The left-hand scale is in 1960 dollars. There’s nothing new here, it’s just a nice long time series. Other than a few periods, premiums have gone up, as well as premium as a percent of income. The only period of level or declining premiums I know anything about is the 1990s, the era of managed care. There are other, shorter periods of stable or falling premiums. A few years are like that in the 1960s, 1970s, and 1980s. Can anybody explain any of those?
Since I don’t spend a lot of time thinking deeply about Social Security and how to fix it (though I did dig into it a little, once), I appreciate that Don Taylor is thinking about it and, moreover, explaining his thoughts simply and concisely. I have a few questions. Hopefully, Don will consider answering them.
First, he wrote,
We should go ahead and focus on Social Security using momentum (assuming there is some,or if not we need to create some) coming out of the President’s Deficit Commission that will report on Dec. 1. I was helping one of my kids with homework planning the other day and told them to complete the easiest assignment first, then move to the next, and so on. Waiting to address Social Security until after Medicare and Medicaid are fully addressed doesn’t seem wise, and it would be good for us (the 310 Million version of us) to actually address a big problem and come up with a solution and prove the concept still exists. Maybe doing this will provide some momentum for Medicare and Medicaid fixes.
I’m not confident that what works for homework applies to governing. Is there really such a thing as momentum from legislative achievements? Or does each struggle for major reform consume political capital and invigorate the base of the losing set of constituents? If the momentum theory applied, wouldn’t we have seen a heap of it after passage of the ACA?
I’m all for solving Social Security if there is no way to make equivalent progress on federal health costs. I’m not for addressing Social Security at the expense of addressing health costs. My position is that if we make progress on the cost of health care financed by the government, it’ll leave a lot more budgetary headroom to deal with the (far simpler) problems with Social Security.
Was that even a question? Sorry. Now for an actual question based on Don’s history lesson of the Greenspan Commission and its consequences:
I favor extending the essence of the compromise that was the Greenspan Commission fix of Social Security in the early 1980s that extended the life of the trust fund until 2039. […] Greenspan et al. set the wage level to which the OASDI payroll tax was applied to the 90th percentile of wages (wage point at which 90% of the population has a lower wage). This level has been indexed by average inflation ever since. The problem is that high end wages have risen much faster in the past 25 years than have average wages, so the OASDI payroll tax now is set to the 83rd percentile of wages.
Don says we should reset it to 90% and fix the update factor so it stays there. My question is, why don’t we take the equivalent amount of revenue generated by that, but get it by exempting the first X% of wages and taxing everything above that level? Why are low income individuals paying a higher percentage of their wages toward this tax than are high income individuals? Shorter: why is it a regressive tax?
If you haven’t read the introduction, go back and read it now. That introductory post also includes links to all the posts in this series on how we can rate the quality of the US health care system. Each of these pieces will discuss another way to look at quality, and how the US compares to comparable countries in that domain.
We’ve asked physicians and practices. We’ve asked patients. So let’s round things out and ask executives what they think.
Telephone survey of hospital executives in Australia, Canada, New Zealand, United Kingdom, and the United States.
Sample of largest hospitals in each country: – 200+ beds in UK and the US – 100+ beds in AUS, CAN, NZ
Final hospital sample size of: – 100inAUS,102inCAN,and103intheUK – 28inNZ – 205 in the US
Like the previous surveys I have discussed, this was a comparison across intentional systems, asking hospital executives for their thoughts. I’m not going to cover every question, but I am going to try to give you some things to think about with respect to the quality of the health care systems.
Let’s start with their feelings on shortages of key staff. Here are nurses:
You may remember from a previous post that we have hard numbers on how many nurses we have per population. But, subjectively, more hospital executives in the United States think there is a “serious” shortage of nurses than in the other countries surveyed. How about physician specialists:
Better. Again, this should be no surprise given the hard numbers we’ve seen before.
Let’s move on to something new. How do hospital executives think that government regulations or policies work to improve the quality of the health care system?
What’s fascinating here is that hospital executives in countries that we think of having huge government intervention and oversight think that the regulations improve things. In the US, which has less in the way of policies and regulations, executives think they aren’t effective. Of course, I’m willing to bet that many of these same executives would argue that there is too much government in the US.
We can get down to more specifics, though. How do hospital executives rate physician morale in various countries?
Worse in the United States than in any of the other countries. And worse by a fair amount. They think that about one in every three doctors in the US has “poor” or “fair” morale.
Finally, how satisfied are hospital executives themselves with their respective health care systems?
The difference isn’t subtle. Just over half of hospital executives in the United States are “very satisfied” or “somewhat satisfied” with the health care system, compared to far more in other countries.
There’s not much to be happy about in here at all. When you think of the people “running” the health care system, this is them. And they don’t have much to say that’s positive.
