More on Socialized Medicine
I'm still working on a more full perspective of the "free-market" versus "socialized medicine" debate, and how each can effect CAM. I very much appreciate the insight in the discussion.
I think Monica's point about government endorsed CAM in Britain is important to think about. EBM, I argued, can take a back seat when politics and bureaucracy run healthcare.
Fixed reimbursements by Medicare and Insurers for services help to keep costs from responding to market influences. Govt. tariffs and subsidies have always been a part of US economic policy, though, and I need a brush-up course in economics. I do observe that if the "free market" analogy about the lowering costs of electronics is not analogous to health care, how about those health care services with no Insurance / Medicare coverage? Laser vision is not covered by most insurance, and has come down in price despite rapidly advancing technology. The same probably can't be said for things like ultrasounds and CT scans.
A US hospital must charge $700 for a bandaid and a tetanus shot at a hospital ER. First, the hospital won't (and under EMTALA perhaps can't) send a needy patient away without a bandaid and tetanus shot. Second, the hospital calculates that it will only get paid for maybe only one out of every 7 bandaids and tetanus shots provided. Hospitals are not really good collection agencies the same as say utility companies or banks, and there's very little cash up front. Many who come to the ER for a bandaid and tetanus shot don't have a ready means to pay for it. Insurance has become good at not paying for non-critical emergency room visits, and many government payers make a substantially reduced payment and restrict the hospital from collecting anything additional.
Nevertheless, getting back to the appeals of CAM. I do not think lower fees at a doctor's office, or for healthcare in general, will have much of an impact on the use of CAM as Paul suggests. People are willing to spend 10x more for a bottle of pills with the USANA label over the same ones with the WalMart label. Most CAM isn't covered by Insurance, but that doesn't stop people from shelling thousands out-of-pocket on CAM remedies in lieu of covered medical care. Making an MD visit cheaper than a Naturopath visit will not lure many more to choose the MD when their fingernail becomes infected. What will is:
Education
Inner understanding
Compassion
As our post-modernistic generation gets older, I think we're starting to learn and mature in understanding. We spent countless hours reading and listening to what others have to say, and this is making us wise and more capable of choosing the best opinions and sources of knowledge based on track-records. Getting the word out about how to use critical thinking, and exposing the silliness in CAM does it's part in changing John Q. Public from being "the mob."
Medicine is about being well. CAM is about feeling well. We can continue to be obsessed with a sense of entitlement that healthcare is a right. But only if we clearly understand what it is we are demanding. Feeling well comes from much more than being well. An inner understanding of that distinction is essential in defining our expectations and obligations about healthcare. We shouldn't confuse or over-mix the human need for what religion or philosophy has to offer with our need for a physically healthy body and mind.
At the same time, healthcare is in many ways synonymous with compassion. Many turn to CAM because they appear friendly, caring, and interested in the individual. In our zeal to promote science-based medicine and stamp out sCAM we can never lose sight of why we do it. We do it because we want the very best for people. That show of true compassion should be the overriding message that comes across in everything we do.
---------------------------
There were some (many) needed health care that were beyond the capacity of even the well-off consumer to afford. That's why third party payers came into existence. The alternative was pain, suffering, and death at not getting the needed care, or a non-viable system for providing it.
1910: Worker's Compensation of New York is the first recognizable "third party payer"
1929: Baylor Hospital accepts pre-payment (capitated payment) for health care for 1,500 teachers
1937: Blue Cross Insurance provides direct ("first dollar") payment to providers for their insured. Kaiser invents what later becomes the "HMO"
1935: Social Security Act initiates epic government intervention into social programs
1944: McCarran Act defines Federal and State jurisdiction for regulation of health insurance industry
1946: Hill-burton Act subsidizes hospital construction and expansion with the intent to provide health care access for the needy
1965: Title XVIII, title XIX (Medicare and Medicaid) health care for retirees and disabled
1973: HMO act states rules and provides federal funding for employer-established insurance plans
1974: ERISA regulates how insurance can operate and use funds
1982: TEFRA establishes Medicare hospital payments based on "cost per case" rather than fee for service.
