From Guest Blogger Anne Kinzel

Earlier in this series I commented that French docs are a long way from the poor house. Today we will talk about what that really means. Next time we will also look into how the French reduce the financial burden of serious illness on individuals and families.

One way of looking at physician incomes is to understand them in relation to national salaries. The hard facts are not that favorable to French doctors. According to Paul Dutton, an American academic who is a leading expert on the French health care system, “the average French physician” earns more than twice the French wage. That is not bad until you find out that the average U.S. doc makes more than five times the average U.S. wage. Yes, that’s right, about 500% more than the average Joe and Jane. But there is a lot more to this story then cold cash.

• Cheap medical schools. French physicians graduate from medical schools never having paid a dime in tuition. They do pay fees of no more than U.S. $500 to a $1000 per year. Ouch – not really!

That’s right – no loans to pay off med school tuition. That is definitely worth something.

In contrast, the American Medical Student Association estimates 86 percent of U.S. medical school graduates enter their residencies carrying debt.  In 2006, median debt was $115,000 for public medical college graduates and over $150,000 for private school graduates! For French docs it has to be a lot easier to buy that first house!

• Not much time in court. While the French have a well-deserved reputation for being prickly, they don’t sue their doctors much at all.

It’s not that they can’t find their way to the courthouse. Instead, cases with bad outcomes attributed to less then stellar physician care are referred to investigative commissions.

There, a magistrate and a panel of experts reviews each case and decides what compensation, if any, is due the patient. Before anybody is compensated, a patient has to prove: 1) Harm occurred as a direct cause of the medical treatment received; 2) the harm was serious enough to have a detrimental effect on the patient’s health; and 3) the patient has to show that he or she suffered at least a 25% reduction in physical or mental capacity as a direct result of the harm suffered. Patients can refuse to accept a settlement from the commission and test their cases in court, but few do.

It’s a pretty drama-free system, meaning that malpractice premiums are not the large cost of a doing business as they are in the U.S. Not being so afraid of patients may not be measurable on the bottom line, but its got to be worth something!

Add to this, offices without a billing staff, not having to deal with multiple insurers, and the five weeks of time off a year, and it’s starting to look like French docs don’t have it so bad!

The bottom line: One of the reasons that health care in France is less expensive than in the U.S. is because doctors earn less money. Would American doctors accept lower salaries? Probably not, but just maybe American doctors would not need so much compensation if they didn’t graduate with huge debts! This could be a reform worth looking into!

Coming up next: Serious illnesses and their financial impact on families.

A friend forwarded this column to us about the French Health Care System by Mary Cline.  We have three more installments coming from Anne Kinzel on French health care, so please stay tuned.  After that I will be doing a series on how other countries handle health care and its cost. 

I noticed Cline’s doctor to patient ratio is different from Anne’s.  We will double check the data and report back.  One of the questions I have is who pays for medical education in these other countries and if there are significant differences in income for primary care and specialty care providers. 

Please follow this link to read Cline's article

Cheers and more later.  Kathleen

Don't tell the French they have socialized medicine!

By Guest Blogger Anne Kinzel

In my last post I noted the French health care system is based on choice.  It’s hard to make that assertion and not face serious skepticism.  After all, the French have to pay huge taxes whether they want health insurance or not.  What kind of choice is that?  The French can’t get out of paying even if they are opposed to receiving health care on moral or religious grounds.  It’s just another system killing the individual through taxes and mandates.

Before we look at how the French have created a tapestry weaving choice and mandates, I want to present a little scenario to you about our own country.  It’s about the question, “When is a mandate a mandate?” Be careful, don’t try this as home!

