So,I wrote earlier about how China's aggressive H1N1 quarnantine policy wasn't really effective for H1N1 because the incubation period is quite short...so when you have symptoms you have likely already spread it. Decidedly different from SARS which had a 10 day incubation period.
Well, multiple knowledgeable people whom I talked with in China about this immediately said 'The gov't knows that...they are just practicing procedures so they will be ready for a more serious outbreak.'
There is a certain logic to practising when the disease in question is not particularly lethal in terms of case fatility rate. However, it is unimagineable that this would/could/should happen in the US. While I hope a new flu/emerging disease doesn't erupt anytime soon, the world will probably be better off if it breaks out in China.
Monday, August 3, 2009
Sunday, August 2, 2009
What not to do
It has been great fun teaching a short course in comparative health systems/financing around the world to students taking the Peking University/Duke University Diploma in Global Health. 90 students from 44 Universities around China.
On friday, they asked me to talk a bit about health reform in the U.S. (I was surprised by how much some of the students were following this). They wanted me to identify some lessons regarding what China might do given their recently stated goal of moving toward universal coverage in China. I am not really sure what China should do. I don't know enough about their system. So, I focused on things they should probably not do based on experience from the USA. Here are five of those thoughts, that I thought the most important. I plan to write a bit more about my experience in China, later. I am returning back to the states on Monday.
1. Do not provide large subsidy for rich to get private insurance. All subsidies provided to stimulate insurance need to be clear.
2. Don’t deny the existence of limits for what medicine can do. This has to do with a cultural conversation about what medicine can do versus public health versus individual choices versus things that can't be fixed.
3. Pay attention to the incentives in how doctors and hospitals are paid. The incentives in the Chinese system are now confusing, and there is a good deal of corruption and 'under the table' payment. We talked a great deal this week about the tradeoffs and incentives inherent in using FFS, capitation, salary as payment means.
4. While there is not much evidence that markets for insurance reduce health costs, you can have some ‘market notions’ inside a system that may help improve quality.
Choice of doctor, hospital and information provided to patients can help keep any system honest.
5. Be careful with age-related insurance financed via payroll taxes, demographic changes will greatly affect such a system. China has recently reversed its one child policy, and a couple who were both only children can now have two children. Lets say they do this for 20 years and then change back to a one child policy....that pig in the python would make the baby boomers impact on medicare look like a little blip.
Finally, you can’t or shouldn’t copy another system. You can learn from them, but your job is to build the CHINESE health system. This is generic advice....all nations can see models and learn lessons from others, but must ultimately build a system that works for them.
On friday, they asked me to talk a bit about health reform in the U.S. (I was surprised by how much some of the students were following this). They wanted me to identify some lessons regarding what China might do given their recently stated goal of moving toward universal coverage in China. I am not really sure what China should do. I don't know enough about their system. So, I focused on things they should probably not do based on experience from the USA. Here are five of those thoughts, that I thought the most important. I plan to write a bit more about my experience in China, later. I am returning back to the states on Monday.
1. Do not provide large subsidy for rich to get private insurance. All subsidies provided to stimulate insurance need to be clear.
2. Don’t deny the existence of limits for what medicine can do. This has to do with a cultural conversation about what medicine can do versus public health versus individual choices versus things that can't be fixed.
3. Pay attention to the incentives in how doctors and hospitals are paid. The incentives in the Chinese system are now confusing, and there is a good deal of corruption and 'under the table' payment. We talked a great deal this week about the tradeoffs and incentives inherent in using FFS, capitation, salary as payment means.
4. While there is not much evidence that markets for insurance reduce health costs, you can have some ‘market notions’ inside a system that may help improve quality.
Choice of doctor, hospital and information provided to patients can help keep any system honest.
5. Be careful with age-related insurance financed via payroll taxes, demographic changes will greatly affect such a system. China has recently reversed its one child policy, and a couple who were both only children can now have two children. Lets say they do this for 20 years and then change back to a one child policy....that pig in the python would make the baby boomers impact on medicare look like a little blip.
Finally, you can’t or shouldn’t copy another system. You can learn from them, but your job is to build the CHINESE health system. This is generic advice....all nations can see models and learn lessons from others, but must ultimately build a system that works for them.
Day 4@ Peking Univ.
Damjan Denoble of asiahealthcareblog.com has posted a write up of the lecture and discussion I did on long term care, here at Peking University.
