Friday, April 29, 2005

Bush's Social Security Proposal

Let me be among the first to congratulate President Bush on finally taking a step toward compromise on social security.

The bottom line is that if social security is expending more than it can take in, there are three basic options:

1. Cut benefits
2. Raise the retirement age
3. Raise taxes

The president has chosen the first, and in a rather progressive vein would impose those cuts on high wage earners, while leaving lower wage earners' benefits the same.

I would argue that the second is a good option too, as SS was designed for a population that mostly died before they could collect, so it wouldn't have been rational for most people to save for retirement; it was insurance against growing old. The retirement age of 65 was initially proposed by Otto von Bismark when he asked his actuaries what age to pick for retirement benefits he could promise the people but would not have to pay as most people would be dead by then. With today's life expectancy it is rational to save, and people should do so if they would like to retire at an age almost a decade before life expectancy. Policies that make this easier, like liberalizing 401(k) rules, should advance this end.

Democrats are not happy that private accounts are still part of the president's proposal, and conservatives should not be either. The 'ownership society' mantra smacks of the mentality of using government to instill virtue into the culture; all well and good when people you like control the government, and are trying to promote a popular virtue individual responsibility. But sooner or later a religious or social movement will have political power and try to promote its agenda (some might say that's already the case). Much harm has been done throughout history in the name of promoting compassion, piety, and justice. The best stance is for government to seek to promote those ends in the culture as it finds it, not to change the culture of its own volition. Government should be the servant of the culture, not its nanny.

Thursday, April 28, 2005

Health Insurance Celebration

Happy Cover the Uninsured Week.

Obviously, there's really nothing here to celebrate.

Among recent studies, lack of insurance is associated with poorer patient outcomes in colon cancer, psychiatric care (less care given, more proportional hospital admissions for suicide), and the elderly in general just to name a few examples.

Another disturbing recent study suggests that it is very common for front-line nonmedical hospital bureaucrats interacting with patients to arbitrarily apply rules limiting healthcare access to uninsured patients.

I am not advocating universal coverage at any price. There are tradeoffs to universal coverage, which may include waiting time, choice of physician, or availability of certain services, if the experience of other countries is a guide. What's more, in a free society people should be able to take the calculated risk of opting out of health insurance. At the same time, it should be available at a reasonable price to everyone, in a society where medical care can make a profound difference in quality and quantity of life. As I indicated in previous posts, the healthcare industry is so different from an ideal free market that it makes a lot of sense for government to be an active player in setting up the environment for competition in such a way that as many people have access as possible.

As extended families have become dispersed across the country with our growing mobility over the last century, Americans have come to rely on nursing homes, home health, acute care hospitals and other institutions to take care of our elderly; health care is not just a product, it is an integral part of our system of looking after each other. That is not to say that health care is a right; but it has become a necessity.

Monday, April 25, 2005

Healthcare Costs: Information vs. Incentives

The President and those who support the idea of an "ownership society" believe that removing third party payment will make costs more transparent to consumers--thus reducing the incentive for patients to seek care, and cutting US healthcare expenditures overall. The president's plan calls for health savings accounts and insurance with high deductibles to cover major medical costs like hospitalizations and surgeries.

Leaving aside for a moment the fact that this plan rewards skimping on one's preventive healthcare while still leaving no incentive to cut down on the major medical expenditures which are the lion's share of total health costs, the President's plan suffers from an even more fatal flaw. The assumption here is that the main driving force behind the low-end health expenditures is individuals trying to get as much medical care as they can for as little cost as they can, as in any other industry. But health care is not just any other industry.

A fundamental condition for capital markets is the idea that individuals have enough intelligence and information to make rational choices. In health care though, individuals don't know enough medicine to decide if they need an echocardiogram or not; they must trust a doctor. And the more doctors there are in an area, the more procedures and consultations are ordered-- supply increases demand. When supply is not independant of demand, the familiar supply/demand curves that determine price are meaningless. Price is determined by many other things, including government policies, cultural values (why is an interventionalist paid three times as much as a healthcare provider who does not do interventions?) and economic arrangements between organizations attempting to secure market share.

But perhaps the most useful way to look at cost of healthcare is to start with regional variation. It has been well documented that the same procedure in different areas in the country varies widely in cost. What is more interesting is that the rates of referral for those procedures varies as well. The Dartmouth Atlas of Healthcare linked above provides evidence that regional medical culture drives much of this cost difference, and shared decision making can bring high cost systems back into alignment with lower cost systems. Here's how it works.

Medical care is divided into three kinds of treatment:
1. Evidence-based (everyone with the given condition clearly should get a certain treatment,)
2. Preference-based (quality of life and cultural features drive decisions rather than evidence of efficacy.)
3. Supply-senstive (primarily in chronic diseases: local supply of the treatment predicts utilization more than patient characteristics: I'll address this sector of care in a later post).

In healthcare systems using Shared Decision Making, patients considered for Preference-based care (a good example is elective back surgery for chronic pain) are given literature and AV materials informing them about regional variation and some information about the known rate of efficacy for the treatment. This simple intervention does >bring costs down without decreasing patient satisfaction or outcomes.

