Wednesday, July 22, 2009

Careful now . . .

There is a fine line between being Populist-in-Chief, a strong advocate for your policy prescriptions, and allowing yourself to be played by the opposition in a way that undermines your credibility as Chief Executive, to the detriment of your objectives.

When President Obama made health care reform a priority, he put forth a set of objectives -- "control costs, expand coverage and ensure choice" -- that are mutually incompatible. What we have seen in the last few weeks is that these desired outcomes are, in fact, coming into conflict with one another during the Washington debate. Even a government dominated by one party is hearing from constituents (like the Governors) that they are worried about the draft plans wending their way through Congress.

Just in the last few days, I have seen hints that the administration is starting to blame insurers and other interest groups for the failure of these plans to move more quickly. Not that Mr. Obama needs advice from me, but I see danger of repeating a worrisome pattern. Years ago, when the Clinton's proposed their health plan and it ran into opposition, Hillary quickly turned from being a thoughtful policy advocate to demonizing those (including insurance companies and pharmaceutical companies) who opposed her proposal. I worry that President Obama could go over the line and do the same thing.

I am not being naive in suggesting that all interest groups are acting in the national interest, nor that they are not being selfish about their concerns. (I recall raising some here, for example, but of course those are legitimate!) As I have noted before, "One person's costs are another person's income." But we also have to respect that most opposition is based on legitimate fears or philosophical objections, not the result of venality. Thus, it will be very hard to craft a coalition for this bill, and therefore the President and his people have to be cautious in their words. Stridency or demonization mainly act to help the opposition congeal and get more support.

The President did not exercise that kind of caution during the AIG bonus episode. Indeed, his behavior at the time sounded more like a member of Congress than a President, and later he had to back away from his rhetoric. This topic is a lot more complicated than that one. Its resolution will take a unity of purpose that only Mr. Obama can create and sustain by keeping people inside the tent. The best negotiators treat their opponents with the same respect as their allies and try to address their legitimate interests and create value for all constituencies.

29 comments:

Frank Opelka, MD FACS said...

Paul,

I truly enjoyed your blog today. I think the role you have asked the President to fulfill is perfect. I am enlightened by your words.

I must disagree with your thoughts that the goals the President has set are mutually incompatible. And, I would add quality to the objectives.

The President seeks to control the cost curve with a 1.5% reduction in GROWTH of services which amounts to a slight reduction in per capita costs. Can we expand coverage without expanding costs? In the early years, the culture of care will not allow for this. But in the out years, we can afford to cover every life by removing wasteful care. How much up front money will we need to get there? Well, it is difficult to say but estimates are around $200-300B. Now that is roughly 8-12% of the total health care spend.

So, can the system find 10 to 14% of the current spend in the waste in the system? The answer is absolutely. Is it easy? Not at all.

I know from the rest of your post that there is one person at BIDMC who can lead that effort - and that is you.

Paul Levy said...

Thanks, Frank. I appreciate the thought. It seems that the definition of "wasteful" is key. We all know, for example, that lots of end-of-life care in the form of excessive procedures and futile life-saving efforts adds costs, but solving that is part of "reducing choice", i.e., some kind of rationing. No one in DC is willing to take that on: It is a radioactive issue. (By the way, since most of that occurs with Medicare patients, the President could use his existing administrative authority to start to attack it.)

There is also pervasive waste in the system that comes from the way we all do our work. That is the kind that takes a major effort in every hospital and doctor's office. See my post below. I'm not sure federal legislation can get at it very effectively, but I'd welcome thoughts on that.

Finally, there is systemic waste that occurs because of the lack of health insurance coverage for people, who therefore don't get preventative and early diagnostic care, and therefore end up in the ERs at later stages of sickness. Giving them access to coverage can be very helpful over the long run, but the Congresisonal Budget Office is not allowed to "count" those savings. In any event, they do not show up for years. It is likely just the opposite, as costs wil llikely rise in the early years.

Anonymous said...

Ever thought of running for President?! Oh wait - you're not down and dirty enough. (:
Although I do not agree with the way either Obama or Congress is approaching this issue, I have learned one thing - the special interests in health care make the special interests on Wall Street look like absolute amateurs. This may be the most disheartening lesson of all, since Wall St. only kills your money, whereas health care kills you.

nonlocal

Paul Levy said...

Read David Leonhardt's NYTimes column today: http://www.nytimes.com/2009/07/22/business/economy/22leonhardt.html?_r=1&hp.

