In thinking about health policy it is important that medical students and doctors understand certain important concepts. To that end I would like to introduce our first important concept: the quality-adjusted-life-year or QALY.
* While not currently used in the United States, the QALY is a concept that often comes up when discussing how best to achieve coverage for all. NOTE: QALY's are currently used as an attempt to control cost in some countries with universal health care.
What is a QALY?
"Quality adjusted life year (QALY): A year of life adjusted for its quality or its value. A year in perfect health is considered equal to 1.0 QALY. The value of a year in ill health would be discounted. For example, a year bedridden might have a value equal to 0.5 QALY."
MedicineNet.com
For more information on QALY's see the links below:
What is a QUALY?
This article gives a somewhat in depth definition of what exactly a QALY is and how it can be used in health policy decision making. It also includes examples of how QALY's are implemented in the UK as part of the decision making process for the National Institute for Clinical Excellence(NICE).
Pricing Human Life(-Years)
An interesting look at the challenge(and necessity) of putting a price on human life and health by prominent American health economist Uwe E Reinhardt.
Friday, March 20, 2009
The AMA's position
The 2007 AMA proposal, "Health Insurance for All Americans" states that "The AMA believes tax credits are preferred over public sector expansions as a means of providing coverage to the uninsured."
See http://www.ama-assn.org/ama1/pub/upload/mm/363/ehi1012.pdf for the full document.
What is most interesting to me is that the AMA does not consider tax credits to consitute public sector expansions even these tax credits would still require greatly increased federal government spending. Other questions that the AMA position does not answer adequately, especially in such difficult economic times, is the problem of adverse selection that arise when private insurers are able to choose who they insure. Finally, the growing number of unemployed may not be able to afford insurance even with tax credits, and as the Massachussets experiment has shown, prices of health insurance tend to rise in private insurance based mandated universal coverage programs.
See http://www.ama-assn.org/ama1/
What is most interesting to me is that the AMA does not consider tax credits to consitute public sector expansions even these tax credits would still require greatly increased federal government spending. Other questions that the AMA position does not answer adequately, especially in such difficult economic times, is the problem of adverse selection that arise when private insurers are able to choose who they insure. Finally, the growing number of unemployed may not be able to afford insurance even with tax credits, and as the Massachussets experiment has shown, prices of health insurance tend to rise in private insurance based mandated universal coverage programs.
Thursday, March 19, 2009
Proposal for Single Payer
The following abstract is from the Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. The article first appeared in the Journal of the American Medical Association(JAMA) on August 13th, 2003. You can read the full text of the article here:
Proposal of the Physicians' Working Group for Single-Payer National Health Insurance
The article makes the case that the United States must pursue a single payer system for the benefit of not only the patient, but also for the physician, the national economy, and especially the uninsured. While it represents only one opinion on how to fix our broken system, it is a testament to the well researched and well reasoned thinking that has been going on in health policy for years.
With that in mind, it is my hope that in reading this proposal, single payer supporters will gain a deeper understanding of the issues at hand, while critics, if nothing else will come away with a greater appreciation of the type of thought and insight requisite in forming alternative proposals.
**Co-author Steffie Woolhandler, MD, MPH (Department of Medicine, Cambridge Hospital/Harvard Medical School, Cambridge, Mass) is one of our guest lectures for the March 23rd event: "Our System, Our Future: Covering the Uninsured and Prospects for Healthcare Reform"**
_________________
"The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care—the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least $200 billion annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program is the only affordable option for universal, comprehensive coverage."
Proposal of the Physicians' Working Group for Single-Payer National Health Insurance
The article makes the case that the United States must pursue a single payer system for the benefit of not only the patient, but also for the physician, the national economy, and especially the uninsured. While it represents only one opinion on how to fix our broken system, it is a testament to the well researched and well reasoned thinking that has been going on in health policy for years.
With that in mind, it is my hope that in reading this proposal, single payer supporters will gain a deeper understanding of the issues at hand, while critics, if nothing else will come away with a greater appreciation of the type of thought and insight requisite in forming alternative proposals.
**Co-author Steffie Woolhandler, MD, MPH (Department of Medicine, Cambridge Hospital/Harvard Medical School, Cambridge, Mass) is one of our guest lectures for the March 23rd event: "Our System, Our Future: Covering the Uninsured and Prospects for Healthcare Reform"**
_________________
The Physicians' Working Group for Single-Payer National Health Insurance*
JAMA. 2003;290:798-805.
"The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care—the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least $200 billion annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program is the only affordable option for universal, comprehensive coverage."
