House of Paine

INVENTIN' A BETTER DOC POKER

to catch a doc dickin off....


this here's 

a better mouse trap
  
     .........MAYBE

BUT ITS NOT THE LITTLE DOCS
  OVER STUFFING US WITH NEEDLESS SHIT 

ITS 
THE STAMPEDE TO PREOFIT
   BY THE MASTADONS OF HEALTH
                            THAT'S REALLY  
                           CRUSHING
                               US UNDER THEIR FEET 



-----------------------------------------------
AT ANY RATE

working title:

 

" from
 fees for service
to 
  pay for performance"


===============================================




  enter 
doc cutler...

"call me dave  "

a harvard econ con 

  and voila


comfort food
for the elite profesional klass 

cutler the butler's
   health cost RX

more of the same

cause

this cost spiral is  everywhere

and where its not

face it guys

we americans
 
we're just different 

yes here in under
a thinking mans 
alibi
and a thinking mans fast shuffle

pinky's prognosis?


 zero progress


cause its mostly 
            a change nothing vital
re-label 
 re-configure

re etc etc

any which way 
but straight at 
the center of the problem....

our devilishly clever 
corporate/foundation 
   medicine  show 


my first cut..

if the shit proposes
we keep 
workin  thru 
corporations and foundations
fuck him

what shit

down the road is heaven's gate

so keep on truckin peons

alls well that ends well

and well...

 
it will all end   well

 ah ah ah

some day 


and when it does brothers and sisters


we'll all be well  together 

sort of .....

------------------------------------------

start with typical harvard yard 
pseudo deep 
pardigm morphing thought .....

''The real reason health-care reform 
has not succeeded,is 
that it is rooted 
in a misconception 
of what health-care reform should accomplish.'' 
                              doc cutler 


-------------------

heres the problem....


"The United States spends 
more on health care 
than on automobiles"

" more on health care 
than the Chinese 
spend, per capita, 
              on everything." 



------------------------------ 

further 
excerpts from a recent feature article 


in that
 " respect (able and full)
                            goo mouthed (fore  and aft)
                                            pro Pro -class "
   combo hand book and  bible
                                the  nyt 

---------------------------------------------------------


"The Medicare drug bill 
is suggestive 
f whats wrong
 with cost containment efforts

 The Republican Congress 
promised restraint 
but then passed a hugely expensive law 
that barred Medicare
 from using its clout
 to negotiate prices with drug companies.

 The pattern has been
 failed efforts to control costs,
 followed by a void of new ideas. "

--------------------------------
"Cutler's approach is radically different.

 He says that most health-care spending
 is actually good.
 Spending has been rising,
 he says,
because it delivers positive,
 and measurable,
 economic value,
 and because it can do more things
 that Americans want.

 Therefore, Cutler says,
 we should focus on improving
 the quality of care 
rather than on reducing 
our consumption of it.

 Rather than pay less, 
he wants to pay more wisely

-- to encourage health-care providers
 to do more 
of what they should 
and less of what is wasteful. "

-----------------------------------

results from
 doc cutler's  chores:

"Looking at the data,
 
 on average, heart attack victims 
       ARE today 
 surviving eight months longer
 than in the 1980's. 

In economic terms, 
 the increased spending is
 ''worth it.'' 

"Subsequently, 
Cutler concluded 
that a 45-year-old American
 could expect to spend $30,000 
over the course of his life
 on all forms of cardiac care
 and that, thanks to improvements 
in cardiac technology alone,
 he could expect to live three years longer"

 That worked out to $10,000 a year 
of added life. 
Cutler can rattle off 
figures to prove 
that Americans value life even more.
 (Air bags cost something like 
$100,000 per year of life saved,
 for instance.) 

But you don't need to be an economist 
to believe that $30,000 for three extra years
 is a pretty good deal. "

--------------------------------------------
"Health care ''lefties,'' 
as Cutler refers to some 
of his colleagues, 
favor a European system
 -- universal insurance
 financed by a single payer 
(the government) 
and some sort of rationing 
to hold down the screaming increase 
in high-tech procedures.

 

While Cutler acknowledges 
the merits of such an approach,
 he also sees its problems.

 The British may be accustomed 
to waiting for hip replacements,
 but Americans do not like rationing.

 Also, systems with just one payer
 do not encourage innovation and experimentation.

 Imagine America if everyone were on Medicare. 
Doctors and hospitals
 would do whatever Medicare
 approved and nothing more"

"In any case, 
the idea that America could trim spending
 to Canadian levels
 is probably unrealistic.
 American doctors earn more 
than those in Canada. 

Our culture tolerates, 
even approves of, 
greater disparities in income;

 Congress is not likely 
to legislate a change.

