An analytical thought on healthcare

Today the cost of healthcare in the US is higher than in any other western country, while the delivery of this healthcare is limited to only those that can afford it (or are old or very broken).

There is clearly no perfect model for healthcare, because there is not an infinite amount of doctors, pharmacists, scientists and support personnel available to deliver it, and of course there is a limited amount of money available to pay the people that are delivering health-related services.

So there is a choice that always has to be made to balance the use of resources against the need.

In the US today the choice that has been made is to charge each individual directly for the health services they consume, effectively meaning that those who are richest get most health care.

In other countries the choice has been made to deliver the available health services as broadly as possible, so as to maintain the health of whole nations.

Both models have pro’s and con’s.

The US system means that the wealthiest people will most likely live longer. Since wealth is (often) a consequence of many attributes that do progress all of society, there is a case to be made that keeping the richest alive longest is Darwinian in nature.

Conversely distributing the available health resources amongst the whole population should increase lifelong productivity for the largest possible number of the population. When more experienced people are able to work longer this should provide a great return on investment.

What is clear though is that there is a limited resource, which is outstripped by demand, and so choices will always have to be made.

When a limited resource is made to be as efficient as possible, by rigorously implementing best practices it can be made to go further.

The US model today is one where health providers generally get paid per-service delivered, as opposed to health outcomes.

In business it can be seen that outcome based remuneration is always preferential to activity based remuneration. If you pay a bricklayer for each wall built, you will get a lot of walls built, but the quality may suffer. While if you pay that same brick layer for each brick laid, you will get a very different outcome (very thick walls). But if you measure both the quality of the wall built as well as the number of walls built, that same bricklayer will really think about how to built the most efficient and effective set of walls.

In business if you paid someone for effort and not results, you would see huge inefficiency. Today that is exactly how healthcare works in the US.

Health insurance companies can offer some economies of scale, and the bigger a network is, then the larger the economies of scale.

Now add to this model outcome based charging and the whole model will be about keeping everyone who is insured as healthy as possible.

And then add it some balances to ensure that sick people are not just dumped from the program to keep costs down and you have a basic working health system.

What is eminently clear though is that the more people in a network, the better the overall efficiency can become.

So why not have everyone is a single healthcare system?

Well the only argument against this is that simply what is the motivation for that healthcare system to get better. But that is an issue that over time can be fixed by clearly defining the reward system for those who work in the healthcare system. We are not there yet, any it will take a lot of smart people a long time to work this out.

Healthcare is expensive, limited and emotive, there is no perfect system anywhere in the world. But that does not mean we should stop trying to be the best we can be.

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NYC Mayor Making Adults Fat. Why?

Mayor Michael Bloomberg is cast as a benevolent Mr. Mom or “He-Nanny” who watches out for New Yorkers, wipes their mouths and fannies, and keeps them safe from evil sugar and 2nd hand smoke.  I’m here to tell you that something else may be afoot… something more sinister and malevolent.

What is certain is that he’s trying to make NYers fat; consider these events:

-He cancelled Halloween and trick or treating so now people will eat all the candy themselves and get fat.

-He still has Central Park closed so we can’t exercise there (and make an adult decision as to whether a road or path is “safe”).  No exercise = fat.
Central Park closed for exercise + NYers with huge bags of unneeded candy. Coincidence?

 

-The YMCA is again closed today which probably is due to some sort of government meddling or funding or tax issues (the ‘C’ stands for Christian so you never know).  No exercise = fat.

-And with no more smoking or large soft drinks allowed, people are drinking more high calorie beer and Red Bull every day!  More calories = fat and since smoking also curbs appetite, this = double fat.

 

It looks to me like NYC’s caring “Nanny Bloomberg” is secretly fattening us all up Hansel & Gretel style for some nefarious purpose.  I’m angry and a bit scared but I must say that my giant bag of Reese’s Peanut Butter Pumpkins looks soooooo tasty that I may yet fall into Mrs. Doubtberg’s evil trap!  You’ve been warned.
Are NYers just Hansels & Gretels to the Mayor’s evil, witch-like nanny?

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So what’s the worst that could happen?

It seems to me that the political pundits on American TV all have a similar attitude when discussing the merits of each crazy plan from the democratic and republican elected officials and candidates for elected positions.

To the average person it’s simply unfathomable just how ridiculous the plans of both parties often are.

Right now there are tens of millions of people out of work, hundreds of thousands of defaulting mortgages every month, a national deficit that has been expanding for decades, thousands upon thousands of military personnel in harms way overseas and thousands more returning home with terrible physical and psychological injuries, crazy countries posturing for a fight, millions of people below the poverty line, a quickly evaporating middle class and an education system failing to educate the next generation.

Yet the key topics of interest are sexual orientation, equal rights for women and how much religion should be allowed in government.