Friday, March 13, 2009
Here is some information about other cover the uninsured week initiatives that I got from a list-serve:
Approximately 46 million Americans are uninsured and there is a desperate need to raise awareness on this issue and bring about change. The American Muslim Health Professional (AMHP) is participating in Cover the Uninsured week (Mar 22nd-28th), a project by the Robert Wood Johnson Foundation by holding events across six major cities to help bring awareness to the need for health care reform.
For more information, please visit http://www.amhp.us or email contact@amhp.us
Fwd: AMHP Events in Six Cities on Health Care Reform
Posted by: "Arshia Wajid" arshia_wajid@yahoo.com arshia_wajid
Thu Mar 12, 2009 8:33 pm (PDT)
Approximately 46 million Americans are uninsured and there is a desperate need to raise awareness on this issue and bring about change. The American Muslim Health Professional (AMHP) is participating in Cover the Uninsured week (Mar 22nd-28th), a project by the Robert Wood Johnson Foundation by holding events across six major cities to help bring awareness to the need for health care reform.
For more information, please visit http://www.amhp.us or email contact@amhp.us
Tuesday, March 10, 2009
Sustained Dialogue Sessions - April 2009
Throughout the month of April, following our 3/23 Cover the Uninsured Week Program, MSS4UHC, in conjunction with MSSM's AMSA and AMA chapters, will be hosting "Sustained Dialogue" sessions --- a series of evening lectures and discussion groups designed to give students an opportunity to dive deeper in their knowledge of issues discussed during Cover the Uninsured Week.
Details and schedule of invited speakers will be posted shortly. Stay tuned.
Saturday, March 7, 2009
Schedule of Speakers for 3/23: Our System, Our Future: Covering the Uninsured and Prospects for Healthcare Reform
Monday, March 23, 2009
1pm - 4pm
The Mount Sinai School of Medicine
Stern Auditorium
Scheduled speakers include:
- Steffie Woolhandler, MD, MPH - Associate Professor, Harvard Medical School & Co-founder, Physicians for a National Health Plan
- Jeff LeMieux - Senior Vice President, America's Health Insurance Plans (AHIP)& Director, AHIP’s Center for Policy and Research
- Stephen Schoenbaum, MD, MPH - Executive Vice President for Programs, The Commonwealth Fund & Executive Director of the Commonwealth Fund’s Commission on a High Performance Health System
Moderated by: Salomeh Keyhani MD, MPH - Assistant Professor, Department of Health Policy and Department of Internal Medicine, The Mount Sinai School of Medicine
Sponsored by the Department of Medical Education, Mount Sinai School of Medicine,in collaboration with the Mount Sinai Students for Universal Healthcare (MSS4UHC).
Thoughts from Atul Gawande on how to achieve universal coverage
In January, surgeon and well known author Atul Gawande contributed an article to The New Yorker sharing his thoughts on how the United States can achieve universal health care. The article, Getting There From Here, tries to take a pragmatic approach by comparing the US health care system to that of other countries. He focuses on countries whose systems had certain sets of problems (both moral and financial), and by modifying their existing systems to include everyone (in most cases by becoming mixed, private/government run systems), achieved universal coverage . While a seemingly moderate and practical approach, Gawande's article drew the ire of several doctors, leading health policy experts and single payer supporters. Single payer supporters, among other things, point out that building upon our existing system pays far to much deference to the for profit insurance industry and fails to account for the huge sums of money that are siphoned out of the system as profit. Central to Dr. Gawande's argument is the contention that it is essentially unfeasible for us to go from our current system to a single payer system overnight. He argues that the massive infrastructural and practical adjustment would be too catastrophic. This point also received some sharp criticism, correctly pointing out that countries like Canada have done this very thing Dr. Gawande sees as unfeasible.
In defense of Dr. Gawande I'm not entirely convinced his pragmatism is as insidious as some critics suggest. The reality is that the health insurance industry possesses great wealth and even greater lobbying power. It is perfectly feasible that one could look at such a juggernaut and come to the conclusion that it may be best to go around it rather than through it, not because it can't be defeated but because it may take years, even decades to do so, all the while the uninsured and under insured suffer. This also assumes that for profits have no place in health care which is far from a universally held belief.
Regardless of what you think, Getting There From Here along with it's critiques are worth reading, and even more importantly, worth thinking about.
In defense of Dr. Gawande I'm not entirely convinced his pragmatism is as insidious as some critics suggest. The reality is that the health insurance industry possesses great wealth and even greater lobbying power. It is perfectly feasible that one could look at such a juggernaut and come to the conclusion that it may be best to go around it rather than through it, not because it can't be defeated but because it may take years, even decades to do so, all the while the uninsured and under insured suffer. This also assumes that for profits have no place in health care which is far from a universally held belief.
Regardless of what you think, Getting There From Here along with it's critiques are worth reading, and even more importantly, worth thinking about.
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