The special interests are ALL of us! "Our health care system is engineered, deliberately or not, to resist change." That's what makes global change in this sector so hard.

Paul Levy said...

Or read this piece by Matt Miller: http://www.nytimes.com/2009/07/22/opinion/22miller.html?ref=opinion.

How's this: Congress passes a law requiring themselves to have the same coverage Congress gives to everyone else? A nice self-correcting impact on the legislative process!

Anonymous said...

"The best negotiators treat their opponents with the same respect as their allies"
Keep your friends close but keep your enemies even closer.

You would be make a good candidate for (although I know you're not the washington type) secretary of health and welfare, Paul.

BIDMC employee

Anonymous said...

These end-of-life issues have to be addressed. We are all going to live longer than our forefathers, and we should plan ahead so that our quality of life at the end isn't meaningless or even tortuous to ourselves and our families.

Jerry said...

I think you’ve missed the boat on several points, Paul.

First, I believe Barack Obama is about the most cautious/centrist/conciliatory person to ever sit in the Oval Office.

Yeah, rightwing authoritarians in their various guises, from wealthy professional demagogues like Rush Limbaugh to institutional obstructionists like the current Senate Minority leader have tried painting him as the secret agent of an agenda taken directly from Mao’s Little Red Book, but that’s just crazy talk.

You’re also well aware that folks like Paul Krugman and Joseph Stiglitz don’t feel that Obama’s gone nearly as far as he needs to with his economic and healthcare policies.

Second, I think that Obama’s a much better politician than Bill Clinton by an order of magnitude, and believe that your concerns about him getting played are misplaced.

Third, regarding Democratic control of both houses of Congress – that and a dollar might get Harry Reid a cup of coffee in the Senate cafeteria. Some of the most persistent obstruction to reforming healthcare financing has come from such nominal Democrats as Max Baucus (MT), Kent Conrad (ND), Mary Landrieu (LA), Joe Lieberman (Lieberman), and Ben Nelson (NB); and in the House from the self-named Blue Dog coalition.

Democrats don’t march in lockstep. And many (see above) have collected plenty of money from the for-profit insurance and pharmaceutical industries. I’m glad to hear that, if need be, the Senate will enact legislation to reform health care financing using budget reconciliation rules that allow for a simple majority.

Fourth, as for the notion of a ‘coalition,’ if by ‘coalition’ you mean some flavor of ‘bipartisan,’ I think that’s the greatest threat to accomplishing anything of any value in this matter. It’s pretty clear to me that the regional rump party currently calling itself ‘Republican’ has had absolutely no interest in contributing to meaningful dialogue and constructive policy development on any of the major messes this President has to start cleaning up.

Fifth, perhaps you’ve forgotten that this is the same party that previously acted on the advice of someone who, despite his many visible errors of judgement and lack of a moral compass, is still amazingly one of its prime strategic consultants, heeding his warning that, “…the long-term political effects of a successful Clinton health care bill will be even worse--much worse. It will relegitimize middle-class dependence for "security" on government spending and regulation. It will revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government.”

(sorry, but embeded link did not work - see http://delong.typepad.com/egregious_moderation/2009/03/william-kristol-defeating-president-clintons-health-care-proposal.html)

Finally, I know that you, as the CEO of a major urban tertiary care medical complex, have to find ways to get along with these players, but I certainly think most of the opposition is quite venal, and based on the most narrowly-perceived immediate financial and controlling self-interests on the part of the industries that best profit from the current irrational system, and on the part of the folks who best serve their agenda.

It took a comedian to offer “the best rebuttal to the numerous GOP talking points on health care.”

See for yourself. (again, embeded link did not work - copy/paste http://www.dailykos.com/story/2009/7/21/756054/-Lewis-Black-destroys-GOP-talking-points-on-health-care)

PS I agree wholeheartedly with Anonymous at 8:56AM. That's my layer of the onion.

Anonymous said...

Organizing for America is currently collecting words from small business owners, medical professionals and Republicans/Independents to share with the House and the Senate. The War of Words is just getting started!

Paul Levy said...

Jerry,

It is just your kind of characterization of people that I hope Mr. Obama and his folks avoid. I don't see how calling people "nominal Democrats" or other terms helps the debate at all. There are lots of legitimate objections to various provisions of these bills.

I was not suggesting necessarily that coalition = bipartisan, although that might be part of it. I was suggesting that there may be the possibility for greater than a 51% vote to approve something, and that there is value to the country in achieving that broader consensus.