Bob, a clever guy, recently read over his payroll stub.  Amazed at how much of his hard-earned compensation was taken out for his health insurance, he did a little research.  Then, he went over to payroll.  He told the insurance specialist, “Look, I investigated these new health savings accounts and I think they are good deal for me.  Here is what I need you to do.  Please fill out this form – It takes the $875 you pay to our insurer for my family coverage each month and sends part of that money to ConsumerCo.  $450 will pay for my new family plan.  $300 is going to go straight to the health savings account that goes along with new plan, and $125 can go to my retirement account as extra contribution.  This works out really well.  My Aunt Mabel left me a nice a chunk of change and I put that into my health account to cover that big deductible.  In our family everyone lives forever and never seems to get sick.  So with this deal, I can’t believe how much we’re going to benefit.”

When Bob got home that night, here is what he said to his wife, “You won’t believe what they said down at payroll! – They said ‘NO WAY!  You’re either in the plan or your outta the plan.  We are not sending any money anywhere just because you say so.  If you want out, we’ll reimburse you $250 a month.’  I said, ‘You gotta be kidding, that’s my money, I earned it, the whole $875!  So honey, I guess we’re just not going to be able to go with ConsumerCo; they’re saying it’s just not our choice.’”

Choice.  What a loaded word when it comes to health care! But what about choice in the French health care system.  There are some realities that have to be understood to ‘get choice,’ French style.

First, the French have the right to choose among all types of healthcare providers, irrespective of income.  They can choose to receive care from public, private, or teaching hospitals and they can pick from a large number of primary and specialist physicians.

In France, the ratio of doctors to residents is 3 to1000. By comparison, in the U.S. it’s 3 to 2700, in Great Britain 3 to 1800, and in Germany 3 to 3400.  The number of French docs is not all that surprising.  The French look down on the British system and those long lines they’ve heard about, dismissing the whole thing as "socialized medicine."  That one sounds familiar!

The French don’t think docs should be employed by the government unless the docs want to work in the public/teaching hospital environment.  So the choice is entirely left to the individual practitioner, just like the choice docs have of participating in La Sécurité Sociale—one almost all physicians make.

All this is paid for by two insurance systems, one public, la Sécurité Sociale, which includes the health care and retirement systems, and a large supplemental health insurance system.  Additionally, there is an intricate system of co-payments, based on diagnosis and income.

La Sécurité Sociale is funded by levies on worker salaries, by taxes on alcohol and tobacco, and by additional taxes paid on income, which includes retirement income as well as capital revenues.  Supplemental insurance, which covers about 90 percent of population, is often provided as a benefit by employers.  According to the French way of defining the things, only the poorest citizens enjoy taxpayer financed “free universal healthcare.”  (See “The French Health Care System,” Embassy of France)

None of this sounds extraordinary; though the distinction between primary and supplemental insurance is something Americans are not familiar with.  And our Medicaid system is nowhere near “universal” in its reach!  Where things start to sound seriously different is the 100 percent reimbursement for the care received by anyone suffering from long-term illness.  What a concept, if you are really sick, you get the most coverage.
Chew on that for a while and I will get back to you soon to talk more about French docs, supplemental insurance, and that incredible idea of cost going down as care needs go up.

For those of you who like a little visual information, check out a little CNN video clip on French health care here.

Welcome to Guest Blogger, Anne Kinzel, JD.   Anne, a CodeBlueNow! Honorary Board Member, is currently employed at large, midwestern public university.  Anne is well-versed in issues of health policy and health disparities resulting from social inequities; she gained this insight working as the Iowa Department of Public Health’s State Planning Grant Project Director.  A Franco-American citizen, Anne writes today about what we can learn from France’s health care system.

It’s a big world out there and Americans are notorious for being oblivious to geography. Nowhere is our ignorance hurting us more than in our favorite topic of health care reform.
 
Bring up universal coverage in the U.S. and more often than not someone will mention Canada, long lines, and those hordes of Canadians crossing the border in search of available and affordable health care. Those with a slightly broader world view usually bring up the failure of socialized medicine in Great Britain. I am not going to debate the veracity of these claims. True or not, I am tired of them, really tired.
 
So, if you are like me – and are bored with Canada and the U.K. – it’s time to take a trip to France and look at health care, French style. Like all things Gallic, France’s system is elegant and pragmatic, admittedly imperfect, and more than a little Cartesian in approach.
 
