Contempo Magazine Blog

by Dr. Tony Magana

Liberal advocates for health care reform point to evidence based medicine as the panacea to a burgeoning dilemma. A true health care change should additionally be based on acquiescence to what contributes to patient satisfaction and how our impious culture negatively impacts this goal.

Medical care developed centuries before humanity began to understand even the basics of science on how the body works. Healers in primitive society often could do little to help the actual condition afflicting the sick, the injured, or the dying but they played an important ritualistic role as a representative of a society that valued that an individual who was suffering merited attention and special care when ill. Today as we talk about the importance of spending our limited health care dollars on quality medical care it’s important to remember that health care is not just a statistic.

Today the major focus of health care reform is to establish guidelines for the treatment of conditions based up well respected scientific studies that have followed strict requirements instead of relying on just traditional anecdotal experience. As a greater portion of individual income and national GDP each year has gone to health care expenditures this seemed a cogent objective way to approach the issue of justifying costs. The Institute of Medicine has further defined health care quality as having six goals: patient safety, patient-centeredness, effectiveness, efficiency, timeliness, and equity of application. Using this concept one can compare for example the costs, risks, and outcomes of two different treatments for the same disease. However, applying this measuring tool to health care systems as a whole is not so simple.

Although major advances in the science of understanding how the body works are well accepted by the general population, how do we explain why non-scientifically based methods of treatment often called “alternative care” still continue to enjoy strong popularity. Felicity Bishop, a post-doctoral research fellow in England found that 46% of the population there utilized alternative treatments during their lifetime. Her research and others have found patients seek like treatments because they are dissatisfied by conventional medicine’s technical nature or the interpersonal interaction between patient and therapist.

Practitioners of alternative treatment who are successful in drawing large numbers of satisfied patients exhibit common themes. Patient participation in the therapy process gives them a sense that they are controlling their own destiny versus just being passive receivers of conventional care. Deep seated beliefs in natural treatments having advantages over artificial chemicals or remedies are reinforced by alternative practitioners. Many people who consider themselves religiously spiritual or cause driven dislike the cold concept of the human body as solely being a machine and find the “mind-body” connection connoted by alternative therapies as rewarding.

Perhaps another way to look at health care is to ask the question what do patients really want from the health care system? Severe acute conditions threatening life or limb or causing horrendous pain makes for obvious conclusions but in reality make up but a small part of the millions of interactions among patients and the health care system. Today, just as in ancient times, many of our visits to the doctor really relate to wanting to be assured that we will continue to be in control of our destiny and have a clear vision of our future.

Scientific “outcome “ studies may denote to the doctor to whom we are complaining about a pain that cancer is a very unlikely diagnosis nevertheless that uncertainty makes us uncomfortable. Americans like to believe that we are immortally young and can be cured of any illness. Why should we consent to a guess when there may a test that we will not have to personally pay for that tells us with great certainty what is our condition and by inference what our future is? This is the crux of the dilemma facing health care reform today.

We have legal system that preaches if we are wronged we have a right to millions of dollars and we have a dominant political party that flagrantly spends trillions of dollars without concern for any thrift. These deeds contribute to the false belief of a significant portion of America that there is no limit to available health care dollars for health care.

There is a perceived difference in the standard of care given to prominent members of society versus the common folk. If a professional athlete injuries his knee he gets a MRI often within hours. The President of the United States gets “routine physicals” at government hospitals which consist of every possible diagnostic test and an evaluation by a team of physicians often lasting several hours instead of the 15 minute physical that Uncle Joe gets at his family doctor.

One great difference among the European countries who have adapted somewhat socialized medical schemes (they still have the private outs for the well to do) and America which must be contemplated in designing our medical system is the culture contrast on how we perceive aging. American society and movies often imagine everyone never gets older than 35 and will live forever. Aging makes us very disgruntled. We have very few mature female sex symbols and rarely see movies demonstrating significant value in the life of the elderly whereas in Europe there is a much greater acceptance of aging and mortality.

In Europe someone presenting to the hospital with chest pain thought to be a small heart attack or angina that could be signs of a possible heart attack is often sent home with aspirin if they are stable. Statistics say that for the vast majority of people treated in this manner, most will survive and only a few will die at home. This preserves significant amounts of health care dollars and reduces hospitalization significantly which can be applied to other uses. In the United States these patients are admitted to the hospital because studies have shown that should they get a complication such as a cardiac arrhythmia rapid treatment in hospital has a high chance of saving their life.

Both of these treatments can be justified by statistics. The mathematics of outcomes research cannot tell us which treatment is right or wrong. All societies must cope with the fact that there is a limit to the total expenses which can be put to health care. The hardest question is how to divide that spending?

