News-Record.com

Medicare, with the complicity of the American Medical Association, has increased the financial pressure on already-pressured primary-care physicians. At least, so says The Health Care Blog.

According to the blog, Medicare's payment structure (and those of many private insurers whose pay structures closely parallel Medicare's) is largely rigged by specialists in favor of specialists despite research indicating that more emphasis on primary care leads to lower health-care costs overall.

It's a self-worsening problem: As financial pressures on primary-care physicians increase, more PCPs get out of that line of work and fewer new physicians enter it. That means a relative increase in specialists, with their higher fees, to handle patient care, with more specialists thus involved in the process by which fees are set.

Read the whole thing -- it's very easy to understand. Unfortunately, it's not a very optimistic piece. Among other things, it points out that Congress would have to act to get Medicare to change its ways (that is, reduce the role of specialists in helping it set its fee structure, if I understand correctly), and as I've pointed out elsewhere in other contexts, expecting Congress to do the right thing by the average person (or small employer, on whom the greatest health-care expense burden falls) is becoming more and more a sucker's bet.

The World Health Care Congress has launched a new site, ReformPlans.com, which compares the health-care plans of the remaining presidential candidates and also offers all manner of news and comment about health-care reform at the federal and state levels. Check it out.

Linked without comment, here is The Health Care Blog's analysis of Sen. Barack Obama's health-care plan.

Because of events such as last year's Moses Cone/Blue Cross Blue Shield standoff over reimbursement rates and the news that the aggressively growing nonprofit hospital company Novant Health might be buying a local medical practice, questions arise about whether nonprofit hospitals really are nonprofit.

Paul Levy tackles the question at his Running a Hospital blog. He is president and CEO of Beth Israel Deaconess Medical Center in Boston. He links to a Wall Street Journal article (only a preview is freely available) as well as reader comments. Levy writes:

In reviewing this issue, it seems to me that there is not always a bright line between the business behavior of a non-profit and a for-profit company. Both need to operate in the black to carry out their purpose. Both need to determine how to compete in a marketplace to achieve that. The strategies employed to do that might look quite similar. Both need to attract qualified people in both supervisory and line positions. The salaries and benefits offered, therefore, might be somewhat similar. Both depend on the vigilance of a Board of Directors to monitor management's performance and behavior. So the structure and functions of the boards overlap in several ways (but not totally, given the pertinent legal requirements). And, as a final level of control, both have regulators to ensure that appropriate community standards are maintained and enforced.

But there is a fundamental difference. The non-profit does not have shareholders who benefit financially from its operations. Its fundamental constituency is the community it serves. For a small community hospital, it is literally the local community. For an academic medical center like BIDMC, it is the local community, but it is also a regional, national, and indeed international community that benefits from the research and educational programs of the hospital.

Is this a difference without a distinction? I think not. I know that our Board and I would be making very different decisions about patient care, research, and training expenditures if we operated under a for-profit rubric. While we always have to be prudent about which services we offer, many more areas that do not generate a profit or that result in perpetual losses would likely be cut or eliminated if we were not a non-profit. As a matter of strict business, many of these could be jettisoned and provided by others outside of our hospital. But we believe that we owe to our patients and to the nurses and doctors who we are training to offer these as part of our public service mission.

What's driving the increase in medical costs -- an increase that, in terms of hospital spending, is roughly twice the rate of inflation? An increase in chronic (and largely preventable) diseases such as adult-onset diabetes? That's part of it. The aging Boomer population? That's part of it, although nowhere near as big a part as most people think, writes blogger and former financial journalist Maggie Mahar. One big driver is the demand for the new -- new tests, new procedures, and, especially, new -- and quite expensive -- equipment:

As Paul Ginsburg, President of the Center for Studying Health Systems Change, explained in the January/February issue of Health Affairs: “hospitals have been increasing capacity, not predominantly by adding new beds but by expanding specialized facilities (such as operating rooms and imaging facilities) needed to serve patients with the latest technology.”

Consider, for example, what may be the world's most expensive medical device: a particle accelerator with a total price tag well over $100 million. The machine, which employs protons to bombard cancerous tumors, can deliver higher and more precise doses of radiation, and we have evidence that it is effective in treating certain rare cancers.