Saturday, August 1, 2009
Asian health care models
The News and Observer has an article promoting Singapore as a reform model for the U.S., and the article laments that Canada and Europe seem to be the only places people look if they want to look at other systems. There are at least 3 Asian systems of note:
(1) Singapore has a gov't catastrophic plan, give gov't support to low income folks to purchase private health insurance, and is well known for use of health savings accounts. There article in the N and O is here http://www.newsobserver.com/opinion/columns/story/1629555.html. Singapore is quite an idiosyncratic place, and while individuals being involved in their own care is a libertarian goal, Singapore is one of the least libertarian places on the planet. Or maybe they make you be libertarian? In all seriousness, it is an example of incentivizing people to think about their health care expenditures...and is the anti-thesis of the U.S. upside down subsidy of private health insurance via the employer paid tax exclusion.
(2) Japan has a social insurance model with an insurer of last resort linked to geography, sort of like if county's insured all persons not otherwise covered. If Singapore is an attempt to de-link insurance from employment, Japan is heavily linked to employment (though you remain covered if you lose your job). Individuals are covered via payroll tax financed sickness funds that are insurance pools (Germany is based on this notion as well). Large employers self insure and run their own fund. Employees of smaller employers are placed in different funds, and there is a specific fund for civil servants. Co-pays are fairly high until one reaches age 70 and then are quite low. Private insurance is not a part of the mix.
Japan (along with Germany) has made the biggest changes in financing long term care over the last decade, with Japan creating a system that was designed to replace informally provided (family) care with care purchased via a gov't program. Essentially the goal of the reform was to address gender inequities and 'crowd out private care' with public money. The bill that created the reform was called the 'daughter in law bill.'
(3) Taiwan has a tax financed single payer approach, essentially US Medicare for everyone. One interesting aspect of Taiwan's system is that it covers western medicine along side of traditional chinese medicine. There is priviate coverage for gaps in coverage similar to medigap in USA.
There are some huge demographic differences in these nations... Singapore has 8.5-9% of the population 65+, USA has about 13% and Japan has about 21%. Also, Singapore is filled with guest workers who get deported if they get sick. But, still an interesting model.
So, there are models of note in Asia. Quickly you find an example of lots of private individual involvement (Singapore), a social insurance model (Japan), and a single payer (approach). Sorta like if you look at Europe and Canada.
All intersting models, but there is no magic bullet.
(1) Singapore has a gov't catastrophic plan, give gov't support to low income folks to purchase private health insurance, and is well known for use of health savings accounts. There article in the N and O is here http://www.newsobserver.com/opinion/columns/story/1629555.html. Singapore is quite an idiosyncratic place, and while individuals being involved in their own care is a libertarian goal, Singapore is one of the least libertarian places on the planet. Or maybe they make you be libertarian? In all seriousness, it is an example of incentivizing people to think about their health care expenditures...and is the anti-thesis of the U.S. upside down subsidy of private health insurance via the employer paid tax exclusion.
(2) Japan has a social insurance model with an insurer of last resort linked to geography, sort of like if county's insured all persons not otherwise covered. If Singapore is an attempt to de-link insurance from employment, Japan is heavily linked to employment (though you remain covered if you lose your job). Individuals are covered via payroll tax financed sickness funds that are insurance pools (Germany is based on this notion as well). Large employers self insure and run their own fund. Employees of smaller employers are placed in different funds, and there is a specific fund for civil servants. Co-pays are fairly high until one reaches age 70 and then are quite low. Private insurance is not a part of the mix.
Japan (along with Germany) has made the biggest changes in financing long term care over the last decade, with Japan creating a system that was designed to replace informally provided (family) care with care purchased via a gov't program. Essentially the goal of the reform was to address gender inequities and 'crowd out private care' with public money. The bill that created the reform was called the 'daughter in law bill.'
(3) Taiwan has a tax financed single payer approach, essentially US Medicare for everyone. One interesting aspect of Taiwan's system is that it covers western medicine along side of traditional chinese medicine. There is priviate coverage for gaps in coverage similar to medigap in USA.
There are some huge demographic differences in these nations... Singapore has 8.5-9% of the population 65+, USA has about 13% and Japan has about 21%. Also, Singapore is filled with guest workers who get deported if they get sick. But, still an interesting model.
So, there are models of note in Asia. Quickly you find an example of lots of private individual involvement (Singapore), a social insurance model (Japan), and a single payer (approach). Sorta like if you look at Europe and Canada.
All intersting models, but there is no magic bullet.
Comments on July 31 article
I can't comments in the comments section...but just a few brief replies to the thoughtful comments posted.