 Canada also enjoys
 a ''free rider'' benefit.
 Drug makers earn a return 
on their investment 
in the United States,
 and so are willing 
to accept price caps 
in the smaller Canadian market.


 And since Canada 
has just one insurer 
(the government),
 its doctors spend less on administration. "


However, health-care costs 
in Canada have increased 
at nearly the same rate 
as in the United States.

In fact, spending growth
 in most developed nations
 -- regardless of how they finance and organize care
 -- has been moving ahead at similar rates.

 Since 1960,
 costs in six of the G-7 countries 
have risen, 
on average, by 4.9 percent a year.

 The rise in costs in the United States,
 at 5.1 percent annually, 
is close to the middle of the pack. 

'no particular characteristic 
of any health-care regime 
is the main determinant 
of growth in costs.'' 

TechnoloGY IS 

----------------------
" Cutler, who reads as many medical journals
 as economics ones,
 does not dispute 
that America buys more health care 
than it needs.
 He estimates that 20 percent 
of spending  is unnecessary,
 much of it for tests and specialist consultations.

 Indulgent Boston,
 for instance, 
has 1.7 times 
As many specialists per capita 
as frugal Minneapolis.

 But it is extremely difficult 
to weed out only the ''bad stuff,'
' Cutler says.'

-----------------------------------

Contrary to the fears 
of many on the left, 
higher prices are not the chief culprit

. Thanks to continued pressure
 from H.M.O.'s,
 doctors' rates have been held in check.

 So have the prices 
of pharmaceuticals 
already on the market.

 But because new drugs 
are more expensive, 
and because people 
take more pills, 
total spending on drugs 
since 1990 has quadrupled. 

------------------------------
Critics of America's profligate ways
 fret about the relentless character
 of spending increases, 
and they have a point.

 Even when technologies lower costs,
 they increase spending 
by broadening the market.

 More people have gallbladders
 removed because laparoscopic surgery
 is less invasive.

 More people take medication 
for depression 
because the Prozac-era drugs 
have fewer side effects 
than earlier drugs. 

In fact, doctors diagnose depression
 more often. 
Better treatments lead to higher use.

--------------------------------

" Right-wingers go for a market approach 
-- it's not the technology 
they object to, 
but people's cheap access to it. 

If people paid 
for their own angioplasties,
they would have fewer of them.

 This is the theory behind 
Bush's health savings accounts,
 initiated during his first term:
 let people buy insurance 
from their own (tax-sheltered) pockets." 

"Cutler points out a shortcoming:
 Most of the dollars spent
 on health care are spent on people 
with serious illnesses 
or conditions. 
Those with coverage quickly move
 into the territory 
covered by insurance. 

Few people really pay 
for their own angioplasties,
 so few care what they cost." 

-------------------------
A tweedy, self-effacing 39-year-old,
 Cutler is a seriously modified lefty. 
He envisions a system 
in which everyone 
could get insurance
 while free-market incentives 
would motivate health-care providers 
to be more effective 
as well as more efficient
. Instead of suppressing 
the market by rationing care, 
restraining prices
 or regulating doctors,
 he wants to liberate it."

''David has showed everyone 
that the way to rein in costs 
is not to squash innovation.'' 


CUTLER
" discovered a curious fact:
 heart attacks were occurring 
less frequently,
 thanks to drugs 
for treating high blood pressure 
and to reductions in smoking,
 but spending on heart attacks
 was rising.

 Surgery rates -- $25,000 for an angioplasty,
 $40,000 for a bypass -- 
had been relatively stable.

 But as the technology improved,
 the operation was being performed 
far more often. "
------------------------------

" Critics responded that good health care
 could be much less expensive.

 Canada spends only 10 percent
 of its G.D.P. on health care
---- VS AMERICA'S 15%-----
, but according to common yardsticks
 like longevity and infant mortality,
 Canadians are just as healthy."

 "Dr. John Wennberg,
 a health-care expert at Dartmouth,
 and his colleague Jonathan Skinner 
point out that some areas 
of the United States,
like Boston and Miami,
 spend far more than others, 
like Minneapolis,
without any noticeable improvement
 in mortality.
 This leads them to conclude 
  that the additional spending
 is fruitless. "



-------------------------------
 
America's fee-for-service system 
does not require doctors to measure.

 It rewards them for each instance 
of delivered ''care,'' 

Cutler notes, but not necessarily
 for the end result -- for ''health.'' 

This is especially true 
for chronic patients, 
whose well-being depends 
on following a long-term regimen of care.