Here’s your eighth scorecard:
And here’s the running total for the series:
A further explanation of these charts can be found here.
As the rhetoric heats up before the election, I’d like to give you a quick reminder* of why we needed (and still need) health care reform:
That thick red line is the United States. For the record, we’re beating Mexico, Turkey, and Chile. But every other OECD country – every single other one listed there – has figured this out. I’ve been spending a lot of time recently talking about the cost and quality of the health care system, but let’s not forget access. We’re terrible. There are so many countries bunched near 100% that you can’t see them all; picking out the very few that aren’t is easy.
Say what you will about the PPACA, but it was designed primarily to get at this issue. It’s not perfect, and it won’t get us to 100% insured, but it will get us closer. Our goal at this point should be to keep pushing to get us up with everyone else, not to return us to this.
One of the largest purchases I’ll make in my life is buying college educations for my children. So, I’m paying close attention to how I save, and how much I need to save, for that expense. Last year and earlier this year I went pretty deep into this issue. (To benefit from my research and save yourself some time, see posts under the “saving for college” tag.)
From it, we learn that average discounts are above 30% at four-year private institutions and the discount rate has grown over the past decade.
Tuition discount rate by sector
The report also tells us,
Because of growth in total grant aid, net prices have risen more slowly over time than have published prices. In the public two-year and public four-year sectors, estimated average net tuition and fees in 2009-10 are lower than those in 1999-2000 after adjusting for inflation. In the private four-year sector, estimated average net tuition and fees in 2009-10 are about the same as those in 1999-2000.
Average published tuition and fees and net tuition and fees per FTE student at private four-year institutions
It’s very nice that there is some hope of slightly lower than astronomical tuition bills for my children. But it’s still very frustrating not to have a good sense of what those bills will be. But, as I wrote before, I couldn’t possibly save enough to fully pay private four-year tuition rates anyway. What I can do is save to meet my expected family contribution (EFC). That doesn’t change much over time unless your income and assets change.
Of course, only being able to save for my EFC means my kids could be in for a lot of debt if they attend a school that costs a lot more than that net whatever tuition discount they receive. Maybe I can steer them toward something more affordable. Maybe not. Either way, it’s a problem for another time. I’ve got over a decade to think about it. And, believe me, between now and then I’ve got far more pressing childhood issues to consider.
(For instance, one recent problem was how to get vomit smell out of a carpet, even after it’s been cleaned many times with the usual stuff you’d think to try. Know the answer? There are lots online, but my sister-in-law knows how to do it in seconds, and now I do too. If nobody gets it I’ll post later in the comments to this post. Lemme here your answers first. By the way, this could come in handy at college too, so it really does belong in this post.)
If you haven’t read the introduction, go back and read it now. That introductory post also includes links to all the posts in this series on how we can rate the quality of the US health care system. Each of these pieces will discuss another way to look at quality, and how the US compares to comparable countries in that domain.
If we are going to look at physicians and practices, we also need to look at patients. As the consumers of the health care system (and ultimately the funders) they should have some say in the matter.
Telephone survey: representative samples of adults ages 18 and older in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.
Final samples: 1,009 Australia, 3,003 Canada, 1,407 Germany, 1,557 the Netherlands, 1,000 New Zealand, 1,434 United Kingdom, and 2,500 United States.
Core topics: Access, Coordination, Patient-Centered Care, Chronic Care, and Safety.
Basically, this is similar to their survey of physicians and practices that I discussed yesterday, but this time they surveyed random people, who could represent patients in the health care systems.
Let’s begin with some measures of patient satisfaction with their physicians’ practices. The first involves whether patients feel like their physicians know their medical histories:
This may seem like a small thing, but as anyone who has ever been to the doctor knows, it’s frustrating when they don’t know who you are and what your needs might be. And fewer people report having that kind of relationship with their doctor in the US than any of the other measured countries.
Another measure is whether the doctor spends enough time with you:
Again, this is subjective, but meaningful. People definitely see this as a measure of quality. We’re paying enough, and we get to see the doctor less than in other countries. You would hope that we get to spend enough time per visit, but that’s just not the case.
Another measure of system quality that patients report is how often errors occur. Let’s look at what percentage of patients in each of these countries report a medical, medication, or laboratory error:
Tied for last. Remember, these are individual patients reports, so it’s hard to spin these away as biased or unfair in some way.
Let’s move onto more direct measures of quality. How do patients in each country rate the quality of care they receive from their doctors?
I suppose middle of the road is an improvement over what we have seen so far. Again, though, this is consistent with other things we’ve seen. The problem isn’t necessarily that our physicians are of lesser quality. It’s that the system might be. Good thing they asked the same patients about what kind of changes they thought the system might need:
Dead last. More patients in the United States felt like the health care system needed fundamental changes or to be completely rebuilt in the United States than in any of these other countries.