Finally, this comment of yours is pretty annoying: "I know that you, as the CEO of a major urban tertiary care medical complex, have to find ways to get along with these players." This suggests that I am somehow pulling punches in my comments here. I don't think I have ever shown a lack of inclination to offer my views on this blog because of where my office happens to be.

Jerry said...

Hi, Paul:

If you’re annoyed, well, I don’t have any specific response to that. I didn’t set out to bother you with any particular comment, and I trust your integrity.

I just think it’s important to acknowledge your position and perspective.

I know what your job is, just as I understand Obama’s, though obviously in general terms. You’re both about making things happen. That’s a precarious balancing act. And there aren’t any nets.

I honestly don’t know where you get the impression that Obama crossed, or is even close to crossing, some kind of rhetorical line that risks demonizing anybody. I thought his most recent comments in particular were quite measured and well-chosen – again, given his position:

” This isn't about me. This isn't about politics. This is about a health care system that is breaking America's families, breaking America's businesses, and breaking America's economy, and we can't afford the politics of delay and defeat when it comes to health care. Not this time, not now.”

I’m all ears if someone wants to take issue with that.

I’m looking forward to his upcoming press conference, and expect more of the same, again because I think he’s as serious a political professional as we’ll ever see in our lifetimes.

Contrast Obama’s sober statement with that of Senator Jim DeMint (R-SC): “If we're able to stop Obama on this, it will be his Waterloo. It will break him.”

Now that’s small-minded, IMO. Will anybody step forward to defend DeMint’s position?

The constituency whose interests rise above all others in this matter is quite clear. Those of us who work in the system have to get in line behind them.

And as for making things happen – never bring a knife to a gun fight. And it is indeed a fight.

Who'd expect any different?

Z.W. said...

Mr. Levy,

As a former mid-level administrator in a major market, I feel that the new healthcare policies will have a dramatically poor effect on overall treatment. The healthcare bill, and I have seen it, is going to be absolute horrid.

What are your thoughts on the beginnings of "cash only" or membership hospitals to surplant some of the disaster of this proposal?

Paul Levy said...

I think that over time they will be illegal, i.e., that providers will not be allowed to turn down insured patients.

Z.W. said...

Turning away patients is not part of the equation. You will still accept the insured patient, but the member who paid his premium to the organization would receive quicker service and a better stay. Just like hotels, if you pay extra you receive better benefits. Of course, if it's emergent, the individual with the gunshot wouldn't wait for the child with the knee scrape to be taken care of, but don't you feel there is a market for such a program, especially with the documented success of cash/member primary care physicians?

Paul Levy said...

It's hard for me to imagine that this would be acceptable to society, or for that matter, for health care providers to discriminate in that fashion.

Paul Levy said...

Jerry,

This is a hint of what I am talking about (just based on a very quick web search): "There's some in this town who are content to perpetuate the status quo, are, in fact, fighting reform on behalf of powerful special interests." Or, "health insurance companies and their executives have reaped windfall profits from a broken system." http://abcnews.go.com/Politics/story?id=8125359&page=1

Admittedly mild stuff so far along the possible spectrum, and maybe you would call it just good old-fashioned populism, but it is clearly design to impugn people's motives -- as opposed to acknowledging that just maybe, they have legitimate concerns.

Let's see how far he goes in that direction versus trying to make the case with more positive statements about how he is going to deliver access, lower costs, and choice.

Anonymous said...

Paul,

"Choice" is critical to your argument that "Obama-care" can't work and is indeed mutually incompatible... I think that this stems from your definition of choice... I choose to define choice as increased access to many different docs ALL of whom will offer the best evidentiary care, NOT to a small group of docs who will offer a wide range of choice in services (the buffet doc if you will) - Good HCR should "limit" choices in your definition - that is, to a certain extent, the point of EBM and of much of QI work (without delving into the arguments of rationing... not going there at the moment). Within my definition of choice, to say that 'controlling costs, expanding coverage, and ensuring choice' are mutually incompatible is inaccurate, with many Western European countries serving as prime examples...

