It's safer to steal

Imagine you're really, really sick, and you're out of money to pay for treatment. Maybe you lost your job. Maybe you never had one. Maybe you've exhausted all the treatments covered by your insurance policy and have to pay for further treatment on your own.

Whatever. You're out of money and you're still really sick and if you don't find a way to pay for further treatment you'll die.

Obviously, you're not alone on the planet. There are other people around who have money and who don't need what they have as urgently as you need it. In a free country, you would be free to ask them for money. You could campaign for little donations from a lot of people (this is how people justify health care taxes, by the way -- it's only a little bit contributed by a lot of people instead of a lot contributed by patients who actually need the health care). You could approach a rich philanthropist for a donation. You could try to find a health provider who offers free or reduced-fee health care.

In short, in a free country, you would be free to seek charity.

And people would be free to not engage in charity. Some sick people don't want to take the chance of relying on charity, perhaps most. What if you ask, you make your best case, and no-one agrees to finance your health care? Do you just give up and die? And how do you deal with the humiliation of having spent all that time and effort begging for help, begging to stay alive -- and then you fail?

Really, it's much safer to just force someone to give you the money you need. Since this is theft, and most people cannot bear to be thought a thief, particularly when it's a self-assessment, some evasions are in order.

Such as -- it's not my fault if people won't accept the fact that other people need their surplus money. Such as -- it's not my fault if people refuse to agree that morality requires you to spend some part of your life earning money to pay for other peoples' health care. Such as -- I'm not stealing from anybody, I'm just exercising my democratic right to vote for a government that supports the use of tax dollars for health care. Such as -- it's not my fault when the government uses guns to heard recalcitrant taxpayers to jail, because citizens should realize that taxation is the price of enjoying all the benefits of society.

But of course, if it walks like theft and talks like theft, it's theft. As soon as you point a gun at someone who was minding their own business and demand that they give you money, it's theft.

The refusal to rely on charity is, at the end, to believe that it's safer to steal.

Eureka!

I have found it! I finally understand what's wrong with our health care system!

The problem is . . . wait for it . . . we're all paying too much money for a crappy product. The providers are taking advantage of us. They know they have what we need -- health care -- and they're going to charge us an arm and a leg for the poorest-quality product they can get away with delivering.

The obvious solution is two-fold:

1) Health care purchasers must be hard-bargainers on price. That is, offer a take-it-or-leave it price for the services offered for sale.

2) Health care purchasers must control the product being offered for sale. That is, restrict providers to selling only those products purchasers are willing to buy, and at the price purchasers are willing to pay for it.

In practice, given our insistance that the government foot all health care bills, that means that governments must slash the prices they are willing to pay for health care, and health care providers must be restricted to producing only certain products.

That's pretty simple.

Except . . . what if the providers say "No?"

But that's unthinkable, so no-one is thinking about it. The health care services will always be there. Doctors, nurses, care-givers, pharmaceutical company executives and employees, insurance company executives and employees, medical device manufactuer executives and employees, hospital executives and employees, none of these people have any other options open to them but to stay in their current lines of work.

I mean, isn't that true of everyone? No-one has any choice about what they do for a living?

So that settles it. The solution is to make providers take less money for producing more, and we know for a fact that they won't say "no" because they're all locked into their jobs.

Of course, there's the issue that the only way to "make" someone do something is to stick a gun in their face. But we don't have to deal with the issue of pointing guns at health care providers because they'll cave into our demands long before we'll have to unholster our guns. And we've holstered our guns in some really pretty euphemisms that blend in with all the rest of the help-the-less-fortunate rhetoric we're spouting, so it's easy for providers to evade that the guns are there. Plus, we can threaten to stop liking the health care providers unless they look at the situation through altruist-colored glasses, so they'll all rally around the battle cry that capitulation to our demands is the moral thing to do, guns or no guns. In sum, we don't have to worry about our guns scaring the providers out of the health care field because we do a bang-up job helping the health care providers ignore the guns.

No problem.

Not sure why I didn't think of this sooner.

Scapegoating doctors

Now coming to a socialized medical system near you . . . scapegoating doctors.

I wrote a day or so ago that all the problems attributed to fee-for-service payments for health care would resolve themselves if health care consumers -- patients -- were directly responsible for paying for what they purchase. We have fee-for-service problems because, ultimately, it is the government that is paying the fees.

But let me elaborate on that a bit. Government money comes from taxes. To the extent government charges fees for services like the post office, and makes a "profit," it's only because taxpayer money provides the "capital" for such a concern to be in business in the first place.

Unless you're in an explicit dictatorship, money from taxes is dependent on votes. So policitians have to pretty much lie to voters about how much things cost, because voters finance the government with their taxes and in general, when presented with a new tax, tend to throw the bum who suggested or implemented it out of office.

