Health insurance is not insurance

A message for conservatives

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Is health insurance a plan to help healthy people mitigate against an unexpected illness, or an income subsidy to help the sick pay for medical care?

Conservatives ought to have a clear answer to that question.  Congressman Morris Brooks from Alabama did not and found himself on the receiving end of liberal ridicule.

By suggesting that those who take better care of themselves should pay lower health insurance premiums, Brooks implied that health insurance is indeed a type of insurance arrangement.  After all, the risk adjustment of premiums is a practice proper to all other kinds of insurance services: A prudent driver pays less for auto insurance than one with a pre-existing driving record.  A home owner pays more for home insurance if the property is on muddy terrain rather than on sturdy ground.  A smoker pays more for life insurance than a non-smoker, as does anyone whose risk of dying prematurely is high, even if that predisposition is inherited genetically.

Brooks’ conception of health insurance, however, intuitive as it may be, is wrong.

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Good health care news from America

My dispatch to Switzerland

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I was kindly asked to provide an article for Courrier du Medecin Vaudois, the French language journal of the medical society of the canton of Vaud.  The article was published as part of an issue on the theme of ‘America First against Obamacare.’ Below is an English version of the piece.

Health care in the United States: The surprising good news

On the surface, the news from America about health care seems rather grim: cost and dissatisfaction keep rising, reforms are stalling, and, for some, even life expectancy may be declining.  If that wasn’t bad enough, President Trump issued a tweet on March 25 predicting that “Obamacare will explode.”

For a small but growing number of doctors and patients, however, the future is surprisingly hopeful. 

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A health insurance CEO daydreams

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Jim was at his desk, looking weary.

The last few weeks had been brutal.  Despite working twelve-hour days, he felt that he had little to show for.  His annual board meeting was to take place the next day, and he expected it to be tense.

With a replacement bill for the ACA about to be voted on, and with Trump in the White House, the situation seemed particularly precarious.  The board members had asked him to present a contingency plan, in case things in DC didn’t go well.

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Should we blame technology for increased healthcare spending?

Healthcare economists mistake cause and effect

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Should we blame technology for the growth in healthcare spending?  Austin Frakt, a healthcare economist who writes for the New York Times, thinks so.  Citing several studies conducted over the last several years, he claims that technology could account for up to two-thirds of per capita healthcare spending growth.

In this piece, Frakt contrasts the contribution of technology to that of the ageing of the population.  Frakt notes that age per se is a poor marker of costs associated with healthcare utilization.  What’s important is the amount of money spent near death.  If you’re 80 years old and healthy, your usage of healthcare services won’t be much more than that of a 40-year-old person.

So far, so good.  But should we accept the proposition that technology is the culprit for healthcare spending growth?

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Interview on the Wake-Up Call podcast.

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I had the pleasure of being interviewed by Adam Camac and Daniel Laguros, hosts of the Wake-Up Call podcast.  We talked about the history of American healthcare.  The interview was broken down into 2 segmenst.  Here is part 1 and here is part 2.  I highly recommend this podcast.  Adam and Daniel are very good hosts and they have terrific guests, covering a wide range of topics.  You can subscribe on iTunes.

The pharma-fed doctor

And the foundation-fed healthcare journalist

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In his recent article “Feed Me, Pharma,” ProPublica’s Charles Ornstein has been calling attention to studies showing that the prescribing decisions of doctors are linked to the amount of money that drug companies can bestow on them, usually in the form of meals, travel expenses, tuition support to attend courses, and so on.

I find nothing surprising about that, and Ornstein need not be so scrupulous when he clarifies that “the researchers did not determine if there was a cause-and-effect relationship between payments and prescribing.” To deny that perks have a causal effect on physician behavior invites improbable considerations.

In fact, the data suggests that doctors are particularly easy to manipulate. One of the researchers interviewed by Ornstein was “surprised that it took so little of a signal and such a low value meal [to influence doctors]” A Chick-fil-A is all that it takes!

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In defense of the employed physician

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I wish to make one clarification and one prediction regarding employed physicians.

The clarification is this:  There is a common misconception that if healthcare operated under free market conditions, it would primarily be a cottage industry of solo practices and of small physician-owned hospitals.  Such operations would not develop the capabilities of large healthcare entities that we commonly associate with central planning.

In reality, however, the opposite would be the case.

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Let’s be clear about transparency

And about the obfuscations of healthcare policy interventions

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Note: This article is jointly posted here and on The Health Care Blog.

Transparency—or its absence—continues to fascinate healthcare analysts and healthcare economists.  A study just published in the Annals of Internal Medicine addresses the effects of public reporting of hospital mortality rates on outcomes.  Its senior author, Dr. Ashish Jha, offered his perspective on the study results and on the topic of transparency in The Health Care Blog.

According to the study investigators, mandatory public reporting of hospital mortality is not improving outcomes.  The result of their analysis surprised them because “the notion behind transparency is straightforward” and the “logic [of public reporting] is sound.”  The conclusion, therefore, is to persist in the effort, but to do it better with better metrics, better methods, and better data. 

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Practicing medicine for the common good

Beware of the fallacies of Spaceship Earth ethics

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In a recent New England of Medicine article titled Considering the Common Good—The View from Seven Miles Up,” Dr. Martin Shapiro tells a story that serves as a parable for a more general point:  Instead of only considering the best interests of individual patients, American physicians should adopt “a more communitarian approach to decision making” and consider “the implications of individual clinical decisions for other patients and society as a whole.”

The parable is as follows: two sick patients are aboard an airplane, each which his own physician.  The first one is terminally ill and on his way home; the second one has a grave illness but stands a small chance of surviving.  A decision to land midway must be made in flight, and it pits the interests of one against those of the other.

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Direct primary care for the poor

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A third-year family medicine resident inquires about the direct primary care model (DPC) and caring for the poor. (more…)