As far as demonization, I believe that media and popular framing often misses the point... You are correct that we shouldn't be demonizing individuals and their companies, but instead, I frame my position as demonizing the ROLE of insurance companies, not THAT they are subserving that role... The point of their existence is to make profit, a goal to which they are legally bound through stakeholder responsibility... aspect of being legally bound to put profits over "patient care" on behalf of serving stakeholders... There are many affiliated with the insurance industry who are doing excellent work (Jarret Barrios of BCBS Foundation is a prime example), but that doesn't eliminate their for-profit role - to make money - If health care is a human right (sadly a contentious point) we should, to a certain extent, demonize that role... The response of the insurance lobby to current HCR efforts is in large part based on their (legitimate?) fears - of a hit to their income - not on their role in taking care of people... that is the role filled by 'the people' and by direct service providers... For President Obama to say that their role is not to provide care but to make profit is simply speaking the truth.

i think that you (perhaps blithely) make a phenomenal point... **WE** are all vested interest groups and speaking about HOW we express that vested interest would be timely and appropriate - (e.g. that 10% of all HC lobby $ are going into Sen. Baucus' pocket - that isn't a 'populist' lobby...how do **we,** the vested interest groups without profit as a motive and therefore without excess cash to toss around, have an equal say? I would be interested in your thoughts on that question...

Paul Levy said...

Thanks, but I don't understand your first point. In many European countries, you do not get to choose to your doctor or your hospital. Nor do you get to choose whether you get certain types of surgeries and other procedures if they are deemed not to be demographically correct for you (i.e., rationing).

On insurance companies, I don't mind if they make a profit if in fact they are risking capital as a counterbalance to absorbing actuarial risks in the population. I do think they can be better regulated, so as to be forced to take all comers and not impose pre-existing condition restrictions. We require that in Massachusetts, by the way.

Jerry said...

Paul, the two Obama quotes you picked sound perfectly rational and completely accurate to me.

I watched from the sidelines a little over 10 years ago when Anthem picked up BCBS/Connecticut. There was some serious money pulled down by some folks in that transaction.

Yeah, that's just an anecdote to be sure, but far from an isolated event in the industry.

And, really, you don't need to do any kind of search beyond simply clicking through to http://www.whitehouse.gov/blog/Reforming-Health-Insurance-Reforming-Washington/ to learn what the President's had to say.

"We can build on the extraordinary common ground that's been forged, and we can do the hard work needed to finally pass the health insurance reform that the American people deserve."

Is that positive enough for you?

Anonymous said...

Paul,
I would ask that you please provide data to corroborate your comment that patients in many Western European countries do not have 'free choice.' I offer you the following resources to demonstrate that at least France, Germany, and the Netherlands (albeit within a 10k radius for good reasons that I'll not delve into) offer free choice...

In the NHS, "Patients may select a GP of their choice, although choice is restricted within geographical areas. The incidence of patients changing their GP – other than for reasons of changed residential location – is low. Most people have a long-standing relationship with their GP."

http://www.commonwealthfund.org/Content/Performance-Snapshots/International-Comparisons/International-Comparison--Access---Timeliness.aspx

and

http://www.euro.who.int/observatory/ctryinfo/ctryinfo

and

http://www.euro.who.int/document/OBS/hcs8countries.pdf

Furthermore, in our current system, there is no "free choice" of providers in the U.S. This is heavily determined by insurance coverage (which can be entirely out of your hands - e.g. your employer changing coverage --> you being forced to get a new doc) and providers opting-in to Medicaid and Medicare (although the latter is less of an issue with 97% acceptance among docs).. Finally, we don't opt-in to the vast majority of non-elective procedures here -they are chosen for us by standards of care (which are adopted in a manner that is loose at best)...

NC said...

Dear Paul,

Could you please provide a list of these "many European countries" where patients don't get to pick their doctors? I am intrigued.

Also, Massachusetts still has plenty of health care problems... having insurance doesn't make everything magically better...

Just a few thoughts from a newcomer to the health care field. Thanks for your posts, as always.

Anonymous said...

I agree they are mutually incompatible if we expect to keep everybody's income the same. You cannot address all three at the same time. To many moving parts. There are many people (insurers, physicians, pharma, hospitals) that have a strong interest in maintaining the status quo. Some, like hospitals find themselves in the difficult position of having to argue against insuring more people after they have advocated for years the need to address the uninsured. So they go along cautiously. Others like insurance companies play the "you can't trust government to run your healthcare" card and try to raise fears. Anyone who thinks Obama is too statesmanlike to play politics and will not beat up/blame someone for legislative inertia is kidding themselves. Of course he will and insurance companies are the best target. Too many times politicians will settle for a minor fix, claim victory and move on. There is a good chance that is what will happen with this issue.

Paul Levy said...

