What SHOULD Healthcare Reform Look Like?

This is such an important topic, I wanted to share with you, something a little off our usual topic. In my last post, I showed how the slippery slope in HR3200 will lead to a socialized healthcare system by mandating employers cover all workers
So don't let anyone tell you that this isn't socialized medicine. Any public option = socialized medicine by default.

However, we can't just attack the current plan without offering alternatives. So, here are my healthcare reform suggestions.
1. Let doctors write off their uncompensated care. Currently doctors are one of the only professions that can't deduct bad debt as ordinary business expenses. Limit the deduction so that primary care doctors have an advantage over specialists. That instantly solves care for the truly indigent.
2. Mandate that all insurance companies offer at least two tiers of coverage.
a. First tier is catastrophic health coverage, like it used to be. However, available to everyone, no preexisting condition exclusion.
b. Additional premium tiers for people who wan't Cadillac policies or don't want to pay copays (see number 4).
3. Let individuals write off the cost of their self-paid health insurance premiums.
4. Make non-indigent patients responsible to pay part of their expenses (ie, copays/deductibles). Currently we have people who don't pay a dime because their insurance has no copay. Yet, these same people have cell phones, cable TV, internet, new cars, etc. If you don't have to pay to take your car to the mechanic, you'll take it in more often. Same is true for healthcare.
5. Illegal aliens. They're not going away and account for a huge burden on our healthcare system. I suggest at least make them pay taxes and play by the same rules as we do. Maybe be grant them citizenship in return.
6. Make insurance portable between jobs to eliminate waiting periods for preexisting conditions when you change jobs.
7. Pass medical tort reform. States that have this have lower costs and have plenty of physicians. States that don't have physician shortages. For example, I have never been sued, but my malpractice insurance this year cost about $20,000. This would probably not pass Congress because most of them are attorneys, but it is the number one thing that could be done to decrease overall healthcare costs.
Why? Doctors order tons of unnecessary and expensive tests to keep from getting sued. It's sad but absolutely true. Let's say a doctor has a patient who has a 1/10,000 chance of having a serious but rare problem. If they don't order the test(s) there are plenty of attorneys advertising on television to take their case to court.
Oh, and illegal aliens can sue also, even though they may go to an ER and never pay a dime. I'm not bashing aliens, I'm just pointing out a major flaw in our current system.

Again both parties have their share of the blame. There are dozens of bills in congress that are more balanced (like Coburn's Patients First Act), but the democrats won't let them out of committee. The flip side is the republicans had a majority for 6 years and never brought anything up.

Health Care Reform

This is such an important topic, I wanted to share with you, something a little off our usual topic.

I'm not sure what you know or think you know about the current so-called healthcare reform legislation known as HR 3200. If you think that socialized medicine is the way to go, then that's your opinion. However, if you think that this bill is not socialized medicine, I respectfully beg to differ--and that's the entire point of this post.

HR 3200 will bring about socialized government run medicine in the United States. You will get the same shameful care that our returning heroes get at the VA. Know someone with Medicare or Medicaid? That will look like a walk in the park. Except now everyone will get it, except for members of Congress and the very rich.

The democrats and even Obama (depending on the day) are flip-flopping on whether this is a public option. Let me be perfectly clear: Any public option in this plan will lead to socialized medicine. Why?

A slippery slope in HR3200 as it stands makes it mandatory that all employers must offer the public option or pay 8% payroll tax (for companies with total payroll 400k +).

Giving insurance to all minimum wage workers would be great. However, look at it this way. Under HR3200, all minimum wage workers will be put into the government plan. Why?

If I pay someone $10 (we'll round up from minimum wage) and they work full time, they get paid $20,800 per year. My choices as an employer are to add them to our company insurance (mine is $10k this year) or pay $1,664 per year for them to be in the public option. What do you think the major low-paying employers like public schools, McDonalds, Wal Mart et al will do?

If you're a public school teacher and you make $30k per year, do you think your school district is going to give you the plan that costs $10,000 or $2,400 (a difference of 4x)?

What would you do as an employer? Pay $10,000 or $1,664 for each minimum wage employee?

So don't let anyone tell you that this isn't socialized medicine. Any public option = socialized medicine by default.

Again both parties have their share of the blame. There are dozens of bills in congress that are more balanced (like Coburn's Patients First Act), but the democrats won't let them out of committee. The flip side is the republicans had a majority for 6 years and never brought anything up.

Response to NEJM Articles

Last week, there were two studies published in the New England Journal of Medicine that posited that vertebroplasty is no more effective than a 'sham' procedure. One study was from the Mayo Clinic (Kallmes et al) and the other was from Australia. I'll focus on the former

I recommend the following analysis debunking the paper. My comments follow. http://www.prweb.com/releases/2009/08/prweb2727074.htm

Unfortunately, both studies have major flaws and it's pretty sad that they made it into such a prestigious journal. Unfortunately, that de rigeur for major medical journals--many of them end up publishing studies that have big flaws. It's also common for Medicare and private insurers to use studies like this to make determinations for coverage. Translation: the authors did their job poorly, yet patients may end up suffering as a result.

First, the suggestion that vertebroplasty doesn't work is simple nonsense. However, let me define this in terms that the authors didn't. Vertebroplasty is highly effective at fixing acute pain from vertebral compression fractures (VCF). It doesn't treat any other kind of back pain. Second, patients who get VCFs tend to get additional fractures.

Major problems:
1. Not enough patients. Not only did the studies fail to their target number of patients, too many patients declined to enroll in the study. Translation: the patients who were more likely to benefit from vertebroplasty went on to have vertebroplasty anyway because they didn't want the risk of having to continue living with the pain.
2. Poor patient selection/Wrong patients. The patients that were actually in the study had relatively low pain ratings. The typical patient I see rates their pain from 8-10 on a scale from 1-10.
3. Flawed sham procedure. What the authors describe as a sham procedure actually amounts to a facet block. This is relatively effective procedure for one of the most common causes of midline axial back pain. Take this and the relatively low pain ratings, it is likely that many of the patients had facet mediated pain and the sham procedure was actually a treatment for that.
4. Crossover. Patients were allowed to crossover after one month. Of the control/sham patients, almost half of them chose to have a vertebroplasty. Yet 88% of the vertebroplasty group patients chose not to crossover. This is consistent with previous studies showing efficacy of vertebroplasty around 85-95%.
5. Statistical significance. The authors state that there was no significant difference in pain levels after one month, but that the vertebroplasty group tended to have better pain relief at 3 months compared to the control/sham group. That is congruent with a positive result from a facet injection wearing off.

Summary
1. Patients who were more likely to benefit from vertebroplasty went on to have vertebroplasty anyway and weren't included in the study.
2. This was not a properly controlled-study; the sham procedure was essentially a facet block.
3. Almost half of the patients in the 'control' group eventually elected to have vertebroplasty.
4. 88% patients who had vertebroplasty were happy with the results.

Lastly, for those who have had patients who have undergone vertebroplasty or kyphoplasty, you know how effective the procedure is. I find it almost farcical that this paper was published in NEJM. However, this shouldn't surprise any of us as we are heading down a road toward increasing government interference in the doctor-patient relationship.