The biggest fear that American’s have about health care reform is that they will have no choices in their personal health care. Even if “scientific studies” proclaim that only one treatment should be given the world wide experience suggests that almost half of the population will likely want alternative treatments regardless of whether they can be proven scientifically valid. Creating a rigid no choice system as proposed by liberals will be politically unpopular not only at the onset of its inception but increasingly over the time of its administration.

Another big issue is raised by the dilemma of heart disease mentioned above. How do we decide whether we will spend a lot of resources to save a few people? Do we apply the ratio of expenditure over dollars as our main priority?

Some non-conventional treatments which cannot be scientifically proven such as chiropractic treatment for chronic pain could still be much more cost effective in achieving patient satisfaction for some patients while others will reject it outright.

Recently McAllen, Texas received a lot of attention in the media for being the second most expensive place for Medicare expenditures in the country. The number of doctors both primary care and specialist there per capita is one of the lowest in the country. Visit a doctor’s office there and one will always find a packed waiting room with many anxious family members accompanying the patient. These physicians are most reimbursed for the number of patients seen not by the amount of time they spend with each patient and practice in area of country where juries routinely award millions of dollars and almost never find for the defendant. Contrast this to Europe where complaints about medical practices are screened by an impartial medical board that only pass on the case to the court system if a significant deviation from the national defined guideline is clearly determined to be evident.

Before America can move forward on real health reform, we must first have a government that clearly declares we are a society with limited resources. We must go beyond defining quality of health care as just a statistical entity and understand that the patient-health care system interaction is about more than just being a fix it shop.

An important part of our society that allows one to come to terms with the inevitable hearkening of aging and mortality, the spiritual peace brought by religion, should play a more prominent role in health care especially for those with untreatable conditions or in the last few months of life.

Thanks for reading Contempo Magazine blog which discusses issues for McAllen, the Rio Grande Valley, and America from a conservative Hispanic point of view. Tony Magaña grew up in McAllen Texas, attended Texas A&M University, served as an officer in Army Reserve, and holds a doctorate from Harvard University. The co-founder of Contempo Magazine has participated in Valley business for over 20 years. He is a member of the National Association of Hispanic Journalists and also writes for the American Daily Review. Follow him on twitter http://twitter.com/contempomagazin

by Dr. Tony Magana

Must Americans choose between the status quo of the public-private mix of health care or a new government controlled monopoly? There exists a third option which is market driven, renders competition in price and quality, and consistent with the Federalist concept of state sovereignty in exercise

Currently in Congress there are two major competing scenarios being put together by the Democrats. The Affordable Health Choices Act sponsored by Senator Ted Kennedy (D-MA) is being contemplated in the Senate Committee on Health, Education, Labor and Pensions (HELP) while the Baucus-Obama design is being perused by the Senate Finance Committee.

The Democratic party plans essentially call for the federalization of the health coverage system. The Federal government would institute guide lines on how doctors and hospitals would treat patients encompassing when technology or procedures would be allowed or not. President Obama has adjured that variance in reimbursement in different parts of the country must cease and that he aspires to establish one standard and one system nationwide.

Both Kennedy and the Baucus plans would comprise private insurance alternatives, Medicare, Medicaid and possibly a third tier of a government sponsored and run health care program for individuals and families not covered by employer based insurance or other government programs. Although President Obama and many Democrats have voiced that their approach would allow private insured Americans to keep their current plans, well respected economic studies and even the Congressional Budget office have revealed that would not be the case. Medicaid, Medicare, and the new government program would aptly underpay the cost of health care so that private insurers would have to make up the difference by paying more for care and thus having to charge more for premiums. Eventually the presence of the government program would drive private programs from the market.

Estimates by private economists, Washington think tanks, and the governments own budget experts have predicted that either Democratic scheme would add trillions to the national debt. The Congressional Budget Office has been generous to the President’s budget regarding health reform mostly because they say “the budget document does not specify the policies that would constitute such reform”. However, President Obama did inform them that he intends to get savings from health reform in three ways to make it “budget neutral”. An analysis shows his logic is faulted.

• Revenues generated by limiting the rate at which itemized deductions reduce tax liability and by taking steps to increase tax compliance

Conservative Analysis: This is a tax increase on employer based health care and itemized charitable deductions

• The estimated savings from several proposals to modify payment rates and other provisions of the Medicare and Medicaid programs

Conservative Analysis: This is cutting reimbursements to hospitals which will force them to charge private insurance more

• The savings from a proposal to establish a regulatory pathway for the Federal Drug Administration to approve the marketing of generic versions of biological pharmaceuticals.