Let me make this really simple, this last set are not government issues. These are solved, done discussions for the great federal government. In law everyone is equal irrespective on sexual orientation or gender or religion, and there is no religious test for any elected position in government and there is already a strict line separating religion and government. It’s done, over, complete, sorted, fini, solved, quod erat demonstrandum. So stop pissing around and focus on what is important!

Do we need more tax revenue? Possibly, but what’s more important is to stop wasting what we already collect. Clearly there are efficiencies that the large purchasing power of the government can control, and this should be used more effectively. That’s not socialism, that’s fiscal responsibility.

We need to stop sending jobs overseas, and that will only happen when it’s not economically advantageous to hire locally.

Healthcare is unbelievably expensive in the USA today, and the quality of service (compared the rest of the world) does not justify the highest costs. We need outcome based cost models rather than litigious and per-service cost models. This drives up efficiency and drives down costs, and does not require anyone to give up quality. There is no perfect solution, as medicine is not perfect, but having bleeding bandaged old people sleeping on subway benches (I see this daily btw) is not the answer.

We need to use the armed forces more carefully. Soldiers are not policemen, when they are asked to meet a goal, make the goal clear, and once they have met it get them home. Our heroes deserve no less.

And the US education system is so burdened by top-down mandates, shrinking funds and finger pointing that it’s time to stop the madness and place it back in the hands of the people who actually care about the students, and this is the teacher’s.

Both political parties today along with the pundits on each and every one of the networks are avoiding the difficult decisions, and instead focusing on the bullshit questions.

There clearly are other issues both trivial and critical, but the only way to fix the big issues is to work together and not put personal reward above ethical responsibility.

Any politician that chooses to make a decision for political gain over the needs of the electorate needs to be called out for what they are, and voted against at every opportunity by the people.

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All the big issues are obvious, and technically quite solvable, once you remove personal gain from the political equation.

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What the hell is going on with healthcare?

It seems to me that there is nothing more deeply personal than your health and that of the ones you love and care about. If you get sick, you don’t just ‘want’ to get better, it will become the most important thing in your life. It’s emotional, and will take precedent over everything else, and it should.

This means that any contract that you enter into about healthcare is loaded with stress and duress, and the basics of contract law are that any contract entered into under these conditions is not fair and equitable, and as such is not a fair contract. This may seem technical but it simply means that those papers a hospital or a doctor makes you sign saying that you are personally responsible for any costs not covered by your insurance shouldn’t be allowed. But yet they are.

The insurance companies, the hospitals, the lawyers and the doctors have created a special legal framework that is entirely weighted to their benefit.

And to add insult to this situation the American system means that the costs you are charged are list price, whereas the insurance companies get a massive discount on the bits they cover.

The costs of medical care in America are incredible, and the quality of the service is directly related to the amount of money you can pay.

Every doctor swears the Hippocratic oath. I’ve read this oath and frankly I feel that most US doctors are not living up to the spirit of the thing

Here’s a couple of sentences from the oath, they I’m sure your will agree are not the normal practice here in America :

“I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

“I will prevent disease whenever I can, for prevention is preferable to cure.”

In this country today people die because they cannot afford to get timely treatment, others go bankrupt because the costs that are not covered by insurance companies consume their entire worth and then some. Millions of people don’t have adequate or even any coverage, either because they cannot qualify due to pre-existing conditions or just cannot afford the monthly costs and still be able to eat.

Some say that for these people there is always the option of going to the emergency room. Well there are two huge issues with this. Firstly the emergency room will just treat them to the point where they are not going to die on that particular day; this is not an answer to a problem, but a stop gap. And secondly the costs that are incurred by doing this are just passed onto the ones who do have insurance, as increased premiums which have the effect of making premiums higher and so making them ever less affordable, exacerbating the situation.

The issue (as I see it) is the huge amounts of money involved. No one wants to give up his or her part of this gravy train. But it is clearly unsustainable.

The concept of reform in healthcare driven by government seems to be the only way to break this logjam.

But the size of the powerbase involved has so far warped the political process beyond anything reasonable. They are many great improvements within the healthcare changes that President Obama has lead. But it is just a small step on a very long road, and some critical elements of any good plan are missing or just wrong.

The cost of healthcare is far too high, and the quality available (on average) is far too low. We need lower drug costs, medical services driven by results and not on a per service basis. And we need to trust that doctors are doing the best they can, by us accepting that suing doctors is not the first step in fixing a mistake.

Healthcare that helps avoid medical issues by preventative support has been proven to be the most cost effective and rewarding way to maximize the quality of life.

This is a very hard problem to solve, but it must be improved. When politicians use any change or proposed change as a political weapon, rather than trying to work together to find the best solution, they are failing everyone.

We all deserve better.

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