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I said this in a Wave that a video editing site started yesterday, in response to others attempting to figure out how to make Wave into a replacement for forums:

At least in the short term, there’s no use in trying to make Wave a forum or online help desk. Creative Cow and others work well for that.

Wave is at its base a collaborative tool. Once you add in too many people or widen the point of a given wave, it loses most of its usefulness.

The better way to use wave is as tool to achieve an end. If we already have video that we need to edit, we load it up in FCP or AVID, but if we have nothing we start in AE or similar programs. Same with Wave. Just because it exists does not mean we have to find a way to use it like we’ve used other tools.

Rather, we should take its strengths (collaboration) and apply the tool when it is needed.

That’s video production specific, but the point is something that’s frustrating me and applies to everyone on Wave. Google Wave, as Google’s engineers created it, is a replacement for email specifically intended to help collaboration. To collaborate is to work together towards a goal or end.

Google Wave has some really cool potential for increasing online collaboration – but it’s a very specific tool. What is frustrating me is this idea that “we have the tool, therefore we must use it!” It’s a common human tendency. If you go buy a hammer, you really want to start knocking stuff around. And stuff may need knocking around. But it might not.

If you didn’t need to collaborate last week, then just because you have a tool to collaborate this week does not make collaboration a necessary thing this week. It is a waste of time to create a need so you can use a tool – a waste of time that could be used in other productive means.

Furthermore,  when we get a new tool that we don’t yet understand, we immediately try to understand it from a familiar viewpoint. We have to fit it into the paradigms we already have, so that we can “conquer” the new tool. We take the motor driven vehicle that has been given to us to revolutionize transportation, and try to hook it to the horses that have been pulling our carts. Then we complain how it’s too heavy and our horses already got us to new places well enough.

So please, stop it with the Google Wave. Sign up, learn how the tool works from a technical aspect, but don’t try to make collaborations happen because you have a tool for collaboration. If Wave has revolutionary potential, it will be discovered – you might even be the one to discover it! But it will be discovered by people who have the right need for the tool and then apply the tool properly.

Until then, you’re just replacing the perfectly adequate with the newfangled for the sake of being cutting edge, and you’re missing the whole point. So stop.

Over at Marginal Revolution (which has the excellent tag line: “small steps toward a much better world”), the author posts healthcare reforms that he would support more than the current bill making its way through Congress. Some of them are really good.

4. Make an all-out attempt to limit deaths by hospital infection and the simple failure of doctors to wash their hands and perform other medically obvious procedures.

5. Make an all-out attempt, working with state and local governments (recall, since the Feds are picking up the Medicaid tab they have temporary leverage here), to ease the spread of low-cost, walk-in health care clinics, run on a WalMart sort of basis.  Stepping into the realm of the less feasible, weaken medical licensing and greatly expand the roles of nurses, paramedics, and pharmacists.

6. Make an all-out attempt, comparable to the moon landing effort if need be, to introduce price transparency for medical services.  This can be done.

He does add the disclaimer at the beginning that these are merely reforms he would gladly trade the Obama bill for, and not the best ever, but I agree that some of these reforms are really desirable. Check out the full post here.

Also, and this is something I hadn’t yet learned, the current Obama plan does away with existing HSA’s, which is a bit sad. I have an employer-funded HSA and the money that is being added to it tax-free is part of my future planning. I hope that I don’t lose it, it really has helped us think carefully about medical procedures.

From the New Yorker, November 9, 2009 issue:

According to various international agencies, fourteen per cent of of the buildings in Gaza were partially or completely destroyed, including twenty-one thousand homes, seven hundred factories and businesses, sixteen hospitals, thirty-eight primary health-care centers, and two hundred and eighty schools. Two hundred and fifty wells were destroyed, three hundred thousand trees were uprooted, and large swaths of agricultural land were made no longer arable, in part because of contamination and unexploded ordinance.