1986: COBRA further legislates employee coverage as well as provider obligations to provide care
1989, 1990, 2003: EMTALA amendments dictate additional legislation to insurers and hospitals based on concerns about access and coverage of emergency care
1986: Additional act that establishes Medicare APG prospective payment system of global payment for outpatient procedures
1989: OBRA: sets up RBRVS for Medicare physician payments based on the amount of "work" done for specific services.
1996: Mental health parity mandates and regulates mental health coverage
1996 (to be implemented in stages through 2003) HIPAA establishes wide-ranging 6industry regulation designed for consumer protection and also puts WHO's ICD-9 and AMA's CPT as the only code sets along with Medicare's own to be used to describe conditions and services on which third party payment is based.
1997: BBA is a huge federal expansion and overhaul of healthcare industry regulation
At risk of drifting off-topic, I'm not so young that I can't remember in the late 70's when people said our US system of healthcare was broken and in ruin. Discontent has come in waves since then. I hope someone can tell me when and why exactly did the US healthcare system start to suck - so to speak, and what event(s) caused it. Note that, for the most part, private insurance has predominantly followed payment methodology analogous to Medicare's evolutions due to Medicare being the "big kid on the block." Also that, for good or ill, healthcare is a highly regulated industry despite essentially following Medicare payment structure and rules.
dras (Pardon the errors and omissions in the above time-line due to faults in memory and time constraints versus google-based net resources)
-------------------------
Observations about CAM in socialized versus more-private healthcare is that CAM can flourish in either system based on the popular opinion of the voter stakeholders in the public system, and payer stakeholders in the private system. I agree completely with the listed motives people have to use CAM, along with advertising being the key to the propagation of CAM use. Correct me if I'm wrong that the inference is that CAM (or quackery) can flourish depending upon regulation of advertising in either a socialized or a more-private healthcare system. And that better consumer protection legislation and enforcement is the means to prevent quackery-based fraud in either system. This really makes a lot of sense. Yet, I'm skeptical that a shift to a federal-based healthcare system will not impact our society's use of science and EBM.
All of us as "payers" can demand that Aetna cover CAM therapies, and we can expect to pay a bit more in premiums the same way we as "voters" can demand the US govt. provide CAM therapies, and expect Congress to provide a bigger budget to pay for it. But, because the two processes above do not equally share all the factors that influence outcomes, I don't think science or EBM will be similarly disregarded by both.
The model for our current private healthcare system involves 3-parties: Consumer, provider, and payer. The provider must be sensitive to the demands of the consumer in providing care, as well as needing to be sensitive to the limits of the payer to cover it. The payer has to be sensitive to the consumer demands for accountability for payments, and sensitive to the provider demands about payment of services. Finally, the consumer controls the market by responding to changes in premiums made by the payer, balanced with the need for coverage of various healthcare services.
In this model, science and EBM can be an effective mediator between the 3-parties. The provider uses science and EBM to justify the care he provides to both the consumer and the payer. The payer can use science and EBM to rationalize restriction or denial of coverage to the provider, or non-coverage or rejection of benefits to the consumer. (Incidentally, the consumer is now being educated about the importance of scientific evidence in healthcare.)
A model for government-based healthcare is different, and takes the consumer out of much of the consideration: The federal govt. provider has a negotiated contract to be payed and does not have to directly respond to the consumer's demands about care. The federal govt. payer has a negotiated contract to provide payments and doesn't directly respond to consumer markets for payment accountability. The consumer, as a mere "voter", is left to go to their legislator with frustrations about healthcare, or excessive taxes due to the cost of healthcare. (The consumer is also encouraged to have a sense of entitlement that whatever healthcare is felt to be needed will be provided and paid for forthwith.) Meanwhile, as the the legislator listens to the constituents complaints, lobbyists, political or party allegiances, contracted providers, and contracted payers are some others that may be demanding attention to potentially conflicting considerations. The
consumer has traded in some
freedom for the reassurance that healthcare will be guaranteed.
In the federal-controlled model, science and EBM can be used, but only as an arguing point to a legislator, who, as noted, has other considerations. Decisions occur legislatively, based on many factors that may or may not give appropriate weight to the scientific evidence. There is no need for EBM or science to be a deciding mediator, and it is relegated to being a mere factor for consideration.
