucracies only get bigger.
    6. Cost control indeed is the issue. Without it any system will collapse.

    We can ensure that they poor get dignified medical simply by giving them the money to buy it with. A Nobel Prize winning economist suggested this. It went no where. Do you trust they poor to make rational decisions about their well being? I suspect not. Okay, give them health coupons with which they can buy health insurance or medical care directly. We don’t have to create the biggest bureaucracy in the history of the world to provide “universal” access to health. In reality, conventional health insurance is not needed by anyone. We would be much better off to replace it with “universal” catastrophic health insurance. If people got used to paying for routine medical care out of their pockets costs would plummet

    I think we’ve taken this as far as it will go. Neither is likely to convince the other.
    Thanks for your input.

  5. Re Apurv’s #2. What illegals pay in taxes is nothing compared to the services they use. In California the estimated cost is 10-12 billion/year and one study showed the care to be not minimal, but slightly better than for citizens.. so as to protect from lawsuits from ACLU and its ilk. Part of the service is free schooling at $10,000/year/kid, and these people have LOTS of kids.
    I’ve only been to an emergency room 3 times with a husband with severe heart problems..finally fatal…….yet the others were there for flu and minor cuts.

    Many emergency rooms have closed in the LA area.

    One third of our prisoners are illegal, another considerable cost

    Our state is bankrupt and will probably be in receivership before the end of this year.

    I remember having no insurance in the 60s. Office visit $10, Specialist $20. Now I only have catastrophic insurance. Not from any intelligence on my part…….it was all I could get.


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