What can we learn from the French when it comes to health care and health care reform? It turns out a lot, and maybe the most important lesson we can learn is that it is absolutely possible to deliver good quality health care, to an entire population, at an acceptable cost.
 
By now, you either think I am high on goose liver pâté, an idiot, or some kind of weird optimist. But here’s the deal – The French are as aware as we are that there is no perfect system and that in health care there are no days without challenges either at the individual or societal level.
 
And yet, the prickly French have managed to devise a system that was rated the best in the world by the World Health Organization in 2001, because of its coverage universality, its recognition and respect for patient and provider autonomy, its ability to promote longevity and good health. In that same year, our American system achieved a ranking of 38th, and I don’t know anybody who thinks we have improved much since then.
 
Here are just some of the things that I think are important about French style health care that I will be addressing:

• Provider choice is sacrosanct. The French system is based on choice.
• Quality costs and it pays. The French system is not cheap ($3,048 per capita vs. $6,711 in the US (KFF Snapshots: Health Care Costs. Health Care Spending in the United States and OECD Countries, January 2007.)
• There is no socialized health care in France. There is a national health insurance, la Securité Sociale, or as the French call it, la Sécu. It coexists with a large private health care system.
• French doctors are a long ways from the poor house. But their pill hill residences are far more modest than those of their American counterparts.

These are just some of the things we will explore. Remember, it’s never too late to learn something new. I hope you will join me as I post over the course of the next week. Why not say, “Zut, alors! Maybe the French are on to something. It’s a big health care world out there and I want to know more about it.”

We just finished reading Senator Thomas Daschle’s book: Critical: What We Can Do About The Health Care Crisis.  This is a must read for anyone interested in the future of American Health Care Reform. Dashle was ably helped by his two co-authors, Scott Greenberger and Jeanne Lambrew. 

This is absolutely one of the best books I have ever read on the ins and outs of American health care reform, written as only an astute insider could do.

Daschle traces the history of health care reform from Roosevelt to Clinton. It is a fascinating history of ideology (“socialized medicine”), stakeholder opposition, and circumstance – such as Kennedy’s assassination and Nixon’s Watergate – derailing health care reform.

Having lived through the Clinton health care reform, I found Senator Daschle’s analysis fascinating in describing the opportunities and players for and against reform. These are lessons to be carefully studied, because even with the current movement and excitement about reform, this support could easily erode as it did last time.  Health care rapidly melted from being almost inevitable to be impossible to pass.

While CodeBlueNow! has not yet endorsed a specific solution, we are seeing many groups and organizations hovering around some key approaches.  From our survey findings in Iowa and Washington, we know the public wants a stronger role in designing and managing a health care system.  There is strong bi-partisan support for public participation with a “public utility model.” This had over 60% support from Republicans; over 80% for Democrats and over 75% for Independents. 

When we asked if they thought the public should have a larger role in designing and managing a new health care system, again, over 50% of all Republicans, 60% of all Democrats and over 55% of all Independents indicated they would support that participation.

Daschle’s solution is a Federal Reserve Board model—an independent agency that is outside of the politics of Congress.  He makes a cogent case for that model by referring the military’s Base Realignment and Closure Commission. 

What comes through loud and clear in his book is why we must not leave health care to Congress and the political dynamics that work against reform and rational coverage and benefit decisions. 

There are many important lessons to be learned from this book.  This book should be required reading for anyone interested in reform and how we can possibly make it successful this time around. 

Cheers and more later.  Kathleen

Welcome to Guest Blogger, Ken Terry.   We are pleased to introduce Ken who served as the senior editor of Medical Economics for 14 years.  He is currently a freelance writer and the author of Rx For Health Care Reform.  