Thirteen Israelis died, including nine soldiers – four of them from friendly fire – and four civilians, who were killed by rockets. (Israeli civilian casualties were kept to a minimum because many residents near the border fled the area, and those who remained hid inside fortified bunkers.) Hamas claims that only forty-eight fighters were lost during the entire operation. The toll on Gaza civilians was far higher. According to Amnesty International, fourteen hundred Gazans died, including three hundred children; five thousand were wounded. Israel claims that only eleven hundred and sixty-six Palestinians died, two hundred and ninety-five of them civilians. The Israeli human-rights organization B’tselem has documented seven hundred and seventy-three cases in which Israeli forces killed civilians not involved in hostilities. So far, the group says, Israel has convicted only one soldier of a crime during the operation – for stealing a credit card.

The progress we have made thanks to technology is an illusion, and I will vehemently debate anyone who disagrees and says the world is a better place than it used to be. These facts are regarding Israel’s war against Gaza last December and January, and they are really really heartbreaking.

Well it’s a good thing I have all of 10 visitors to my blog daily. First it keeps me humble – I really have to write for myself if I’m going to post because I’m not letting any fans down, and second it means that the external pressure to produce is not that strong.

So here it is, Tuesday, and I’ve not been able to complete my thoughts on what makes sense to me in healthcare. The truth is, there hasn’t been enough good analysis of systems already in place worldwide (Atul Gawande did one for the New Yorker, but that was just one piece), nor have I seen some trustworthy, fact based examinations of the different solutions being offered from what I consider non-partisan sources. We can throw around claims of bias and partisanship for all media outlets, but the best journalists attempt to overcome their personal bias in their writing. Rather than starting from one side and working to a conclusion that stays on that side, they recognize where their leanings are, and attempt to subvert that in their examination of the facts.

It’s a reason that I enjoy reading long-form journalism such as is in The New Yorker and The Atlantic and similar periodicals. The writers are able to spend time with the subject, which allows bias to be more clearly seen.

But that’s not what I’m attending to say with this post. Truth is, I just don’t know what steps make sense to solve healthcare. And that’s ok in that it’s not up to me to save healthcare, but it is frustrating as someone who is trying to educate themselves and have an informed opinion about the subject. The problems are systemic, complicated, and to truly repair they require sacrifice, something Congress avoids when passing bills. Rather than delay gratification to solve problems, we always end up spending our way out of them. And then have to revisit the issue a decade later.

In all my reading and all my admittedly amateur and haphazard researching, there have been two, maybe three solutions that begin to repair the healthcare issue but do not represent a system-wide fix. Here they are in brief:

1. Enact a system nationwide similar to what Maryland has in place

Every year a state commission sets the prices in Maryland for all medical procedures. This is the price that everyone has to pay – large Insurers, small Insurers, uninsured citizens. This reduces variance of medical costs, and (according to those who support the system) forces healthcare providers AND insurers to compete not on price but on quality and other benefits. But the other benefit is that we can get a handle on medical costs – medical providers are forced to operate under the prices they can charge and this can theoretically curb the ridiculous yearly increase of healthcare costs.

2. Standardize billing and record keeping for all healthcare providers

Right now a great deal of your insurance dollar (estimates are that it is over 30%) are spent on administrative costs – billings and records keeping. If you go to a different doctor or move to another state, there is no standard way for your records to be transferred nor are healthcare providers required to keep them in a standardized form. Surely in America someone or some group is smart enough to figure out this problem and to solve it. Normally I would be inclined to wait on a free market solution, but what motivation does the market provide to this? It seems that it needs to be motivated by someone else.

That’s it. That’s all I’ve found. Really, just two simple solutions that don’t at all get to the heart of the issue. So I guess what this means is, for now, I have to keep reading and keep digging to find out more about the proposed solutions, to see if they do make sense and will be able to help. And anyone who tries to convince me using political party propaganda will be summarily dismissed and blacklisted.

Well, today is the day I should have culminated my personal overview of the healthcare system from my point of view; but alas I haven’t had much time to write this week, and reviewing solutions I’ve heard and seen is the hardest part. So, that part is delayed, hopefully just until Monday. In the mean time, check out this post on Snarkmarket, that criticizes some of the more prominent articles of late about healthcare:

These arti cles per pet u ate the belief ram pant in jour nal ism that sys temic change hap pens in sweep ing ges tures. And very, very occa sion ally, it does. But over the past 90 years, almost every sweep ing change pro posed to over haul the health care sys tem has gone down to crush ing defeat. The real changes have been step by step, bit by bit. Even Medicare when enacted was a mere con do­lence for the death of the com pre hen sive insur ance sys tem Tru man had envi­sioned 20 years before.

