12 April 2007

TPMCafe with more single-payer

Maggie Mahar's post at TPMCafe kept me up until 1 in the morning last night, reading it and all its links.

I decided to buy her book on the spot — Money-Driven Medicine is a great deal for $8 at Amazon. Here's how she begins the TPM piece:
I understand why some believe that radical reform is politically impossible. But they remind me of those who said that we could never pass Medicare. Eventually, the pain became too great. Too many seniors could not afford care, and popular support trumped the then-powerful AMA. In 1962, Gallup polls showed public support at 69% and President Kennedy called for Medicare in front of crowd of 20,000 in Madison Square Garden.

Still, it wasn’t easy.

After Kennedy’s speech, the Medicare bill was defeated 52-48. This did not stop the Democrats—they understood what was at stake. They knew that the opposition would be fierce, but they also understood that this was like civil rights. It was not a time for caution. It was a time for politicians who cared about issues....

Great stuff.

Mahar seems to say, however, that even if we did institute a single-payer system that costs could still be out of control unless we fixed provider reimbursement: "The most honest physicians admit that in our system, over-treatment is driving healthcare inflation."

This sounds like the conservative argument that overuse is the problem, but in fact overtreatment and overuse are different creatures — although they're both created by the perverse incentives of our current system's for-profit market structure. Both would be most easily rectified via a single-payer system.

She criticizes fee-for-service — which seems to be a sacrosanct part of the single-payer deal for many physicians who support reform.

To support her position, Mahar links to a wonderful piece she did for Dartmouth Medicine Online about their research on costs.
In study after study, the Dartmouth team has shown that Medicare spends twice as much, per patient, in some regions of the country than in others--for reasons that have absolutely nothing to do with medical science, the severity of the patient’s illness, or even his or her preferences.

What’s driving the higher costs? Supply.

“Build the beds and they will come.”

Based on their research, the Dartmouth team estimates that one out of three of our health care dollars are squandered on redundant tests, unnecessary hospitalizations, unproven bleeding-edge procedures and over-priced new drugs and devices that are no better than the products that they have replaced.
Some hospitals spend two-and-a-half times what others do, without better outcomes. In fact, outcomes are worse.

Both pieces are thought-provoking. Single-payer will only be part of reining in costs. If we have single-payer and continue pharmaceutical advertising, or single-payer Plan D, shackling government's ability to negotiate for better costs, or single-payer with physicians still over-utilizing questionable pharmaceuticals, lab tests, technology, etc. — we'll still have problems. Other countries are so far ahead of us on all of this.

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