Cheers and more later.  Kathleen

Medicare For All Is No Silver Bullet

By Special Guest Blogger, Ken Terry, author of Rx For Health Care Reform

Single-payer proponents received support from an unexpected source last week, when a survey published in The Annals of Internal Medicine reported that 59 percent of physicians now favor national health insurance—a 10 percent rise from 5 years earlier. Considering the recently announced support of the American College of Physicians for a single payer system as a possible reform model, it would seem that physicians, if not the AMA, are finally fed up with the current system and would rather work for the government than for the insurance companies. That’s a sea change, and a sign of the times.

But even though a majority of the public also wants national health insurance, don’t expect a single payer system to emerge, even if a Democratic Congress and a Democratic President are elected next year. The consensus among health policy experts is that turning over such a big percentage of the economy—16 percent at last count—to the government remains a political non-starter. Aside from the massive new bureaucracy that this would entail, insurers, employers, and pharmaceutical companies, among other powerful interests, would oppose it.

Equally important, “Medicare For All”—as the single payer advocates term their system—would not guarantee universal access to good, comprehensive health care. The reason is that unless the government imposes a cap on health spending—which it has never been able to do with Medicare—cost growth would quickly outstrip our ability to pay for universal health care. 

The problem with most liberal reform proposals, including those of the Democratic candidates, is that they stress coverage expansion more than cost control. And when you pattern a new health care system after Medicare, you’ve got a really big problem: Medicare is scheduled to go broke by 2018. As health economists Victor Fuchs and Ezekiel Emanuel have pointed out, we’d have to either halve benefits or double Medicare taxes to put it back on the road to long-term solvency. 

But the single-payer people are enthralled with the simple, uplifting message of Medicare For All. After all, they point out, seniors are very satisfied with Medicare. And look at its low administrative costs. In The Huffington Post, for example, Miles Mogulescu recently estimated that a single payer system could save $400 billion a year just by reducing the costs of administering insurance. That would be more than enough to cover the uninsured.

He’s right on the latter point; but in actuality, a single payer system would save only about a third as much as he says (though still nearly enough to cover the uninsured). Mogelescu claims that insurance companies spend 30 percent of premiums on “overhead, profits, and executive salaries.” In actuality, the insurance industry spends roughly 85 percent of its revenues on patient care. If administration costs Medicare 3 percent of revenue, and private insurers, 15 percent, moving to single payer would save 12 percent of the cost of private coverage, which represents about a third of total health costs. By reducing the work of dealing with multiple plans, providers would probably save another 5 to 7 percent of the amount they receive from private insurance. So we’re looking at total savings of 17-19 percent of a third of health costs. At our current spending level of about $2.2 trillion, that comes to $132 billion a year.

Mogulescu makes another interesting observation: He notes that we shouldn’t expect the public plans included in the Obama and Clinton reform proposals to lead to a single payer system, because Medicare is so expensive.
”If this plan is modeled on Medicare, it would be a fairly generous plan in which you can choose your own doctor, in which most treatments your doctor recommends are covered, and in which deductibles and co-pays are low. Even with reduced administrative costs, this would be expensive insurance. Private insurance companies would offer lower cost policies with high deductibles and co-pays. This would lead to what's called ‘adverse selection’. The young and healthy would opt for the cheaper plans. Mostly older and sicker people would opt for the public plan. Far from slowly evolving into a single payer system, the Medicare-like plan is likely to become increasingly expensive, making it even less affordable and forcing more and more people back to bare bones private insurance.”

Again, he’s probably right, but here’s my question: If Medicare costs so much today, how does it become less expensive if it covers everyone? The underlying growth in health costs that’s chiefly responsible for driving up private insurance rates would continue to increase the costs of Medicare, as well. We could control spending by adopting the kind of top-down budgeting that’s done by the U.K.’s National Health Service and Canada’s provincial governments. But it’s unlikely that Americans would accept that method of rationing care, especially if it were introduced overnight.

