A recent survey described in the April issue of Health Affairs reveals widespread disenchantment with the US healthcare system, as compared to a number of other developed countries.
Keep these results in mind the next time you hear someone raving about how the US healthcare system is the best one in the world.
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Health policy wonks have been pointing for a while now to large variations in Medicare spending across different parts of the country. Live in Miami, and the government is probably going to spend a heck of a lot more for you on Medicare than if you live in Minneapolis, even after accounting for how healthy or sick you are. Here’s a picture demonstrating some of this variation from a recent article by Joseph Newhouse and Alan Garber in the New England Journal of Medicine.
The picture shows that some regions of the country spent almost $200 lessthan average, per month, per person while others spend almost $200 morethan average, per month, per person. (The really big spike on the right side is the city of Miami. No use trying to understand Miami!)
These variations have struck many policy experts as a chance for a win-win situation. As one group from Dartmouth put it: “To slow spending growth, we need policies that encourage high growth (or high-cost) regions to behave more like low-growth, low-cost regions.” This is a controversial claim, in part because the mere existence of variations doesn’t prove that high utilization, high-cost regions are spending too much on healthcare. It is possible that the low cost, low utilization regions are spending too little. Most people, who’ve looked closely at this topic, including me, believe that much of the spending in the high-cost regions is excessive, and can be curtailed without harming health significantly. The claim is also controversial because even if you were convinced that high spending regions are offering wasteful care to their patients, it’s not clear how to cut costs without harming patients, how to cut fat without also cutting meat… (Read more and view comments at Forbes)
I have long been a fan of single sentence paragraphs.
I really have.
When used properly, an occasional one-off sentence can really stand out, amidst the tumble of longer paragraphs made up of complicated sentences. Here’s a good example from The Power Broker. In this part of the book, Robert Moses has spent an intense year, one that followed upon some pretty intense years preceding it, fighting to build parks and parkways on Long Island and elsewhere. But he found himself blocked at every turn. Too many powerful interests were stacked up against him, and it really looked like his plan was doomed to fail. Robert Caro describes his situation in the following two paragraphs:
It had been more than a year since Robert Moses had announced his revised and broadened Park and parkway plan, a plan which had, after all, included parks and parkways not only on Long Island but throughout the rest of New York State, along the Niagara Frontier, in the Genesee Valley, in the farmland of the Taconic region, and among the peaks of the Alleghanies, Catskills and Adirondacks. Now, more than a year later, parks and parkways were still located nowhere but in the map of Moses’ imagination. After all the talking, all the planning, all the fighting, he simply didn’t exist. And at the end of 1925, there seemed little possibility that they would come into existence at any time in the foreseeable future. If one looked ahead a decade, even a generation, it seemed unlikely that any substantial part of the dream would be reality.
Within three years, almost all of it would be reality.
And then Caro continues on to the next chapter. That last sentence, to the point and standing alone, thereby magnifying its impact on the reader. Don’t you want to read on and find out what happens? Not a surprise that this guy has won multiple Pulitzers.
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Imagine you are a small business owner deciding whether to hire two new employees, your 50th and 51st workers respectively. Would you hire them knowing that, by surpassing the magic number 50, you will now be obligated under Obamacare to pay a penalty unless you offer all your employees affordable healthcare insurance?
Imagine you are owner of a large business, with a significant part-time workforce. It is the busy season and you need more labor. Would you increase the work hours of your current part-time employees, past 30 hours a week, knowing that you will now be obligated under Obamacare to provide them with affordable health insurance? Or would you hire new, less experienced workers and forgo those costs?
These are a couple of the decisions businesses are forced to make as they come to grips with their new obligations under the Affordable Care Act (the ACA).