The Philosophical Problems

A previous post pointed out that Americans expect perfection in doctors, and often times if perfection is not achieved, a lawsuit is served. This seems to stem from our modern philosophical idea of healthcare, something that has yet to be addressed in any bills or debates on TV.

The issue of drugs and drug costs discussed in the previous post is illuminating in this regards. It is a natural human desire to find an easy way to solve a problem, that’s the goal of most technology and progress. But modern society doesn’t just look for solutions that make sense, instead we look for solutions that are convenient. Just look at the evolution of most devices we use in our modern life – we’ve gone from a mechanical lawnmower that used human power, to a engine powered mower, to riding mowers that have cupholders. Now mowing the lawn is extremely convenient. This is the way modern life works across the board, from coffee machines to razors to, most alarmingly, healthcare.

Modern society has elevated the cure-all to the level of science, and we’ve convinced ourselves that with science, we can live however we’d like. Part of this means we look to drugs to solve ailments conveniently. Most Americans with high blood pressure could eat a little better, exercise a little more and be fine – but it is much more convenient to take this exciting new drug that reduces blood pressure without the lifestyle changes.

The problem with this thinking is that ailments and illnesses become separated from the way we live – each one is something to be dealt with when it arises (with SCIENCE!) and meanwhile the root issue – an overall unhealthy lifestyle – is never addressed. PSA’s and certain observers have of course been saying this for years, but in the specific context of our healthcare system, there is no overall attempt to defeat this fragmented philosophy of health. When we go to the doctor and they find a problem with us, they are rewarded by running a series of tests, prescribing the necessary drugs, and sending us on our way. The insurance company dutifully covers everything because that’s what we pay them to do. But our health, when viewed from an overall lifestyle perspective, does not improve, and the effects later on might be harrowing.

Is this a problem with the healthcare system? Yes and no. It is, as my riding lawn mower example shows, more a pervasive societal philosophy that our technological and scientific advancements have given us the ability to have convenience above all else. But the healthcare system only reinforces this philosophy, and in doing so increases the costs to consumers and further alienates those who cannot participate in the system (the uninsured).

I mention all this because the built in assumption of the healthcare debate is “because we can, we should.” Healthcare is a very sensitive subject, and any talk of limiting its availability seems horrific (see: fears about “death panels”), but the philosophy of excess and convenience we have today has a very real and very steep cost, and when we discuss its availability and how to fix this system, we either have to crown convenience king, at the sacrifice of the cost-cutting, or as a country we have to be willing to sacrifice on certain things to be able to afford the necessary things (e.g. sacrifice on drugs that replace lifestyle changes, in order to afford life-saving cancer treatments for everyone). So in the next post, we’ll look at some potential solutions that make sense to me.

This is rather fitting with the topics of my posts this week.

How Diets affect Weight around the World

Yay, America’s winning!

These blog posts started months ago, with me questioning why exactly Universal Health Care was innately bad on Facebook and proceeding with me reading various analyses and articles on the issue. So the following blog posts are a summarization of my understanding of the issues at stake and an overview of the solutions that have made the most sense to me in my readings. I’m writing this for my benefit as well as anyone who would like a bigger picture view of the system and it’s flaws. I am organizing the posts so that I explore all the flaws first, and then some potential solutions that make sense to me, and I am trying to keep the posts to bite-sized chunks. I am of course, always open to discussion.

Regarding the Uninsured

Democrats say 30 million. Republicans say more like 6 million. No matter which figure you believe, that’s a lot of people in America who are legitimately uninsured. Even more worrisome is that every year the majority of personal bankruptcies are declared because of medical bills that are too expensive to be paid. Insurance providers have no incentive to compete on the individual market because they make the majority of their money from businesses who provide employer-based insurance as a benefit. Healthcare providers do not compete on an open market and thus set the prices of services based on their own estimates, then negotiate with insurance providers for the price that those insurers will pay. But uninsured individual consumers have to pay full price, meaning that most medical services are overpriced and the uninsured avoid medical services unless they are absolutely necessary.