 Diabetics, for instance,
 should receive yearly eye exams,
 regularly monitor blood sugar
 and cholesterol 
and take other steps 
to avoid problematic 
(and expensive) complications.

 ''Doctors say, 
'You really should get
 your eyes examined,'''

 Cutler notes. ''There is no follow-up.
 Every doctor you talk to says:
 'I know we don't do a good job on that.
 We don't get paid for it.'

 My way, we would pay them.'' 

How would ''paying for performance'' work? 

In the late 90's, HealthPartners,
 a not-for-profit health plan in Minneapolis
 with 630,000 members,
 instituted a bonus system 
to providers.

 It paid doctors extra 
if their diabetic patients 
got blood sugar and cholesterol
 below certain levels, 
ceased smoking and took aspirin daily.

 In 1996, 5 percent of patients 
met all criteria.
 By 2003, 17 percent did. 
Similar gains were registered 
with heart patients. '

'These clinics are trying 
to provide quality care,'' says Dr. George Isham,
 the plan's medical director.
 ''What we're doing 
is putting a measurement on it.''

 In 2003, the plan awarded 
a total of $9 million 
to doctors on merit.
 But was it worth it? 

At Isham's request,
 Cutler and a team of colleagues 
analyzed the economic payoff.

 They found that the program 
reaped huge rewards.

 It cost $330 a patient 
and was expected to save 
roughly $30,000 over each patient's life.

 While the analysis is not precise,
 Cutler wrote, 
it ''illustrates a general point 
that professionals
 in health care have known
 intuitively for some time: . . .

 comprehensive disease-management 
programs 
are clearly worth the investment.'' 

The rub is that the investment
 was only marginally worth it for HealthPartners.

 The gains went to the patients,
 in the form of better health, 
and to their employers, 
who were expected to suffer 
less absenteeism.

 HealthPartners did recoup some
 of its investment,
 as members were hospitalized 
less frequently. 

But some of those people
 would change jobs and change insurers,

 so the benefits were largely
 reaped by someone else.

 Ultimately, as patients retire,
 they will be reaped by Medicare. 

This ''exemplifies
 some of the problems
 inherent in our current system,'' Cutler writes

 A program with huge benefits 
for society (and for patients)
 offered only a marginal incentive
 to the health plan to create it.

 HealthPartners did not have 
the option of simply raising its rates,
 because healthy patients 
would have departed for a cheaper plan.

 This is why closed-loop systems 
-- systems in which patients made healthy don't leave 
-- tend to work best. 

----------------------------------------
Kaiser Permanente,
 the huge health plan based in California,
 is something of an example.

 Both insurer and provider, 
Kaiser pays its doctors 
a fixed salary regardless 
of how much (or little) they do. 

Its doctors also receive a bonus
 tied to measures of performance.

 The theory is that its integrated approach 
will pay off both 
in terms of patients' health 
and economically. 

So far, the approach has shown significant improvement
 in health and after some missteps
 has been able to stay competitive
 (though it is hardly cheap). 

Other major health plans 
in the state recently
 agreed to a similar system 
of quality bonuses, 
so California could become 
something of a closed loop. 

General Electric is another intriguing case.
 Despite its supposed fervor for quality,
 until recently G.E.
 had been shelling out more than $2 billion a year
 in health coverage 
without regard to the quality of care.

 Robert Galvin set out to change that.

 In 2000, G.E. and several other companies 
began a program 
to reward doctors in certain cities 
on the basis of quality.

 Specifically, the companies split 
with doctors the savings 
that flowed from better care 
of diabetes and heart disease. 

According to G.E., 
the average cost 
of caring for diabetics
 who are properly treated drops
 by $350 a year,
 even before factoring 
in the cost 
of the long-term complications 
of leaving the disease untreated
-------------------------------------
" Cutler says,
 medical spending isn't increasing because
 of inflation 
so much as because 
of people consuming more ''good stuff.''"
 --------------------------------------------------------
CUTLER
" proposes a variant of the voucher system.
 Let the government finance people's 
-- everyone's -- health care,
with  credits to be spent 
on private providers or insurers.
-------------------------------------------


VOUCHER BOY # TEN MILLION 


" Cutler MOSTLY
wants insurers, 
both public and private,
 to redesign
 the way doctors and hospitals
 are compensated, 
to give them an incentive 
to compete on quality."
-----------------------------------------------


AS IN ....


"All this would ease 
the way to Cutler's ultimate goal,
 which would be to abolish 
the distinction between
 Medicare and private plans."

 That America has a separate plan 
for seniors is an accident of history:

 it was a compromise adopted
 in the 60's 
when business and the American Medical Association
 lobbied to defeat universal coverage.

 Many corporations, however,
 are now quite eager for the government
 to resolve the mess. 