Medicare and Medicaid could make evaluated Shared Decision Making protocols the standard of care. Shouldn't we expect healthcare systems to adhere to the same standards of evidence-based care that individual physicians do?

Before we treat healthcare like it's just another commodity, let's give patients/consumers the tools they need to take ownership of their medical care, and do so in the sector of medical care where it makes sense to limit expenditures.

Saturday, April 23, 2005

Have the talk

I'm taking care of a survivor.

This is a 76 year old man who was playing hockey last week, and came in for an elective hip replacement. Unfortunately he had a heart attack right after the operation, and when the cardiologists tried to open up his coronary arteries, some clot broke off into his brain and caused several strokes.

When I first met him he was unconscious, with a balloon pump. That's a device that operates a long sausage-shaped balloon inserted the length of the aorta, so that when the heart pumps forward the balloon deflates to help forward flow, and when the heart is filling it inflates to help push blood into the tissues, including the coronary vessels themselves.

His prognosis was dismal.

We had a conversation with his son, who said he knew that his father would not want to live if he couldn't play hockey. He dug out a living will that said as much. This is a man who coached the game all his life and had a rink named after him. But the specific situations detailed in the living will were not quite relevant to the realities and decisions lying before us, and it was essentially useless to his poor son, whom we had to ask how hard we should try to save his father.

With his family, we decided not to artificially feed or hydrate him, and to take out the balloon pump after 1 day in order to see if he could survive. He did, and today he is awake, conversational, and able to eat and move his left arm. Nobody would have predicted it. He will never play hockey again, but he is glad to be alive.

Nobody can predict the future, and a few pages of words can hardly be an adequate guide to life and death without a trusted person in charge. I know we're all Schiavo-ed out, but that's why I wanted to take this opportunity to remind people to talk about these issues with loved ones now, especially that it's no longer a hot issue. The message we heard over and over throughout the Schiavo fiasco was exhortation to get a living will--but without having a confident understanding of your wishes, the odds are that your family will botch it, even if they're trying their best in good faith to honor your wishes. A living will is no substitute for having had a frank, detailed discussion with your loved ones about what you value, and to give them permission to use some judgment since they'll have to anyway. Do it today.

Friday, April 22, 2005

Welcome--What are Moderate Republicans

Welcome to this new blog. It will be a forum of commentary on politics, healthcare, psychiatry, culture, etc. from the standpoint of that key demographic, the Northern New England moderate Republican psychiatrist.

What is a moderate Republican? In a party composed of such an array of factions, moderates are often labeled as RINOs--Republicans In Name Only--implying they are allied with the majority party but in fact lean to the Left.

I submit that there is a third Anglo-American political tradition, distinct from liberalism in the Mill-Bryant-FDR strain, and distinct from conservatism in the Burke-Goldwater-Buckley strain. There's a political philosophy that David Brooks has called "progressive conservatism" and he traces it at least back to Alexander Hamilton. In an excellent NY Times essay entitled "Reinventing the GOP" Brooks details this Hamilton-Lincoln-Teddy Roosevelt tradition: one that believes in using government to foster an environment for individuals to succeed economically. This tradition has less of an emphasis on its role in personal morality than the conservatives while still retaining a brand of pragmatic nationalism in the service of order. Programs that enhance national unity are favored, recognizing the Union itself to be a federation of often competing interests--hence support for national parks, universities, and promotion of the arts. Progressive-conservatives have more emphasis on fostering individual class mobility than the Millsian liberals who looked more toward wealth redistribution via the state.

Hamilton's legacy was carried on by Whigs like Clay whose "American System" fell to his political admirer Lincoln for full execution--strong national banking to level the economic playing field, infrastructure development (canals, land-grant colleges and other internal improvements), and tariffs to prevent excessive British control over the US economy. Teddy Roosevelt busted trusts to protect competition, not simply to oppose large economic organizations.

Progressive-conservatives saw that the problem is not government itself or business itself, but rather that large organizations inherently produce diffusion of responsibility and anonymity, conditions that foster inertia and corruption, respectively. The mission of politicians then is not so simple as to protect the little guy from the corporation or to protect individual rights from the government, but rather to use government to promote a set of incentives that tend to make it difficult for any party to abrogate anyone's rights.

The twentieth century saw a struggle between the liberal big/active government camp and the conservative small/limited government camp, and Brooks describes the progressive-conservative vision as being askew of this debate, and so fell by the wayside. But leaders like Eisenhower and Nelson Rockefeller favored a government active in creating economic infrastructure but limited in its scope of direct economic activities. They favored strong defense, but warned against a military-industrial complex. They favored an active international policy, but treated our clearly unequal postwar allies as equals, and so gained more allies. They were privately spiritual but not publically religious. Republican politicians in this vein are still around.

This is the type of Republican Party that a moderate Republican supports. The question is often asked why someone who differs with many of the current policies advanced by the Republican leadership does not simply join the Democrats. Not an easy question--but I hope I have shown why they would not feel quite at home with the Democrats, and there are other compelling reasons that will be a theme of this blog.