["Uh, where's the part about scapegoating doctors?" -- I'm getting to it.]

In Massachusetts, all taxpayers know that their taxes are supposed to be paying for the health care of every Massachusetts citizen. They also know that the 2006 health system reforms are costing hundreds of millions more dollars than projected. (We're all shocked, I know.)

The regulators are all posturing by saying things like, "we always knew we were in for a two-part process: first, make sure everyone has someone else paying their medical bills, then deal with the explosion in costs that will necessarily follow." (See p. 20 of the Recommendations of the Special Commission on the Health Care Payment System.) As if that's what taxpayers consciously voted for when they were being told that covering everyone would lower health care costs by eliminating the care that providers give to people who can't pay for it. As if any taxpayer who cries "foul" is somehow forgetting the bargain he made. It's insulting.

But I digress. The regulators, in accord with this "process" everyone supposedly agreed to, are now explicitly tackling the skyrocketing costs associated with the plan. So they came out with their Recommendations on how to curb costs.

This is where the doctor scapegoating comes in. The regulators recommend that Massachusetts move to a "global payment system," which is not the dreaded "capitation" system of HMOs past because the regulators insist that it isn't (see p. 29 of the Recommendations). Under global payments, providers would be paid a set fee to handle all of a patient's care for a given time period. So, $20,000 per year to take care of me, let's say. I have no idea if that's a figure that the regulators would come up with, it's totally random. The move to global payments would be accompanied by various measures meant to ease the pain on providers transitioning away from fee-for-service -- but it would also be accompanied by "pay for performance" in some form or other ("P4P" -- see p. 35 of the Recommenations).

P4P means that providers have to achieve certain health care quality outcomes in order to receive their global payment in full.

P4P means that if providers -- DOCTORS -- don't check the regulators' boxes, they won't get paid.

P4P means doctors lose even more autonomy than they have already. It means that when a doctor is trying to diagnose you and to decide on a course of treatment, she has to consult a regulator's list of do's and don'ts or see her compensation go down. Ask yourself if you want a bureaucrat deciding your treatment, or if you want some politician who is answerable to taxpayers to make the decision whether to spend money on your treatment.

P4P is just another way of slashing doctors' monetary and intangible compensation, which means it's going to reduce access to health care in Massachusetts. The doctors who were good enough to make money allowing them to retire, will retire. Other doctors who think they can make enough money doing something else, will do it.

The doctors who are willing to practice under P4P, who are willing to get paid for following instructions instead of exercising the judgment developed by their training and years of experience, are not the kinds of doctors Massachusetts patients are going to want to have. P4P will attract doctors who think that thinking is too hard, who think that they'd rather have a job that doesn't require them to think too much.

And when waiting times go up, quality declines because its delivered by doctor-bureaucrats, and costs continue to spiral because now people are getting sicker, the regulators will blame the doctors.

They'll blame doctors for not producing quality health care for less money and with their brains outlawed.

Doctors, you have been warned. In Massachusetts, you are about to be excoriated for not doing more with less.

Please please please pretty please don't take this lying down. Go on strike.

Here's a good one

Here's another beaut from the Recommendations of Massachusetts' Special Commission on the Health Care Payment System:

Considering a group of 45 core measures that represent the most important and scientifically credible measures of quality, the 2008 National Healthcare Quality Report (NHQR) found that nationally the median level of necessary care received was just 59 percent (AHRQ 2008).

Imagine you're a patient. You're really worried about some symptom or other and you went on WebMD and you're sure it means you have cancer. You insist your doctor perform a test, and she refuses. Your symptoms worsen, you show up the following year, this time your request for a test is honored, you get the test for the more obvious symptoms, and sure enough you have cancer but now it's untreatable and you're terminal. Now I ask ya -- would you give a f*** if the doctor was operating on the assumption there was only a 59% chance that the first time you asked for it, the cancer screening was "necessary?"

Fee-for-service nonsense

I am just beginning to educate myself on the nitty-gritty of the Massachusetts health care system. I have been trying to resist the urge to blog on what I read as I read it, because everything is so new to me – I assume that at some point all this information clong will resolve itself and I’ll have a sense of the essentials of what I want to spend time blogging about.

HOWEVER, I couldn’t resist on this one. So sue me.

The Special Commission on the Health Care Payment System recently published recommendations on, essentially, getting rid of fee-for-service payments for health care (the “Recommendations”). What is really meant by this is: getting rid of fee-for-service payments in a system where payment for health care services by third parties is the only system permitted by law. Everything that the Recommendations asserts is wrong with the fee-for-service model assumes that it is a third party, and not the consumer, paying for the service consumed. NEVER is that assumption questioned; I guess there’s no one at the table in that particular debate who questions the propriety of requiring payment of medical bills by someone other than the patient. At least, no one whose voice is recognized or heard.

