Tuesday, March 27, 2007

TennCare Network Inadequate

Concerns expressed by the Tennessee Health Care Campaign that network access for TennCare enrollees is inadequate are consistent with information obtained by The Oracle. One participating primary care provider with whom I spoke informs me that she received last week a slate of new patients that includes several hundred more names than she could possibly take on in her practice.

The problem she faces is two-fold: TennCare patients tend to be high maintenance and time consuming for the health care provider. Second, reimbursement under these insurers' provider contracts is so low that a practice seeing too many TennCare patients can not make enough money to stay open.

Monday, March 26, 2007

The Pending Health Care Disaster

A couple of weeks ago, I was in a meeting at which a congressman spoke of sponsoring legislation that would amend the United States Constitution in order to make access to health care a constitutional right. During the Q&A session that followed his presentation, I posed the following to the congressman:

There are two areas of concern with regard to our current system for providing health care coverage. One is the issue of expanding access to uninsured populations. The second relates to spiraling medical inflation. Your proposed constitutional amendment would address the issue of access to coverage. Do you have any proposals for containing medical costs?

The congressman at first said that he did not understand my question. After I elaborated a bit, he admitted that no one had been able to explain to him the reasons for medical costs rising faster than the general inflation rate and that he had no ideas for how to address it. To his credit, he asked me to call his office and set up an appointment to discuss any ideas I had. I intend to follow up.

This congressman is hardly alone in failing to address the problem of rising medical costs. Most of the proposals, at both the state and federal level as well as those offered by those running for president, focus on the problem of providing access while doing little or nothing related to cost containment. Of course, increasing access, if treated alone, is a much simpler issue, as it can be essentially limited to addressing the mechanism for funding access to coverage. Finding ways to contain costs without rationing care is a much trickier proposition, though it should be a central part of the debate?

Why is that? First, spiraling costs constitute one of the primary reasons that people lack coverage. Individuals and small businesses can't afford it. Second, expanding coverage without reducing costs only amounts to cost shifting, and we will hardly be better off if the only result of new policies is to replace ever increasing payouts to insurers with ever increasing payouts to government. Given the inability of our federal leaders to confront realities related to unfunded entitlement mandates already in existence, a new, unfunded health care mandate without cost controls may simply add to the coming tidal wave of federal debt. And, it is almost certain that expanding access to care will result in more frequent utilization of health care services, thus accelerating the rise in overall costs.

Notably, the problem with health care costs is not related to fees per service. For most health care providers, fees have fallen in real dollars over the last decade, yet overall health care costs have continued to soar.

Some savings can be achieved from the development of health information technology, which is a major priority of the Department of Health and Human Services, as well as other administrative efficiencies. Money can also be saved through medical malpractice reform. However, the major driver of growing health care costs has to do with utilization, and that is not an easy issue for the government to get a handle on. Who wants Uncle Sam to tell their doctor that they don't need to do that MRI?

Anyone who is associated with the health care industry has some awareness of the scandalous variety of treatments provided to patients with identical diagnoses. In an unpublished study I saw some time ago, for a specific injury, patients in California had surgery in 5% of cases; in Tennessee 30% had surgery. The researcher who presented the information said that she had not studied outcomes, so she was not sure which group of patients had better results. However, she said that such variety almost certainly meant that one of the two groups of patients was not receiving optimal care.

Addressing such variations in treatment and developing models for assuring that patients receive appropriate care is crucial for containing costs. It is also probably not a role that can be fulfilled by an arm of government.

Tuesday, March 20, 2007

Not Much Blogging Lately

The Oracle apologizes to all of his loyal readers (or to both of them, as the case may be) that blogging has been rather light of late. Preoccupation with issues related to employment have prevented me from giving more attention to my blog.

I have been traveling on business a great deal more than normal of late. There have also been other upheavals that require my attention. Several weeks ago, I thought there was a significant likelihood that I would be required to relocate to another state (a rather flat one, in fact, which created concerns as to my pseudo-identity, as Oracles are known to live on mountaintops). Anyway, it is now almost completely certain that I will be remaining both gainfully employed by someone and in the Nashville area. Nearly everything else is unknown.

In addition, I just learned that my son will be having surgery -- a thyroidectomy --soon.

Blogging will pick up again once some of this calms down.

Friday, March 09, 2007

Civility and Censorship

Peggy Noonan has a simple, yet profound, essay on the recent flaps created by unseemly remarks by Bill Maher and Ann Coulter that merits reading. At its climax, she writes this:

Fifty years ago, no one speaking at a respected political gathering would say, would even think of saying that Adlai Stevenson is a faggot. Nor would Arthur Godfrey or Jack Paar have declared on their television shows that we'd be better off if Eisenhower died. Is our discourse deteriorating? Yes, it is.

Part of the reason is that Grandma had more sway in the public sphere 50 years ago, which is to say common sense and a sense of decorum had more sway. Another part is that privately people felt they had more room to think or say whatever they wanted without being shamed or shunned. It let the steam out. We think of the 1950s as buttoned up, but in a way America had more give then. Men were understood not to be angels.

Our country now puts less of an emphasis on public decorum, courtliness, self-discipline, decency. America no longer says, "That's not nice." It doesn't want to make value judgments on "good" and "bad." We have come to rely on censorship to maintain decorum. We are very good at letting people know that if they say something we don't like, we'll shame them and shun them, even ruin them.

But censorship doesn't make people improve themselves; it makes people want to rebel. It tells them to toe the line or pay a price. People who are urged in the right direction and taught in the right direction will usually try to discipline and improve themselves from within. But they do not enjoy censorship from without. They fight back. They are rude in order to show they are unbroken.

Read the rest here.

Sunday, March 04, 2007

Movie Review: Amazing Grace

When I explained to a potential date that the movie I wanted to go to was based on the protracted effort of a member of Parliament to bring about the end of the British slave trade, I watched her eyes glaze over as she wondered exactly how boring I must be. However, she agreed to go, and we both found the movie to be well worth it.

Amazing Grace is a rare movie that manages to be a compelling drama for someone only interested in a good story while also displaying a considerable amount of historical and philosophical subtlety. Thus, the movie successfully differentiates the classical liberalism of Wilberforce and his allies from both the status quo conservatism of his Tory adversaries and the radicalism of those who would import the French Revolution. It also manages to emphasize the Christian underpinnings of British abolitionism without becoming preachy or pedantic. Wilberforce is the hero of the tale, but he is no superhero. The movie emphasizes the impact of the struggle on Wilberforce's health, as well as the periods of doubt and mistakes he made in his efforts.

One of Wilberforce's allies was John Newton, the author of the classic hymn Amazing Grace, from which the movie gets its title. Newton was a former captain of a slave ship who later fought to end the slave trade. While the title should help draw Christians to the movie, in some ways it is unfortunate, since non-Christians may assume the movie to be something they would not want to see. This is a great story for either Christian or non-Christian, and the religious underpinnings show Christianity in a way that it is rarely seen in modern pop culture. Wilberforce's Christian philosophical foundations helped form his political classical liberalism, which led him to support humanitarian reforms including, but not limited to, the abolition of the slave trade.

I highly recommend the movie.