Some observers claim that Medicare does control costs better than private insurers do. The government program has a fee schedule for physicians, and it pays hospitals fixed amounts based on “diagnosis-related groups” of services. But in fact, neither payment method has had much effect on restraining cost growth. In response to Medicare’s fee limits, physicians have pushed up the volume of services, and Congress has declined to cut their fees to compensate. Hospitals have also become very creative about billing for higher-reimbursed DRGs over the past 20 years. And the availability of Medicare payments has spurred a major expansion in ambulatory surgery centers, imaging services, dialysis centers, and specialty hospitals.

During the period from 1970 to 2000, researchers Cristina Boccuti and Marilyn Moon found, the costs of private insurers grew slightly faster than those of Medicare for comparable services. But from 2002 to 2005, according to the CMS Office of the Actuary, the average annual cost of private coverage grew by 7.7 percent, much less than the yearly increase of 9 percent for Medicare. (And that was before the addition of the Medicare drug benefit in 2006.) Of course, private insurance rates include administrative costs, too, but there’s no indication that the latter changed significantly during those three years.

The bottom line: we shouldn’t expect Medicare For All to reduce health costs. That should come as no surprise, considering that countries with national health insurance are also struggling with rising costs. But if we don’t want to slap a cap on all health-care spending, which would lead to a degree of rationing that most people would find intolerable, what can we do?

The short answer to this question—which I hope to explore in future articles—is that we need to overhaul the financing and delivery of health care. The financing changes are necessary to achieve universal coverage and to provide the right incentives to health-care providers. But we also need to restructure the delivery system in ways that will guarantee that care is patient-centered, coordinated, integrative, uniform, and reliable. These are some of the principles of what I call “deep reform.”

Deep reform goes beyond the options for coverage expansion that now form the substance of debate over health care reform. It includes ideas that are common to reformers on the left and the right, and it provides a new way of thinking about those ideas so that people who want a better health care system can build bridges across partisan divides.

Let’s start thinking about how deep reform can affect everything that health care providers do, how they work, and how they communicate with one another and with patients. When we start looking at the problem in this manner, I believe we can make significant progress within a short time.

Ken Terry is a freelance writer and the author of the book Rx For Health Care Reform.

In one of the Democratic debates earlier this year, a reporter asked Barack Obama if he would accept public financing of his presidential campaign.  His response was “Yes, but first I would sit down with McCain so that we would jointly agree on what that meant and agreed on the same terms,” – Or something very close to that. 

On April 3rd, the Boston Globe ran a story on McCain’s desire to “cover all our citizens,” but that he does not yet have a plan in place.  While the Democrats have plans in place, they will not pass as they are presently constituted since they would not have the support of the Independents, which are essential to the successful passage of any health care reform proposal.

Right now the candidates of both parties are stuck with proposals that would not be supported by the majority of Americans.  What would be refreshing—instead of fighting each other over whose health plan is best—is to make the same pledge on health care reform that was alluded to in the aforementioned public financing of the campaign.

What we should be asking the candidates to do is make a vow to find a solution to health care that will work for the American public. The reality is to achieve health care reform it must have bi-partisan support.  

We could get to that bipartisan support if we could get the candidates to vow to work with the American public to find solutions they will support.

We think the first step in that direction, is asking the people what they would support.  Many groups have general guiding principles:  we can start by focusing on those and identify common ground and build consensus.  Much consensus already exists.

Cheers and more later,  Kathleen

We have been blessed recently with some wonderfully fresh health reform perspectives. 

First, we have several books about how we are over treating our patients—from Halvorson’s and Ishem’s Epidemic of Care and Halvorson’s book Health Care Reform Now, to Shannon Brownlee’s Overtreated, excellent cases are made and documented that the real culprit in health care is not the public’s perception that it is “managed care.”  The real culprit is fee for service—since no money changes hands without doctors doing something to the patient.  Ironically, there is no incentive or reward to keep us healthy.

We have Mike Magee, MD’s, book on Patient Centered Health Care, where he so beautifully paints a picture of what a truly patient-centered health system could look like. He relies heavily on technology, but as a former caregiver for an aging parent, his model of family centered care really resonated with me. I could actually see his model working in the not too distant future.   I think if more people read this book, they could actually see how a restructured health care system could work—something people tell us they will need it they are ever going to act for change.