I haven't finished reading through the Recommendations yet, so I could be putting my foot in my mouth here. But my blood is up so I don't care. Here’s an excerpt from the Recommendations, purporting to list everything that is so dastardly about fee-for-service – with my biting commentary added.

FFS rewards overuse of services, does not encourage consideration of resource use, and thus cannot build in limitations on cost growth. If the consumer was directly paying the fees for the services he was consuming, you can bet he would be considering the use of his own resources (his money), and therefore wouldn't be over-using anything.

FFS does not recognize differences in provider performance, quality, or efficiency, and thus does not align with evidence-based guidelines or outcomes. If the consumer was directly paying the fees for the services he was consuming, you can bet he would be taking his money elsewhere if he didn't like the service he got. He votes with his dollars, and so do all the other consumers, and the outcome of the "election" is an evaluation of quality. Cream will rise.

FFS focuses attention on prices, not costs, and fees do not relate to the actual cost of providing care. If consumers are paying their medical bills directly, providers will definitely pay attention to cost, which introduces price competition among providers. Which means the providers will be focused on reducing their costs, because it's for damn sure they're not going to get people to pay increased prices. And, in their capacity as consumers of goods they need in order to provide their services, they will in turn be encourging their providers to pay attention to cost.

FFS is complex and difficult to administer given the wide array of individual health care services and changes in health care delivery and technology. If consumers were paying for their own health care directly, they would become expert on the prices charged for the kinds of services they wish to purchase. Since there wouldn't be one purchaser having to figure out how to get the best deal for every bloody patient on the planet, there wouldn't be a need for that purchaser to consider the fees for every possible health care service. Providers would specialize in their own pricing models, and if the pricing models did not deliver quality care at a good price, consumers won't be directly paying those providers.

Multiple payers negotiate different rates for a service, leading to different rates both within and among providers for the same service. These rates are more often based on relative market leverage, not health care value. Again -- if consumers were paying their own medical bills directly, providers would be dealing with the consumers directly. Consumers would have an excellent reason to pay attention to rates, and providers to compete on the basis of rates. Look at it this way -- consumers currently put a hell of a lot more effort into price shopping for cars and DVDs and computers than they do for health care services. What is Consumer Reports for? Is there an equivalent directed to the health care consumer? (Uh, no.)

Varied payment levels for services leads to variation in profit margins across services; variable margins incentivize volume in high profit services, not value. This one is Economics 101. When consumers responsible for paying their own bills want a desirable good that is limited in quantity, they bid up the price -- check out eBay. When the price goes up on something greedy business flood the market to produce that thing, to try to cash in. When too many greedy businessmen are trying to produce the same thing, the price goes down, and consumers have more money to bid prices up for some other product. Because businessmen are REALLY greedy, they're always looking for ways to make more money, so they try to find the products with higher profit margins. Whatever profit margins exist will be exploited. In other words, every niche market will be filled. Look at how many different kinds of cars and computers there are. However, people who want really specialized products, and who are members of really small markets, will not be the first people that greedy businessmen try to serve. But I'm not saying that like it's a bad thing. The niche markets will NEVER get served if businessmen are not permitted to chase profits in the big markets first.

Some highly valued services are not currently recognized in the FFS system and thus not compensated. What "highly-valued" services are we talking about, here? Why are those services not profitable? I think the complaint here is that primary care physicians make less money than specialists. Feature this -- maybe they should. This one is on physicians, and has less to do with third-party payors than on government-backed monopolies on the practice of medicine. To wit -- get rid of government licensing and let nurses and other less-expensive providers take point on primary care. If that happened, consumers who insisted on having a primary care doctor instead of a primary care nurse would be welcome to pay for it, just the way some people pay for Lexuses -- but the people who buy Toyotas would still get to work reliably and on time.

Caregiver incentives are not currently aligned among acute care hospitals, physicians, behavioral health providers, and other providers. Sorry, can't make heads or tails of this one. My guess is that this refers to different fee-for-service payment regulations for various types of providers. If consumers were paying for their own care directly, there would be a single incentive that everyone could understand and line up behind -- the gawd-almighty dollar. The difference would be that consumers, not just providers and the government, would be watching the bottom line as well.

And as it says on my masthead logo: here endeth the lesson.

What IS it about health care?

Many people who argue against a "right" to health care make the following point, in one form or another: there's no "right" to "food," yet people manage not to starve; therefore, people would still be able to get health care if there were no "right" to it.

It is not strictly true that the government doesn't recognize a "right" to food -- what is welfare? But the argument does hold in this sense: whatever "right" to food there is, does not encompass a right to the best, most expensive food available, price no object.

That is what people mean when they mean a "right" to health care. They mean everyone, no matter their ability to pay, has a right to the best health care services currently on the market, price no object. The assertion is that no-one should suffer worse health -- worse to any degree, no matter how infinitesimal -- than some other person, because he cannot afford to purchase services that could improve his health.