Conservative Analysis:This will create a disincentive for the private development of new drugs. At best pharmaceutical companies will be forced to charge more for drugs initially before they are forced to sell it at “generic prices”

Congressional experts estimated that over $257 billion in new tax revenues would be necessary to pay the for Kennedy proposal at a cost of tens of thousands to hundreds of thousands of dollars to give one uninsured a benefit worth about $6000.

There is a Republican sponsored ambition, The Patient’s Choice Act (S. 1099/H.R. 2520) which offers a significant different approach to health care reform and addresses the issue of government programs undercutting private insurance. The bill’s main sponsors, Paul Ryan (R-WI) and Devin Nunes (R-CA) have said that the government cannot create a public program “ where the government serves as both the referee and the player in the game” which would cause private insurers to dump millions of enrollees. They have labeled the choice of continuing the status quo or succumbing to a total government takeover of health care as a “false choice”. They affirm there is a third option which accomplishes the following goals “tackling the fundamental drivers of exploding costs; empowering patients and providers with greater choice and competition; and ensuring access to quality, affordable health coverage for all Americans.”

The core of the Republican plan involves creating state based health care exchanges to ease individual purchase of coverage and create a market to compete on price and quality. Premiums set by these voluntary exchanges would not be under government control but would be subject to transparency and recognized “risk adjustment mechanisms” including independent boards, health security pooling, and reinsurance options. Although anyone may opt out of the program there would be mechanisms to enroll automatically state residents who visit emergency rooms, have a driver license, or appear on state records as employed in the state. There will be no exclusions for pre-existing conditions and the setting of premiums will not allow “cherry-picking” of low risk clients to the exclusion of those who might be expected to have higher health care costs.

The exchanges working within state or multi-state groups will be enmeshed in more than just providing health care coverage including being involved in helping to determine quality of care measures and health care planning, reducing fraud and abuse, establishing wellness tactics, and looking at stemming the costs of lawsuits to health care.

The program does allow states to cooperate but does not force an one size fits all system across the United States. Premiums, coverage, and options will be determined by state or multi-state groups in a way that preserves the concept of the states as individual laboratories as conceived by the framers of the Constitution. This concept is further enhanced by provisions that allow for payments to be structured in alternative ways as determined by the state exchanges including new payment methods for preventive care, prospective payment for visits over time, capitation, and chronic disease management.

One biggest problem of the Democratic plan is that they would most likely penalize employer based health plans and not significantly help the tax deductibility of insurance purchased directly rather than through employment. The Republican plan would create a tax credit that could be applied to either an employer based or privately purchased insurance plan. Additionally people would have the option to buy high or low deductible plans which could be supplemented by a medical savings accounts. This may be very important in helping to control the cost of health care as a market driver.

Perhaps the most exciting aspect of the new proposal is that it would change Medicaid from a defined benefit to a defined contribution program. Funds for Medicaid patients would be placed in the pools with others in the state groups rather than having them function as a separate entity. Although the bill leaves Medicare alone one can only ponder the possibility with great encouragement that eventually perhaps this program could also evolve to include Medicare. There is the potential for this approach to be truly a revolutionary new way to deal with health care.

The Republican sponsored The Patient’s Choice Act offers a market based approach to health care reform which will allows the federalist concept of individual states to act as laboratories. No doubt, the greatest criticism of the monolithic Democratic approach is the naiveté that a competent comprehensive solution can be reached so easily. Contrarily, the concept of Congressman Ryan and colleagues creates a national workshop which maximizes the opportunity for innovation and testing of different forms of health care administration and delivery.

Thanks for reading Contempo Magazine blog which discusses issues for McAllen, the Rio Grande Valley, and America from a conservative Hispanic point of view. Tony Magaña grew up in McAllen Texas, attended Texas A&M University, served as an officer in Army Reserve, and holds a doctorate from Harvard University. The co-founder of Contempo Magazine has participated in Valley business for over 20 years. He is a member of the National Association of Hispanic Journalists and also writes for the American Daily Review. Follow him on twitter http://twitter.com/contempomagazin

by Dr. Tony Magana

Health care reform which encourages the hidden tax on private insurance by cost shifting of government programs like Medicare, Medicaid, and the new Democratic proposal of the alternative public plan will not allow Americans to keep their current insurance plan.

This week President Obama began the callous bustle to garner his health reform package being passed before the end of the summer. The President’s health plan propounds to help improve the economic recovery of the nation by controlling health care costs. Key components of the plan encompasses creating a government sponsored health program that would compete against private insurance companies, establishing best practices quality of care standards that would pay only for care that followed approved guidelines, the digitalization of medical records, and stronger emphasis on preventive care rather than procedure based medicine which may compromise the restructuring of payments to providers for disease management rather than by individual events such as procedures and diagnostic tests.