Now we have Rx for Health Care Reform by Ken Terry.

While appearing lengthy at 350 pages, thanks to its formatting and style, it is still an easy read.  The chapter structures have a precision and logic to them that is clear to any reader.  In fact, this book is another must read for any thoughtful person trying to wade through health care reform. 

Terry clearly understands physicians and how their practices work, which is a critical to any understanding of what physicians need to succeed in a new environment.  And if they don’t succeed, health reform will ultimately fail.  He also understands the successes and failures of reform efforts in Hawaii, Massachusetts, California and Minnesota.  As senior editor of Medical Economics for the past 15 years, he has had the opportunity in a rare way to see the direct impact of changes on physician practices and hospitals. Consequently, he has had real life experience with reform in ways few people have.  As a journalist, he makes that experience come alive with vibrancy. 

Terry’s Rx for Health Care Reform is an interesting model.  Interestingly enough our market research in Washington and Iowa suggests the public might actually support such a model.  He proposes a public utility model—a shared responsibility of individual, employer and government.

I was quite taken by his “Loss of Tax Deduction” description. This is an issue that has eluded me for years.  Given that employers reap tax benefits by having their premium payments come from pre-tax dollars, I thought this would be one of the thornier issues in health care reform.  But Terry makes an excellent case about how a few simple revisions might work—and it makes sense. 

I have just dipped into the surface of the rich and thoughtful content of his book.  I highly recommend Rx for Health Care Reform.  We Americans are a pragmatic people who love to solve problems.  While I don’t agree with all his conclusions, he clearly has experience in both successful and unsuccessful reform efforts, and he understands the results of such efforts. 

Refreshing New Voices

There are more and more of us now hovering around some key issues and some areas of potential agreement.  While I am not sure all of us would agree on all of our proposals, various groups and individuals are coming up with relatively similar findings—that are for a change—pragmatically driven versus ideologically driven. 

I think exciting opportunities lie ahead in 2008. 

Next book review in the hopper:  Critical: What We Can Do About the Health Care Crisis by Senator Tom Daschle.

Cheers and more later.  Kathleen

Many good exchanges recently took place between Brian Keppler and Maggie Mahar on obstacles to health care reform. This exchange can be read on Dr. Mike Magee’s, Health Commentary blog. I would like to weigh in with what I think the major obstacle is to reform: Our failure to paint a compelling picture of a preferred/new health care future.

In 2006, CodeBlueNow! held a series of focus groups and one of the things we were told is, "Show us what it could look like."  That's what we consistently fail to do in health care reform. Mike Magee, MD, does a great job of doing this in his book: “Patient-Centered Health Care.” I am reading Ken Terry's book, "RX for Health Care Reform", so I am not sure what he has completely painted, but I like the direction he is headed.  Next in line is Senator Daschle's book, "Critical:  What We Can Do About the Health Care Crisis."  We took a beginning stab in our "It's Time to Speak Up on Health Care," which ran in January in the Seattle Post-Intelligencer and later ran in March in the Des Moines Register. 

People don't move without dreams and visions.  You don't cross the Red Sea unless you know that there is milk and honey on the other side.  Or march for civil rights, without the dream and vision that your current sacrifice will lead to something better.  The Founding Fathers did not start with legislation to beat the Brits. They started with the Federalist Papers.  They did not start the Papers with the Presidency and taxation. They painted pictures of what we could be and it was not until the last five of 85 papers that they talked about the Presidency, Senate, House, Judiciary and Taxation.

That's what we need to do. Paint the picture for reform, not dive into legislation. 

At a luncheon today in Seattle, Don Hewitt, founder of 60 Minutes and executive producer, CBS News, was asked what made a good reporter.  He replied " Someone who makes stories come to life with words." That's what we need to do. Make a new system come to life with words. 

As bloggers, I think we have the rare opportunity to paint that picture collectively.

Write on!  As the saying goes.