And the present hodgepodge system 
(or nonsystem) simply has no logic to support it.

 As former Senator Bob Kerrey testified in 2002,
 ''There are six main ways a resident 
of the United States can become 
eligible for insurance'':
 wait until he is 65,
 demonstrate that he is disabled, '
'get blown up in a war,'
' prove he is poor and '
'promise to remain poor,''
 work for the federal government
 or find a job with an employer 
who offers insurance. 

Those who fall through the cracks
 get only half as much care
 as people with insurance. 


To make coverage universal,
 Cutler advocates a $6,000 credit
 for poor families
 (and less, on a sliding scale, for others,
 tapering off to a small credit for people earning
 $50,000 and up).

 The credits would be redeemable
 as a sort of health-insurance voucher. 
Significantly, 
Cutler would extend credits to everyone 
-- even to people who are covered now.

 Many employers, for competitive reasons,
 would still offer coverage,
 but access to care would no longer
 depend on either employment status or age. 

Vouchers are a leap for a Democrat,
 but the idea is popular 
with conservatives. 
Bush has also proposed tax credits,
 though on a smaller scale 
and for only the uninsured.
 Stuart Butler
of the Heritage Foundation
 prefers Cutler's universal model.

 Butler points out
that the government already subsidizes 
people in corporate plans, 
who do not have to declare 
their employers' contributions
 as income. 

his is a huge break:
it costs the United States Treasury
 more than the mortgage deduction.
 It is also distributed,
 illogically,
 only to people whose employers
 provide a subsidy.
 As Cutler declared in his book,
 ''Health insurance is not something
 that is made better by tying it 
to employment.''

 Even the A.M.A. has come around 
and favors having the government
 finance universal access. 

Cutler's idea is to preserve
 the diversity of America's system 
while subsidizing people's access to it 
-- to let the G.E.'s 
nd the HealthPartners of the world, 
and also the Mercks,
continue to innovate. 

Cutler says that under his scheme,
 the government might spend 
an additional $100 billion a year.

 Some of that would represent 
new spending for people 
who previously did not have insurance;
 some would represent a transfer 
to the government of costs 
now borne by others -
- employers, or hospitals
 that provide charity care.

 That's a big number,
 but, to keep it in perspective,
 spending for Medicare and Medicaid 
currently totals just over $500 billion. 

More problematic 
is that Cutler's plan 
ould seem not to brake
the projected future escalation of spending.

 By 2040, according to various projections,
 that spending could rise 
from its present $1.8 trillion 
to something like $3 trillion 
- that is, to 20 percent of G.D.P.
 or conceivably 25 percent.

 This is why 
so much attention is focused
 on cost. 

According to Henry Aaron 
of the Brookings Institution, 

''We can't continue to provide
 all care for all people.'' 

Cutler's answer to these fears 
is not exactly cavalier, 
though some might find it so.

 If we institute a more results-oriented,
 and a more health-conscious, system,
 our dollars will buy us better care
 and probably cheaper care. 

By emphasizing prevention 
and effective treatments 
for the chronically ill, 
we might also reduce 
the rate at which spending grows. 



cutlers pop book:

your money or your LIFE

-----------------

HERES THE CORE PART WHOLKE PROBLEM
SOCIALIZATION SOLVES BEST...

  Cutler and a team of colleagues 
analyzed the economic payoff. 
They found that the program 
reaped huge rewards.
 It cost $330 a patient 
and was expected to save roughly
 $30,000 over each patient's life.
 While the analysis is not precise,
 Cutler wrote,
 it ''illustrates a general point 
that professionals in health care 
have known intuitively for some time:
 . . . comprehensive disease-management
 programs 
are clearly worth the investment.'' 

The rub is that the investment
 was only marginally worth it
 for HealthPartners. 

The gains went to the patients,
 in the form of better health
, and to their employers,
 who were expected 
to suffer less absenteeism.

 HealthPartners did recoup some
 of its investment,
 as members were hospitalized 
less frequently.
 But some of those people 
would change jobs 
and change insurers,
 so the benefits were largely
 reaped by someone else. 

Ultimately, as patients retire,
 they will be reaped by Medicare. '

CLASSIC EXTERNALITY PROBLEM

TIP TOEING AROUNDGROSSLY BLOATED
 PROFIT CENTERS 
IN PAYMENT PLANS
 DRUG PEDDLING 

HIGH NUT 
   HOSPITAL CHAINS

ONLY MAKES THE REAL DEAL MORE OBVIOUS

NO FANCY
CANTAB'S DECK TOP
             TAP DANCE 
CHANGES THE POSITION 
      OF THE ICE BERGS