This means that an individual or family who does not have access to employer-provided healthcare insurance is stuck between a rock and a hard place. Their first option is to pay full price on insurance premiums out of pocket or face the other option – avoid healthcare until they are faced with an emergency, and then face medical bills that are debilitatingly expensive. This is a real problem in America – the human side of the healthcare debate. That is why it has seen the most amount of attention in the debates.

But it’s not just the uninsured who have these problems – even people with insurance are often faced with incredibly high medical bills because they reached the limit of their coverage or their insurance was revoked due to whatever medical problem they have. It is a documented issue that many people nationwide face what is called rescission – the revocation of their policy when a major medical issue arises. Insurance companies have been known to pore through medical histories to find problems which they can claim were preexisting issues, or even to find typos on the original forms which they claim as a lie and therefore reason enough to revoke the policy. These are the extreme cases, but they are documented and the insurance company CEO’s are on record in front of congress saying these practices will continue because they are currently legal.

A sidenote about Drug Companies

All of this information regarding our Healthcare system boils it down to two major players; Insurance Providers and Healthcare Providers. But there is a third party that does a great deal to increase confusion and costs in the medical system. The drug companies, or “Big Pharma” as they are often called, have a really large hand in the pot stirring things around, attempting to profit off our misfortunes as a society. That would seem a dramatic statement, but the Government and journalists have documented the nefarious activities that drug companies practice to increase their market share and profits.

Big Pharma is profitable. The number three most profitable industry in the US in fact, with 20% profits last year alone, which translates into billions and billions of dollars. But Big Pharma has a lot on the line as well – each year they spend billions on research and development of new drugs, and often times drugs can get well into testing (after billions have been invested) before failing out of clinical trials. So Pharmaceutical companies have a lot of risk, and work hard to offset that for their investors by increasing their profits yearly. The problem is, normal ailments just aren’t that profitable.

The laws right now are very strict on how a new drug can come to market – it must be proven through clinical trials and multiple studies against placebos. Once a drug is approved by the FDA for sale, it can only be marketed by its manufacturer for the specific purpose the drug was approved for. This is usually a very specific ailment or problem. However there are no laws restricting doctors on their prescriptions – so drug companies have discovered that an easy way to increase the profitability of a drug is to recommend to doctors that it be prescribed for “off-label” uses. This is a common practice now – and there is very little science that goes into these prescriptions. Drug companies merely tout (to doctors) the great uses of their drug for a certain use, and doctors proceed to prescribe it for that use – whether or not there are any studies to back  what is being touted.

Insurance companies meanwhile are constantly fighting drug companies to keep down costs. A generic version of a popular drug might have the same efficacy and side effect risks, but can cost hundreds of dollars less each month. It is thus very desirable to insurance companies to promote generic drugs to their consumers. Drug companies don’t like this because they need the revenue from their drugs to keep making new ones, so each time the insurance company attempts to encourage generic usage by putting up obstacles to getting brand-name drugs (such as more costly co-pays for the brand name drugs), the drug companies fight back (by offering coupons that remove the copay for the consumer). The consumer loves this, but the insurance company is left paying hundreds more for the drug.

This issue of drugs and their prices might not be so powerful were it not for the philosophical problems in our healthcare system today, which is the topic of tomorrows post.

These blog posts started months ago, with me questioning why exactly Universal Health Care was innately bad on Facebook and proceeding with me reading various analyses and articles on the issue. So the following blog posts are a summarization of my understanding of the issues at stake and an overview of the solutions that have made the most sense to me in my readings. I’m writing this for my benefit as well as anyone who would like a bigger picture view of the system and it’s flaws. I am organizing the posts so that I explore all the flaws first, and then some potential solutions that make sense to me, and I am trying to keep the posts to bite-sized chunks. I am of course, always open to discussion.