To those who raised the choice issue, yes, they often get to pick their GP, but then they take whoever is next in line with regard to specialists and surgeons.

Jerry said...

Some very interesting comments in the thread. Is this what you had in mind when you started blogging, Paul?

Personally, though, I think you started with a pretty weak hand in this one, and it only seems to have gotten worse, IMO.

Paul Levy said...

Jerry,

You have a nasty streak that comes through pretty clearly -- or maybe you are just sarcastic. It can be hard to tell from the written word.

To answer your question, what I had in mind with this post and the others I offer is to set forth my view of a situation and welcome comments. This is not a game of winning or losing. This is a forum for discussion and education and occasional entertainment for me and my readers.

Anonymous said...

As a patient with a (useless) HSA and $6000 high deductible plan whose premium just rose 22% in one shot ("due to the recession"), I am concerned the bill says nothing about capping premiums for all these coverage mandates. We raised our deductible to $10,000 to keep the premium even slightly reasonable. What's to stop the insurance companies from offering the mandated coverage, but at a premium that is unaffordable? Their past behavior gives every indication that is exactly what they will do, and it still amounts to cherry-picking the healthy. This will leave me, in the individual insurance market, worse off - and I know how to use or not use the system, being an M.D. Pity those who do not.
And BTW, Paul, I define "special interests" as those stakeholders who are solely concerned with maintaining or increasing their profits as this bill progresses, rather than accepting a reasonable profit while providing care with integrity and ethics. Although we are all special interests as you define it, we do not all hire lobbyists to achieve the above aims.

nonlocal MD

Paul Levy said...

On point #2, I think if we were to check the rosters you will see lobbyists for virtually every group you can imagine working this bill, most of whom are trying to get more money or save more money for their constituents. Not surprising given that the President is trying to reallocate one-sixth of the US economy.

On point #1, national regulation of the insurance company premiums, coverage plans, and the rest is clearly called for if they are to be required to offer universal coverage -- as opposed to regulation by 50 individual states.

Jerry said...

(Note from Paul: I have edited this comment to remove profanity.)

Nasty streak?

Well, I suppose it could be one among my many characteristics.

I think I understand what you’re saying. Sometimes I’ve reacted similarly in online exchanges – even to the point of feeling that the other person is deliberately provocative or hostile.

I admit to sometimes reacting badly when challenged on a personal opinion I’ve presented as fact.

I sometimes get my guard up if somebody calls me out on a glib, hasty, or half-baked comment of mine. I could get defensive – maybe even a bit thin-skinned.

And if anybody else was paying attention to such an exchange in a rich thread, they might see the evidence of my agitation and obfuscation most clearly by looking at the questions and comments from others that I’ve ignored, and not just at what I've said.

At those times I have to remind myself of the real transparencies afforded by the technology and process called blogging.

I can say whatever I choose to a potentially very large and diverse audience, but I have to be honest. My opinions need to be identified as such, and the facts that I present need to be backed up by evidence.

And if I really want to engage, and not just talk to myself or bask in the adoration of sycophants or people who honestly think and feel as I do, then I have to be willing to hear out anybody who's making the effort to connect. I think they deserve it as a basic courtesy and sign of respect.

And if those connections include challenges, all the better, because I think real dialogue is often messy, confrontational, and difficult – even unpleasant. Just like the real world, and the problems we confront in it.

I have to try hard sometimes to not get hung up on tone or language, because those are distractions. I try to take people as they are, not as I want them to be.

George Orwell said it best when he decried the “sheer cloudy vagueness” coming from the politicians of his time. He said it was their way of “defending the indefensible.”

I think that the pearl-clutching I mentioned in a previous post of yours is much the same, and I try not to use it as a way to hide from something that I don't like. That happens way too much today, not just in the blogosphere and other mass media, but in everyday, face to face conversation.

...


As for the true jerks out there who really are just trying to muck things up - and of course they're out there - their actions and motivations become clear sooner or later. I'd rather let their stupid comments stand on their own. It's no skin off my nose.

I mean, online exchanges are great ways for me to share my ideas and opinions, to hear from others, learn something, and even be entertained.

Anywhoozle, this is probably getting more meta than it should for a thread about tone, language, perceived intent, etc. in political/online discourse, etc., so I'll stop here.

Besides, enough about me. After all, this is your blog.

Peace out.

Jerry said...

(Note from Paul: I have edited this comment to remove profanity.)

Seriously?

Enough said, dude.