Did it have to be this way? Did the ACA have to draw such sharp lines, between 29 and 30 hours per week and between 49 and 50 employees? Or could these artificial dichotomies have been avoided while preserving the goal of increasing the number of employers who offer people affordable health insurance? …(Read more and view comments at Forbes)
For most Medicare patients in United States right now, Medicare pays for hospital stays on the basis of what are called Diagnostic Related Groups or DRGs. You get diagnosed with pneumonia, and your hospital gets payment to treat a typical case of pneumonia. Name the diagnosis, and the hospital will know what it gets paid. And if the hospital keeps you in the hospital for 10 days longer than the average pneumonia patient, it will lose money on your care. On the other hand, if the hospital discharges you from the hospital quickly, it still receives payment for your pneumonia care. Plus, physicians and clinics can charge Medicare for outpatient services to follow-up on your hospitalization.
Under Obamacare, Medicare is going to start using more bundled payments, where the money the hospital receives for a diagnosis not only pays for the hospital care, but also for subsequent care after hospital discharge. Based on experience in Europe, this is a really good idea. As described in an April article in Health Affairs, the DRG systems in Europe are finer tuned than in the United States, promoting high quality of care while containing costs. One of the reasons is because the DRG extends beyond the hospital, as shown in the figure below:
Jennifer spends lots of time with dead things, dead humans actually. She works in a pathology lab. One night, she is asked to incinerate a fresh human cadaver, and she is struck that it would be a waste to throw away perfectly good meat. So, even though she is against killing and is a vegetarian for moral reasons, she cuts a chunk of flesh off the cadaver, takes it home, and has it for dinner.
Got a problem with that? Almost everyone does. But the vast majority of people cannot explain why, at least not to the level that would earn a B-plus in a freshman philosophy seminar. Instead, as Jonathan Haidt explains in The Righteous Mind, it is often our moral intuitions that come first, rapidly or even automatically, with ethical reasoning coming later.
Haidt’s book is one of many that have come out in recent years highlighting the relevance of psychology (and its close cousin, neuroscience) for understanding human morality. As a behavioral scientist, I have devoured many of these books. I am fascinated by human nature and love trying to understand why all of us behave and think the way we do. But as a physician ethicist, I often find myself reading these books with a parallel agenda: not just to understand human nature, but also to see whether this line of research has relevance for my work as an ethicist. My bottom line: Understanding moral psychology ought to be a required component of ethics training, not because the science will help us to differentiate between right and wrong… (Read more here)
In 1925, a handful of extremely wealthy Long Island residents tried to thwart state plans to run highways from New York City through Long Island to beaches that the masses could enjoy. These wealthy people were understandably upset, that part of their property would be taken away to make room for highways and the like. But they resisted to the point of inflexibility, and the millions of lower and middle class New York City residents who hoped to find weekend refuge from summer heat looked like they would be shut down by a few dozen multimillionaires. But Gov. Al Smith was not happy with this arrangement. And in a speech arguing in favor of these parks and beaches, he also made some pretty profound statements about democracy:
The cure for the evils of democracy is more democracy. Let us battle it out right in the shadow of the capitol itself and let us have a decision, and let us not permit the impression to go abroad that wealth and the power that wealth can command can palsy the arm of the state.
Healthcare systems are big and complex beasts, that are very hard to transform overnight. In the United States, for example, we have long had a system of care dominated by fee-for-service payment. In this kind of system, the more tests and procedures and office visits that a physician orders, the more that physician gets paid.
A little over 10 years ago, fee-for-service also dominated primary care practice in Ontario, Canada. You can see that with the light blue area in the circle on the left. But look what is happened in the past 10 years! System has dramatically shifted away from fee-for-service. And guess what? Primary care physicians in Ontario have greater job satisfaction than they had a decade ago.
If you want to read more about this transformation, check out the article by Brian Hutchison in the April edition of Health Affairs.
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In high school, I was taught not to repeat words too often in the same paragraph, or even within a relatively short essay. I know I am not alone in having been taught that way, because many of the people I’ve mentored over the years present me drafts of their writing which show that they have been working hard to give a different name to the main topics of their writings, each time those topics occur. A person writing about congestive heart failure, for example, may call it congestive heart failure one time, CHF another time, systolic dysfunction yet another time, etc., leaving the reader to wonder whether these are different but related concepts or simply the same idea put forward in a variety of guises. But often, repetition is a mark of good writing, not only because it is easier to understand, but because repeating the same word over the course of a paragraph, or even a longer chunk of writing, can give the writing rhythm.