The Problems with Doctors

There have been a lot of words thrown around about the “fee for service” structure that we have in place – where a doctor’s income is based not on a salary but on each specific service they provide. A patient may be diagnosable with reasonable confidence based on one test, and multiple tests may not increase the confidence of the diagnosis at all, but the system is set up so that the doctor gets paid more for ordering more tests, the patient sees no extra cost (because insurance covers it all), and furthermore the doctor is seen as going above and beyond due diligence which protects him from malpractice lawsuits. A great number of analysts point out these three reasons as the main drivers behind the unneeded medical services provided each year (the 30% figure previously mentioned).

Fee-for-service is the immediate incentive that lawmakers hope to address. Doctors swear, of course, to only do what is best for the patient, and no doubt most intend to do only that. But the system has a built-in incentive to provide more services – which also has the side-effects of giving a doctor incentives to see more patients and spend less time with each to maximize the “effectiveness” of their time (and their income).

Patients have no problem with more taking more tests – from a non-medical point of view, more information can only be a good thing. And the cost of the tests is never known due to the insurance blinder, so it’s a win-win in that your doctor is better able to diagnose your problems while you don’t have to pay anything else. Except that tests – like MRI’s or CAT Scans – can cost thousands of dollars, and the more people who get them the more insurance premiums go up. Consumers aren’t able to link the two – the system does not provide any connectivity between more tests and higher premiums.

This is even worse in markets that are heavily saturated with healthcare providers. Certain analysts have surmised that in over-saturated markets there is a built-in market incentive for excess; because if one doctor won’t order the extra tests, surely another will. So a doctor is compelled to go above and beyond to keep his patients and thus is able to make a living in an otherwise very competitive market. It has been estimated that this can double overall medical costs for markets with this problem.

The hardest aspect of this issue to rectify is that more information does not increase a doctor’s ability to diagnose you – the extra information can many times be unnecessary to a diagnosis. But consumers don’t know this, and because they also see no connection between extra tests and rising premiums, they do not understand that excess is a bad thing. In reality, we want excess because it gives us peace of mind, assures us that doctors are solving all possible issues with our health.

This is where malpractice comes in – the issue of tort reform is another one thrown around in the political debates. America is a very litigious society and medical malpractice lawsuits abound – they are so troublesome that for healthcare providers often the biggest operating cost for providers is malpractice insurance. In these suits it must be shown that due diligence has been performed by a doctor, and if it has not been performed then settlements in the millions of dollars are not out of the ordinary. But what is due diligence? It’s a very nebulous idea, specifically in the realm of a specialized field like medicine. If a doctor does what he knows will give him the best diagnosis and reaches a confidence of 99% that someone does not have cancer but it turns out he was wrong, has he performed due diligence? To a trained medical person, the answer may be yes, but to a lay person this answer is often no – whatever could have been done should have been done, no matter the cost or unlikelihood of helping. And there is no real incentive to the doctor to not order the extra tests and do the extra procedures – he makes more money that way.

Once again, the system incentivizes excess: the doctor cannot do what would be necessary to reach a confident diagnosis, instead he must do every possible thing he can to ensure that there is no doubt left in his mind. We expect perfection from doctors, and if they fall short we sue them.

These blog posts started months ago, with me questioning why exactly Universal Health Care was innately bad on Facebook and proceeding with me reading various analyses and articles on the issue. So the following blog posts are a summarization of my understanding of the issues at stake and an overview of the solutions that have made the most sense to me in my readings. I’m writing this for my benefit as well as anyone who would like a bigger picture view of the system and it’s flaws. I am organizing the posts so that I explore all the flaws first, and then some potential solutions that make sense to me, and I am trying to keep the posts to bite-sized chunks. I am of course, always open to discussion.

The Healthcare System

There are two main critiques of the healthcare system that we are supposed to be solving with whatever bill emerges. The first is that there are millions of uninsured people in America who either can’t obtain care because of “pre-existing conditions” or are unable to afford healthcare but don’t qualify for the existing government programs. Secondly, there is the issue of excess, fraud, and inflation in healthcare – estimates are that about 30% of all medical services provided are unneeded, but are still covered by insurance thus contributing to the rising costs. Because of these unneeded services, healthcare costs are rising faster than the GDP or the average American’s income.