But we don’t know whether it offers any benefits when it comes to treating common cancers."That's far from established, and there's a good deal of controversy about it," said J. Frank Wilson, a professor of radiation oncology at the Medical College of Wisconsin recently told the Milwaukee Journal Sentinel.

Nevertheless, roughly a dozen proton therapy centers have been proposed throughout the country ...

The Minnesota-based UnitedHealthcare Children's Foundation, a charitable nonprofit, is making grants of up to $5,000 for children who need critical health treatment and are not covered or not fully covered by their parents' health-insurance plans.

Parents and legal guardians can get more information or apply online at www.uhccf.org. The children must be 16 or younger. Families must meet certain economic guidelines, live in the U.S. and be covered by a commercial health benefit plan.

Via Health Beat, here's a compendium of articles in The American Prospect discussing health-care reform. (Intro here; follow "related articles" links to the right for the others.)

One key takeaway: The problem of the uninsured, big as it is, isn't the biggest problem with our health-care system. The biggest problem is cost, and until costs are contained, the problem of the uninsured may well not be addressed. Health Beat blogger Maggie Mahar quotes Dr. Marcia Angell, former editor-in-chief of The New England Journal of Medicine: "Costs are the central problem; universal health care would be easy if money were no object."

Almost as big as the issue of cost is the issue of what's politically possible: Out of all of the many ways in which health-care costs could be cut, what way, or combination of ways, can make it through the House and the Senate, particularly the latter, where not just 51 but 60 votes are needed (to prevent a filibuster)?

2009-10 may not be 1994 all over again, but the obstacles to any meaningful effort to control costs (and make other changes, such as expanding coverage) are many. Backers of significant change, of whatever type, shouldn't be confident that that change, or any change, will happen.

The Henry J. Kaiser Family Foundation, which does research and communications related to health care, has a new poll up that, unsurprisingly, ranks health-care costs among Americans' top economic concerns.

Currently, the economy is Americans' No. 1 concern, but that issue takes in such disparate factors as gas prices, the jobless rate and stagnant/falling wages as well as health care.

You can read more here.

Maggie Mahar at the Health Beat blog has posted the first part of a two-part review of the book "Health Care, Guaranteed" by Dr. Ezekiel Emanuel. (Here's a Borders link; BN.com and Amazon.com don't appear to have it up yet at the moment.)

I haven't read the book, so I offer Mahar's post to you for whatever you might find it to be worth.

UPDATE: Second part of the review is now up here.

Maggie Mahar at The Health Care Blog writes about physicians who no longer accept any kind of health insurance.

How does it work? From the physician's standpoint, it means less time and resources devoted to insurance paperwork, which in turn means more time with patients. The down side? It's likely that fewer people will get health care because they can't afford it. Still, for certain types of practices (primarily primary care) it might work. Take a look at her post and tell me what you think.

Also: Do you know of any physicians locally who aren't taking any insurance? Please let me know.

Is serious reform of our health-care system dead before it's even introduced in Congress next year? Yeah, probably, writes Brian Klepper at The Health Care Blog.

Why? Well, as the songwriter Randy Newman once pointed out, it's money that matters. Industry lobbyists have spent tens of millions of dollars in contributions to congresscritters. It's a lot of money to you and me, but negligible to the industry when hundreds of millions, or even billions, in revenue may be on the line for them.

That system's ramifications affect not just the health-care system but also people's health, as Klepper notes in his analysis of the U.S. obesity epidemic (31% of Americans are obese, compared with distant runners-up Mexico (24%) and Britain (23%). There are a lot of reasons for that, but money is the predominant one, Klepper writes. And here's the most depressing part:

... since weight is important to fitness, fitness is important to overall health, health is an important component of productivity, and productivity drives competitiveness, the US' future prospects are already lousy and headed south. In terms of our health AND our competitiveness, we're committing slow suicide.

Anyone looking for cheaper or better health care will find the post depressing. Klepper offers a couple of solutions but says they're both improbable.

Is he missing something? Is the situation as dire as he says? Are solutions as few in number and as unlikely to be achieved as he says?