One of the most controversial points of contention is whether formulating a government health plan, which would probably be similar to Medicare, competes for clients with private insurance and would increase the costs of private insurance or even drive it out of existence.

Currently in the United States just over half of all patients who go to hospitals are covered by the government program, Medicare. Because Medicare almost exclusively blankets the elderly and it is well established that the greatest medical costs in life befall within the last six months of life for most of the population, this government program is the payer for the most expensive part of American health care. That both Medicare and to an even lesser extent Medicaid have traditionally paid less than the true cost of care has been well documented by published studies. Since the conception of Medicare under President Johnson there has been a planned incongruity between what Medicare actually pays providers and the genuine cost of care received. Currently Medicare pays only 95% and Medicaid 89% of the honest expenses of hospitalization for enrollees.

Since the creation of Medicare two tactics have been in place to make up for the deficit created in hospital costs for treating government program enrolled patients. Medicare invents modifiers and incentives for hospitals to get additional payments or payment increases for a variety of factors. The overall severity of illness of patients admitted, presence in a geographically under served area, indigent patient burden, cost of labor, capital improvements including new technology or programs, and the sponsoring of graduate medical education programs are a few examples. The other tactic was to cost shift the care of Medicare patients to private insured patients who would pay more to the hospital relatively.

Analysis of private insurance hospitalization payments versus government program payments has demonstrated that private insurance often disburses more than the actual cost of hospitalization to the tune of 122% in the year 2003. The total expense of the this cost shift exceeds $88 billion per year and increases the cost of the typical family’s insurance premium by $1,512.

The Obama administration and the Center for Medicare and Medicaid Services have recently announced major cutbacks are looming in payments to hospitals for Medicare patients. The special modifiers and incentives mentioned above have, they claim, resulted in wide disparities in payments across the country. The future plan is to replace this compensation for new ones that will reward disease management outcomes and best use utilization of technology. Opponents of the new public health alternative say these changes could exacerbate cost shifting even further.

Critics of the creation of a new public health plan alternative cite that if its payments are too low to hospitals in the same way as Medicare there will be even more cost-shifting to private insurance. The “artificial” reduction of lower premiums compounded with lower payments to providers will amplify not only the premiums demanded by insurance companies for private programs but also will demand that hospitals increase their charges to those in private programs to make up the losses for public program patients.

Some proponents of the public health alternative say that discretion should be limited to those who do not already have employer coverage, the self-employed, and the uninsured to reduce the cost shift but not in Congress agree to these restrictions. Albeit Obama in his campaign said his plan would allow Americans to keep the coverage they have if they wished, well based estimates of the number of people who could loss their private coverage if the public plan option is unrestricted could reach 171.6 million people or 70% of those currently insured privately.

A possibly better alternative to the public plan has been alluded by a moderate Democrat, Senator Kent Conrad (ND) which would consist of a nonprofit cooperative program for individuals and very small businesses (<10 employees). To be advantageous co-ops would have to be able to enroll large numbers of individuals to draw competitive bids from insurance companies. This idea is too fresh to evaluate fully yet but is worth exploring more comprehensively.

The impetus to commence a stimulus package and bailout of many failed American banks and corporations has clearly proven the old adage “Haste makes waste”. I fear the same may ensue if Obama and the liberal Democrats are enfranchised to speed a poorly conceived health reform package through Congress. There is strong historic and economic evidence that a public health plan alternative to private insurance particularly if unrestricted in enrollment will ultimately lead to a single payer system because private insurance will not survive.

No one should vacillate that our health care system needs reform. The best system for America should be a market based system not a government mandated public scheme. Rather than fantasizing increasing government program enrollments more ideas looking at non-governmental models should be appraised for all Americans including Medicare and Medicaid recipients. Our current thinking about health care reform thirsts to be more “out of the box” to novel inspirations and not just restricted to conventional insurance vs. conventional government program.

Thanks for reading Contempo Magazine blog which discusses issues for McAllen, the Rio Grande Valley, and America from a conservative Hispanic point of view. Tony Magaña grew up in McAllen Texas, attended Texas A&M University, served as an officer in Army Reserve, and holds a doctorate from Harvard University. The co-founder of Contempo Magazine has participated in Valley business for over 20 years. He is a member of the National Association of Hispanic Journalists and also writes for the American Daily Review. Follow him on twitter http://twitter.com/contempomagazin