***economy of scale and public option***
I agree one of the arguments for a single payer or a public option is economies of scale, and a fear of private insurance is that public option would use knowledge gleaned from Medicare to give it competitive advantages. I think most opposition to public option and certainly single payer is based on general notions of 'gov't can't do anything right.' I wrote a few weeks ago about Medicare as a innovator in health insurance. In fact, most health insurance innovations of the past 25 years have come from Medicare. Prospective payment of hospitals which developed DRGs, which are now used by priviate insurers, RBRVS which allowed for attempts at differential payment policy designed to encourage primary care, etc. I suspect that there are innovations that have been developed by private insurers, but they are mostly related to underwriting and trying to not cover bad risks. This is what insurance does. So, culturally, we are stuck in no man's land. We say we don't want gov't (most people say they don't want gov't; you are saying opposite). Then when private insurance does what private insurance does, we say we don't like that. Lets develop regulations, etc. to stop private insurance from doing what private insurance does.
A very coherent argument can be made for single payer. I think if I were the king I might have universal single payer with very high deductibles, esp at younger ages and private insurance on top to fill the gaps. However, that is not going to happen this time around, and I suspect a public option won't either. If you really want single payer, you should probably be for whatever option ends up having indivdiuals do the most themselves for arranging their own health insurance...there will be many pitfalls and the experience may well make folks more ready for single payer later.
**do cross national comparisons include all persons or exclude uninsured**
They include all persons. You are saying that uninsured people are not as healthy as insured people...I agree and it is part of the point. If you add in 47 Million uninsured, the fact we spend twice as much as most is all the more amazing. Also, your general point is why people often look at measures such as healthy life expectancy at age 60 or life expectancy at 60 or 65....these measures mean given you live that long, then what is your experience. Just about all persons in US are covered when they reach age 65, and one of the knocks of other nations is that they don't invest as heavily in tertiary care...these later life measures are therefore comparing insured people across nations. And we still lag behind.
**how can you assess/change intensity without malpractice reform**
I think it is interesting how quiet malpractice has been in the debate. However, I suspect it is the CENTRAL political issue that paves the way for a consensus bill. I am writing about malpractice and patient safety this coming Friday.
**how would you propose to assess intensity?**
I would end or greatly limit the tax exclusion of employer paid insurance for one, which should at least stop insulating heavily insured folks from their decisions.
Key to me is developing a commission that is insulated from Congress to take a comprehensive look. I would start with the 10 most expensive conditions and look closely at what services may have little to no benefit and/or extremely high cost per benefit and perhaps stop paying (Medicare) for certain services or at least changing the current procedure whereby Medicare heavily sets payment rate but does virtually nothing about what can be done and when. This group would need ability to be very comprehsive not only in potentially red lining some stuff, but also proposing payment changes. Congress would then have to vote up or down a la base closing commission.
Note, the CBO said that the commission AS OUTLINED IN THE LETTER wouldn't do anything of consequence to alter costs. We need something consequential. Lessons learned from Medicare can move into private insurance...this is almost always how insurance innovation goes.
Note this will likely incrase admin costs of Medicare, especially if you likely end up with appeals or having to make the case for certain procedures in certain circumstances (like with private insurance) but you could argue Medicare doesn't pay enough in admin in this context.
***economy of scale and public option***
I agree one of the arguments for a single payer or a public option is economies of scale, and a fear of private insurance is that public option would use knowledge gleaned from Medicare to give it competitive advantages. I think most opposition to public option and certainly single payer is based on general notions of 'gov't can't do anything right.' I wrote a few weeks ago about Medicare as a innovator in health insurance. In fact, most health insurance innovations of the past 25 years have come from Medicare. Prospective payment of hospitals which developed DRGs, which are now used by priviate insurers, RBRVS which allowed for attempts at differential payment policy designed to encourage primary care, etc. I suspect that there are innovations that have been developed by private insurers, but they are mostly related to underwriting and trying to not cover bad risks. This is what insurance does. So, culturally, we are stuck in no man's land. We say we don't want gov't (most people say they don't want gov't; you are saying opposite). Then when private insurance does what private insurance does, we say we don't like that. Lets develop regulations, etc. to stop private insurance from doing what private insurance does.
A very coherent argument can be made for single payer. I think if I were the king I might have universal single payer with very high deductibles, esp at younger ages and private insurance on top to fill the gaps. However, that is not going to happen this time around, and I suspect a public option won't either. If you really want single payer, you should probably be for whatever option ends up having indivdiuals do the most themselves for arranging their own health insurance...there will be many pitfalls and the experience may well make folks more ready for single payer later.