Consider this paragraph from The Power Broker, by Robert Caro. In the paragraph he is writing about the main character of the book, Robert Moses – a behind the scenes politician, to most eyes, who nevertheless had an enormous impact on New York State and New York City, from its highways and parks to many other aspects of urban design. Moses had a brilliant legal mind, and was famous for throwing language into obscure sections of bills that would sneakily enable him, in whatever government position he held at the time, to garner more power.
Quoted below, Caro writes about the way he slipped concepts of “entry and appropriation” into the law in a way that clearly circumvented what anyone else wanted the law to accomplish, thereby accomplishing exactly what Moses wanted to:
To realize a dream of unprecedented scope, Robert Moses, by use of the law, had armed himself with unprecedented powers – and then, finding that these powers were still inadequate, he had deliberately gone beyond them, beyond the law. “Entry and appropriation” was, even as defined in law, of questionable constitutionality in its negation of the individual’s rights when his property was coveted by the state. And Moses had gone beyond the definition to use the power of the state with even less restraint than the law allowed. But both courts and Legislature understood the situation; before both courts and Legislature, Moses stood stripped of all defenses and, it seemed in February 1925, both courts and Legislature would now step in and rectify the situation, the courts by affording redress to the individuals injured by his actions, the Legislature by ensuring that he never again have the opportunity similarly to injure any other individual.
But the ultimate court in which the fate of Moses and his dream was to be resolved would be the court of public opinion. And in this court, Robert Moses had close to hand three formidable weapons…
Like a drumbeat, the words courts and Legislature recur throughout the paragraphs. And the closely related concepts of law and court do too. But rather than make the writing boring and repetitive, they propel the writing along. Beautiful stuff. Expect to see more over the next few weeks.
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I’m currently in the middle of reading Robert Caro’s first book, The Power Broker: Robert Moses and the Fall of New York. I’ll be blogging intermittently about this wonderful book over the next few weeks. Expect a few of those posts to be focused on drawing writing lessons from this wonderful author.
But a relatively early in the book, only 129 pages into it in other words, a paragraph jumped out at me that struck me as very relevant today: on the importance of finding the right balance between ideals in politics and accomplishing something in politics. The paragraph occurs in a chapter about Al Smith, the longtime governor of New York. He was not an intellectual, didn’t like to read it all, but was nevertheless very intelligent and shrewd. And what he understood most of all how to get things done. And that meant he sometimes lost patience with people who fought so hard for their ideals that they missed opportunities to implement policies that improve upon existing policies.
He has no patience for reformers who, unlike Belle Moskowitz, didn’t understand the importance of practical politics and getting things done, who refused to compromise, who insisted on having the bill as it is written, who raged loudly at injustice, who fought single-mindedly for an unattainable ideal. Their pigheadedness had the effect of dragging to political destruction politicians who listened to them, of ruining careers men had taken years to build. He had seen it happen. And more important, what was the inevitable result of their efforts? Since they refused to compromise and operate within the political framework – the only framework within which their proposals could become reality – the laws they proposed were never enacted, and therefore at the end of their efforts the people they had wanted to help, the people he knew so well needed help, hadn’t been helped at all. If anything, they had been hurt; the stirring up of hard feelings and bitterness delayed less dramatic but still useful reforms that might have been enacted. When the reformers were finished with all their hollering and were back in their comfortable homes, the widows of the Fourth Ward would still be forced to give up their children before they could get charity. What good was courage if it’s only effect was to hurt those you are trying to help?
I do love the writing of this paragraph – the back and forth between long and short sentences, for example. The rather than dwell on the writing per se, it’s the idea here worth noting right now: political courage doesn’t mean being unwilling to compromise. It means doing what you can, within the political realities you inherit, to make the world a better place.
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