It would seem that the two problems are directly linked – as healthcare costs rise yearly, insurers must be more careful about who they cover and what issues they cover, leaving millions of people uninsured with no hope for coverage that is reasonably priced.

This is the simple version though – and as I’ve read what I’ve had time to read and parsed the sometimes overwhelming amount of information, my frustration has risen at the amount of people who take this simplification at face value and assume that this is the totality of our problem and that’s why a simple solution is needed. This is the American way though – we boil something down so simple that it’s seemingly a straw man, and then we just fix the straw man. But the devil is in the details, and healthcare is all about the details so that is why I’m writing these posts.

The Complications

The Healthcare system as it stands now is not a free market system. Politically minded people want us to believe that the choice is between our free market status quo and Obama’s socialistic plan. This is not the case, and it is confusing a lot of people. Right now as a consumer of insurance, my best bet for obtaining coverage is through an employer based group plan. That plan is provided by a Insurer that can only operate in the state I live in, meaning that in every state in the US insurance works differently and has different main players. To provide coverage in each market, each insurer must negotiate with each Healthcare provider to decide on rates and coverage for each service provided – and the rates that the Healthcare provider and Insurer decide on in no way change the rates that another insurer might get with the same healthcare provider.

Because of these problems, we work in a very monopolistic market, where each state is dominated by two or three major insurers. Those insurers are the only choices employers have for providing insurance, and anyone who cannot join group coverage is faced with the exorbitant costs of premiums that come with individual coverage. They have no real choices because there are only two or three major providers and these insurers have any incentive to compete with each other on individual plans because their main consumers are businesses who obtain group coverage.

I should note – the laws right now do not allow insurers to provide coverage across state lines, this is a legal hindrance and not a choice on the part of insurers. Because of this, each state is a unique market in healthcare and prices fluctuate from state to state (and often city to city within states) because there is no actual open market that guides pricing.

Pricing in the healthcare industry is yet another confusing, non-free-market system. Every hospital sets the prices for what it thinks the services it offers are worth. This is probably not completely arbitrary, but it can vary a great deal within a city. No hospital is required to publish a price list and there is no free market pressure to reduce prices as each hospital usually is only competing for business from a few major players (the main insurers in that market). Consumers have no knowledge up front of the cost of their medical procedures and thus are unable to make economically-minded decisions about healthcare. That point will be revisited.

For an insurer to provide coverage at any specific healthcare provider, the insurance company has to actually go to that healthcare provider and negotiate rates for all the services they provide. If a hospital says that a certain test costs $1000, the insurance provider will negotiate how much they have to pay for all the people they cover if those people receive the test, and it will typically be a drastically reduced rate (like say, $300-400). But EVERY insurance provider has to do this negotiation, and all of them will get different rates. It used to be (until a decade or so ago) that hospitals were the losers in this battle, because they were the small dog at the negotiating table.

A decade or so ago, coinciding with the rise of the HMO’s, hospitals began banding together into networks, increasing their negotiating power with insurance providers. Because the insurers goal is to have as many choices for the people they cover, when hospitals banded together, insurers had more incentive to come to an agreeable deal with the hospital networks so that their insurees had more options. Before the hospitals banded together, the insurer always had the option of saying due to unreasonable rates, we will not provide coverage at your hospital to the thousands of people in your market. The hospitals banding together into large networks removed this threat because an insurer couldn’t risk not providing coverage for so many hospitals in a certain market.

This move on the hospital’s part, and the increased power on their part at the negotiation table meant that rates started rising – insurance providers could no longer lowball. But the combination of state line limits on insurance providers with the new hospital networks means that in each state the size of the insurance provider dictates the rates they receive – the hospital networks didn’t just even the scales, in many cases they tipped the scales in the hospital’s favor. If an insurer in a specific state doesn’t have a lot of clout (meaning a large amount of people that they cover in a given hospital network’s area), they cannot negotiate lower rates. This only increases the monopolistic market of insurance, as only the biggest insurers can negotiate lower rates with more healthcare providers so that their premiums don’t rise as fast. The smaller providers are stuck with higher rates that they must pass on to the consumer.

Tomorrow: “The Issues with Doctors”