One opinion,
dras
I think Monica's point about government endorsed CAM in Britain is important to think about. EBM, I argued, can take a back seat when politics and bureaucracy run healthcare.
Fixed reimbursements by Medicare and Insurers for services help to keep costs from responding to market influences. Govt. tariffs and subsidies have always been a part of US economic policy, though, and I need a brush-up course in economics. I do observe that if the "free market" analogy about the lowering costs of electronics is not analogous to health care, how about those health care services with no Insurance / Medicare coverage? Laser vision is not covered by most insurance, and has come down in price despite rapidly advancing technology. The same probably can't be said for things like ultrasounds and CT scans.
A US hospital must charge $700 for a bandaid and a tetanus shot at a hospital ER. First, the hospital won't (and under EMTALA perhaps can't) send a needy patient away without a bandaid and tetanus shot. Second, the hospital calculates that it will only get paid for maybe only one out of every 7 bandaids and tetanus shots provided. Hospitals are not really good collection agencies the same as say utility companies or banks, and there's very little cash up front. Many who come to the ER for a bandaid and tetanus shot don't have a ready means to pay for it. Insurance has become good at not paying for non-critical emergency room visits, and many government payers make a substantially reduced payment and restrict the hospital from collecting anything additional.
Nevertheless, getting back to the appeals of CAM. I do not think lower fees at a doctor's office, or for healthcare in general, will have much of an impact on the use of CAM as Paul suggests. People are willing to spend 10x more for a bottle of pills with the USANA label over the same ones with the WalMart label. Most CAM isn't covered by Insurance, but that doesn't stop people from shelling thousands out-of-pocket on CAM remedies in lieu of covered medical care. Making an MD visit cheaper than a Naturopath visit will not lure many more to choose the MD when their fingernail becomes infected. What will is:
Education
Inner understanding
Compassion
As our post-modernistic generation gets older, I think we're starting to learn and mature in understanding. We spent countless hours reading and listening to what others have to say, and this is making us wise and more capable of choosing the best opinions and sources of knowledge based on track-records. Getting the word out about how to use critical thinking, and exposing the silliness in CAM does it's part in changing John Q. Public from being "the mob."
Medicine is about being well. CAM is about feeling well. We can continue to be obsessed with a sense of entitlement that healthcare is a right. But only if we clearly understand what it is we are demanding. Feeling well comes from much more than being well. An inner understanding of that distinction is essential in defining our expectations and obligations about healthcare. We shouldn't confuse or over-mix the human need for what religion or philosophy has to offer with our need for a physically healthy body and mind.
At the same time, healthcare is in many ways synonymous with compassion. Many turn to CAM because they appear friendly, caring, and interested in the individual. In our zeal to promote science-based medicine and stamp out sCAM we can never lose sight of why we do it. We do it because we want the very best for people. That show of true compassion should be the overriding message that comes across in everything we do.
---------------------------
There were some (many) needed health care that were beyond the capacity of even the well-off consumer to afford. That's why third party payers came into existence. The alternative was pain, suffering, and death at not getting the needed care, or a non-viable system for providing it.
1910: Worker's Compensation of New York is the first recognizable "third party payer"
1929: Baylor Hospital accepts pre-payment (capitated payment) for health care for 1,500 teachers
1937: Blue Cross Insurance provides direct ("first dollar") payment to providers for their insured. Kaiser invents what later becomes the "HMO"
1935: Social Security Act initiates epic government intervention into social programs
1944: McCarran Act defines Federal and State jurisdiction for regulation of health insurance industry
1946: Hill-burton Act subsidizes hospital construction and expansion with the intent to provide health care access for the needy
1965: Title XVIII, title XIX (Medicare and Medicaid) health care for retirees and disabled
1973: HMO act states rules and provides federal funding for employer-established insurance plans
1974: ERISA regulates how insurance can operate and use funds
1982: TEFRA establishes Medicare hospital payments based on "cost per case" rather than fee for service.