Consider a recent blog post at the Ayn Rand Center for Individual Rights:

With insurance covering all kinds of medical services and the premiums paid by someone else, Americans have little financial incentive to curtail doctors’ visits for minor ailments, to question whether a test is worth its cost, or to seek out cost-effective care. Before we buy virtually anything else, we ask ourselves whether it is worth its price and whether there might be a better deal elsewhere. When we go to the doctor, we don’t even see the price until it shows up on the invoice—with all but a small co-pay or deductible (relative to the total bill) paid by the insurer. History has shown that this system increases demand for health care, encourages wasteful consumption and ultimately increases costs for third-party insurers.

What this blog post fails to capture is the life-or-death quality of the choices involved in health care. Perhaps when the issue is whether to see the doctor when you have a runny nose, it would be easy enough to say, nah, it's probably not the flu, I'll spend my money on a new iPod and wait for the cold to go away. But what if the issue is cancer? If a new expensive treatment is available and it has a 1% chance of putting my cancer in remission, do I even consider the cost? If it bankrupted me, would I consider the money spent on the treatment as "wasteful consumption?" What if I were required to consider the cost, because I did not have some third party paying for my treatment, and then saw some worthless playboy trust fund baby suffering from the same kind of cancer and blithely writing a check to pay for the new expensive treatment?

THAT's what it is about health care. An absence of health is an absence of life. An absence of food will ultimately be an absence of life, but coming up with a meal when you're starving is much simpler than coming up with a new cancer treatment that took hundreds of millions of dollars and thousands of hyper-educated individuals and years and decades to bring to market. An absence of food can be remedied by coming up with a few dollars, and with very little input from others. An absence of health care when you're dying of cancer leaves you virtually helpless to remedy the situation without a juggernaut of others' efforts.

All of this isn't to argue to "we should do something about it." Death comes to us all, and if we didn't face the prospect of death, we wouldn't be alive. It is to point out how easy it is to experience a sense of powerlessness and unfairness when you cannot afford some measure that would prolong life -- no matter how misguided or misdirected that experience of powerlessness and unfairness is.

The proper view is to recognize that health care is care by other people, and that to force someone to help you is just as wrong as forcing you to help them. The proper view is to realize that forcing someone to provide or pay for your health care, no matter how badly you need it, is neither more nor less than theft.

The proper view is to ask yourself: If I were dying of cancer, asked my rich neighbor for money to pay for treatment, and my rich neighbor refused, could I shoot him for refusing? Because this is what a right to health care means -- the right to shoot your neighbor if he refuses to give you what you claim to need.

Steal and deal

I'm trying to learn about the nuts and bolts of the health care laws in Massachusetts. Here's an evaluation from Michael Tanner, an analyst at the Cato Institute:

Massachusetts health reformers rejected proposals that would have reduced the rising cost of health insurance, such as eliminating regulations that drive up insurance premiums or those that limit competition in the insurance industry. Nor did they create incentives, such as increased cost-sharing, for consumers to become more value-conscious in their purchasing decisions. Instead, they increased regulatory costs and then simply threw money at the system through subsidies.

(p. 5)

In other words: Massachusetts health care reformers decided that the best way to fix a broken system was to steal people's money (through involuntary taxation of the unwilling at gunpoint), and then pass laws about how they were going to spend their plunder.

Massachusetts is a Medicare access "hot spot"?!

Look at this from American Medical Association's amednews.com:

Access to care for Medicare patients is already at risk in 21 states and the District of Columbia, an AMA analysis found. "Hot spots" are: Alabama, Arkansas, Florida, Georgia, Idaho, Indiana, Kentucky, Louisiana, Massachusetts, Mississippi, Montana, New Mexico, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, West Virginia and Wyoming. The AMA looks at five measures of access problems.

The AMA deemed states hot spots if they had a poor enough showing, based on:

- Practicing physicians per 1,000 Medicare beneficiaries.
- Medicare seniors with incomes less than 150% of the federal poverty level.
- Seniors living in places deemed primary care health professional shortage areas.
- Hospital emergency department visits per 1,000 residents.
- Seniors not seeing a doctor during past year because of cost.

Notice anything funny about that list of states? I did.

The states can be grouped into three general categories: 1) they're in the South, or 2) they're in the middle of nowhere, or 3) they're Massachusetts?

Southern states often have a lower per capita income, and many attract a lot of retirees. One can easily see how these two factors would affect the affordability of and access to medical care. Montana, North Dakota, Wyoming and Idaho are largely rural states that aren't exactly emigration magnets for doctors, which could definitely affect access.

Why is Massachusetts on that list when it's not southern, not poor, not a retirement state, not rural, and filled with medical schools and doctors?

Could it be that our new health insurance system in Massachusetts is raising the cost of and killing access to medical care?