**do cross national comparisons include all persons or exclude uninsured**
They include all persons. You are saying that uninsured people are not as healthy as insured people...I agree and it is part of the point. If you add in 47 Million uninsured, the fact we spend twice as much as most is all the more amazing. Also, your general point is why people often look at measures such as healthy life expectancy at age 60 or life expectancy at 60 or 65....these measures mean given you live that long, then what is your experience. Just about all persons in US are covered when they reach age 65, and one of the knocks of other nations is that they don't invest as heavily in tertiary care...these later life measures are therefore comparing insured people across nations. And we still lag behind.
**how can you assess/change intensity without malpractice reform**
I think it is interesting how quiet malpractice has been in the debate. However, I suspect it is the CENTRAL political issue that paves the way for a consensus bill. I am writing about malpractice and patient safety this coming Friday.
**how would you propose to assess intensity?**
I would end or greatly limit the tax exclusion of employer paid insurance for one, which should at least stop insulating heavily insured folks from their decisions.
Key to me is developing a commission that is insulated from Congress to take a comprehensive look. I would start with the 10 most expensive conditions and look closely at what services may have little to no benefit and/or extremely high cost per benefit and perhaps stop paying (Medicare) for certain services or at least changing the current procedure whereby Medicare heavily sets payment rate but does virtually nothing about what can be done and when. This group would need ability to be very comprehsive not only in potentially red lining some stuff, but also proposing payment changes. Congress would then have to vote up or down a la base closing commission.
Note, the CBO said that the commission AS OUTLINED IN THE LETTER wouldn't do anything of consequence to alter costs. We need something consequential. Lessons learned from Medicare can move into private insurance...this is almost always how insurance innovation goes.
Note this will likely incrase admin costs of Medicare, especially if you likely end up with appeals or having to make the case for certain procedures in certain circumstances (like with private insurance) but you could argue Medicare doesn't pay enough in admin in this context.
Friday, July 31, 2009
Day 3 Peking University
www.asiahealthcareblog.com is covering the class I am teaching at Peking University on comparative health systems and financing of health care. I will write comprehensively about doing this later. It has been very interesting.
July 31 News and Observer column
is now up. http://www.newsobserver.com/opinion/columns/story/1628028.html
Again, sorry for not being able to link it here or on the side bar...the proxy server I am having to use to access the blog while in China greatly reduces the functionality of blogspot and I am not such a whiz without the point and click options.
Point of today's column is to put a bit more clarity on the cost issue that everyone says is so important. Two questions are key: can we afford our system? Answer here is a value judgement (I say no). Question 2: do we get our money's worth for what we spend? Decidedly not is my answer.
It seems as though we had a pause which was related to trying to refocus on cost control in reform bills. Some progress has been made in terms of getting closer to a consensus bill in the House and Senate, but all coalitions are a bit wobbly I think. The House Republicans have offered a bill, but a quick glance does not lead me to think that it is a serious proposal. It does contain a more robust malpractice aspect than did the patients' choice act (Senate Republican alernative) with some caps; this is closer to what most Republicans want, I suspect. Malpractice hasn't been talked about so much so far, but I suspect it turns out to be quite important if any deal on a comprhensive bill is to be reached.
Often the August Congressional recess is a sleepy time politically, but not this year.
The next few weeks I am planning to write in more detail about policy options to address different cost areas outlined in today's column. Next week is patient safety and malpractice.
Again, sorry for not being able to link it here or on the side bar...the proxy server I am having to use to access the blog while in China greatly reduces the functionality of blogspot and I am not such a whiz without the point and click options.
Point of today's column is to put a bit more clarity on the cost issue that everyone says is so important. Two questions are key: can we afford our system? Answer here is a value judgement (I say no). Question 2: do we get our money's worth for what we spend? Decidedly not is my answer.
It seems as though we had a pause which was related to trying to refocus on cost control in reform bills. Some progress has been made in terms of getting closer to a consensus bill in the House and Senate, but all coalitions are a bit wobbly I think. The House Republicans have offered a bill, but a quick glance does not lead me to think that it is a serious proposal. It does contain a more robust malpractice aspect than did the patients' choice act (Senate Republican alernative) with some caps; this is closer to what most Republicans want, I suspect. Malpractice hasn't been talked about so much so far, but I suspect it turns out to be quite important if any deal on a comprhensive bill is to be reached.
Often the August Congressional recess is a sleepy time politically, but not this year.
The next few weeks I am planning to write in more detail about policy options to address different cost areas outlined in today's column. Next week is patient safety and malpractice.
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