1986: COBRA further legislates employee coverage as well as provider obligations to provide care
1989, 1990, 2003: EMTALA amendments dictate additional legislation to insurers and hospitals based on concerns about access and coverage of emergency care
1986: Additional act that establishes Medicare APG prospective payment system of global payment for outpatient procedures
1989: OBRA: sets up RBRVS for Medicare physician payments based on the amount of "work" done for specific services.
1996: Mental health parity mandates and regulates mental health coverage
1996 (to be implemented in stages through 2003) HIPAA establishes wide-ranging 6industry regulation designed for consumer protection and also puts WHO's ICD-9 and AMA's CPT as the only code sets along with Medicare's own to be used to describe conditions and services on which third party payment is based.
1997: BBA is a huge federal expansion and overhaul of healthcare industry regulation
At risk of drifting off-topic, I'm not so young that I can't remember in the late 70's when people said our US system of healthcare was broken and in ruin. Discontent has come in waves since then. I hope someone can tell me when and why exactly did the US healthcare system start to suck - so to speak, and what event(s) caused it. Note that, for the most part, private insurance has predominantly followed payment methodology analogous to Medicare's evolutions due to Medicare being the "big kid on the block." Also that, for good or ill, healthcare is a highly regulated industry despite essentially following Medicare payment structure and rules.
dras (Pardon the errors and omissions in the above time-line due to faults in memory and time constraints versus google-based net resources)
-------------------------
Observations about CAM in socialized versus more-private healthcare is that CAM can flourish in either system based on the popular opinion of the voter stakeholders in the public system, and payer stakeholders in the private system. I agree completely with the listed motives people have to use CAM, along with advertising being the key to the propagation of CAM use. Correct me if I'm wrong that the inference is that CAM (or quackery) can flourish depending upon regulation of advertising in either a socialized or a more-private healthcare system. And that better consumer protection legislation and enforcement is the means to prevent quackery-based fraud in either system. This really makes a lot of sense. Yet, I'm skeptical that a shift to a federal-based healthcare system will not impact our society's use of science and EBM.
All of us as "payers" can demand that Aetna cover CAM therapies, and we can expect to pay a bit more in premiums the same way we as "voters" can demand the US govt. provide CAM therapies, and expect Congress to provide a bigger budget to pay for it. But, because the two processes above do not equally share all the factors that influence outcomes, I don't think science or EBM will be similarly disregarded by both.
The model for our current private healthcare system involves 3-parties: Consumer, provider, and payer. The provider must be sensitive to the demands of the consumer in providing care, as well as needing to be sensitive to the limits of the payer to cover it. The payer has to be sensitive to the consumer demands for accountability for payments, and sensitive to the provider demands about payment of services. Finally, the consumer controls the market by responding to changes in premiums made by the payer, balanced with the need for coverage of various healthcare services.
In this model, science and EBM can be an effective mediator between the 3-parties. The provider uses science and EBM to justify the care he provides to both the consumer and the payer. The payer can use science and EBM to rationalize restriction or denial of coverage to the provider, or non-coverage or rejection of benefits to the consumer. (Incidentally, the consumer is now being educated about the importance of scientific evidence in healthcare.)
A model for government-based healthcare is different, and takes the consumer out of much of the consideration: The federal govt. provider has a negotiated contract to be payed and does not have to directly respond to the consumer's demands about care. The federal govt. payer has a negotiated contract to provide payments and doesn't directly respond to consumer markets for payment accountability. The consumer, as a mere "voter", is left to go to their legislator with frustrations about healthcare, or excessive taxes due to the cost of healthcare. (The consumer is also encouraged to have a sense of entitlement that whatever healthcare is felt to be needed will be provided and paid for forthwith.) Meanwhile, as the the legislator listens to the constituents complaints, lobbyists, political or party allegiances, contracted providers, and contracted payers are some others that may be demanding attention to potentially conflicting considerations. The
consumer has traded in some
freedom for the reassurance that healthcare will be guaranteed.
In the federal-controlled model, science and EBM can be used, but only as an arguing point to a legislator, who, as noted, has other considerations. Decisions occur legislatively, based on many factors that may or may not give appropriate weight to the scientific evidence. There is no need for EBM or science to be a deciding mediator, and it is relegated to being a mere factor for consideration.
One opinion,
dras
posted by nawledge at
1:15 PM
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