You will hear some say that people in the United States feel that they have the best health care system in the world. They may think that. But people in the United States don’t seem to understand how much better people in other countries feel about their systems.
Here’s your seventh scorecard:
And here’s the running total for the series:
A further explanation of these charts can be found here.
Today’s WSJ includes a report by Mark Schoofs and Maurice Tamman about things we can and cannot learn from Medicare administrative data.
[T]he Medicare data come with a severe limitation: While the services and earnings of hospitals and other institutional providers can be publicly identified, such information is kept strictly confidential for doctors and other individual providers. The reason is that the American Medical Association, the doctors’ trade group, successfully sued the government more than three decades ago to keep secret how much money individual physicians receive from Medicare. The AMA has continued to defend this ruling, including in two cases in which federal appeals courts issued decisions last year.
This means the American public is barred from examining in detail how Medicare spends roughly an eighth of its funds, about $62.5 billion in 2009. While that may seem like a small piece, health-care experts point out that physicians have disproportionate power to direct spending in all the other areas of the system because they admit patients into hospitals, prescribe drugs and order procedures and equipment.
This is related to a broader concern about health system data I’ve raised before (andnotjustonce) but tends to get very little attention from the media. There is insufficient access to data for well-meaning researchers. We don’t know enough about what we’re getting for what we spend.
Taxpayer money funds about 40% of the over $2 trillion we spend on health care. Collectively we, the people, spend the rest. This is our system. We bought it. What can we learn about how it is functioning? Not as much as we should.
Not only are elements of of Medicare data out of reach of researchers (physician identifiers, which specific plans individuals are enrolled in, among other information), but entire sectors of our health system are virtually impenetrable in a comprehensive way due to lack of systematic reporting requirements. Data on private-sector plans and related utilization can only be obtained by special arrangements and/or at great cost. Even then, it is far from complete. As I once wrote,
The hidden data imposes a hidden cost on taxpayers. Though it can’t be fully quantified, there is a likely cost in the form of inflated payments. Insurance companies know far more about their costs and enrollee characteristics than regulators or academics. The information asymmetry plays to their advantage and can only drive up taxpayer costs. Unless plans are compelled to provide data, their advantage is likely to continue as the public begins paying a substantial sum to subsidize exchange-based coverage in every state.
I’m aware of the privacy issues that pertain to individuals and firms. They’re legitimate. But so is our need to craft a more efficient health care system. I also once wrote,
[U]se of administrative data does raise privacy concerns (as does survey data use). My threshold for privacy concerns is much higher than most. In general, I’d like to see greater ability for researchers to access, combine, and analyze data so long as they are de-identified whenever possible and there are strong yet reasonable penalties (with enforcement) for misuse and sound, workable remedies for those who might be harmed by such. As a country we have a long way to go in terms of sensible collection and use of data for research and penalties/remedies in the case of misuse.
My main concern about the WSJ article I quoted at the beginning of this post is that its focus on finding doctors that misbehave plays right into our fears about data, that they’ll be used to “get us,” that “big brother” is watching. As important as fraud detection is, that’s not the first (or even the second or third) thing I want to see done with data. We may be wasting some money on fraudulent activities. But I bet we’re wasting even more in other ways. We’ll never know without better access to data. We won’t get that access if we keep scaring everyone into thinking their privacy or will be violated.
In a recent American Journal of Managed Care commentary, Shared Savings Program for Accountable Care Organizations: A Bridge to Nowhere?, Bob Berenson described how the ACO concept can fail to achieve the savings and quality goals it ostensibly would promote. Sections 3022 and 10307 of the ACA permits the HHS Secretary to implement shared savings programs that would pay ACOs bonuses if they spend less than a target amount while meeting quality standards.
Berenson identifies two problems. The first is that
there are no downside penalties for missing the spending targets. Given the reliance on fee-for-service, it is hard to see how a speculative bonus attained in the future would counter the direct fee-for-service rewards for providing more reimbursable services, especially for hospital-sponsored ACOs.
And the second is that the spending targets are based on the ACOs’ historical spending. Thus,
previous practice inefficiency is baked into the calculations. Indeed, prospective ACOs even have an incentive to spend more before onset of the program to build up their […] historical spending base. It is no wonder that some have described the anticipated ACO program as the “lottery.”
See how badly things could go?
Theoretically, a program that offers shared savings without any financial downside provides weak incentives for providers to change behavior.
So, it’s not looking good. But the program need not be structured as Berenson described. That’s just one very bad way to do it. He goes on to suggest better ways, which include some sharing of the downside risk and ways of reducing the spending targets. (See the paper for details.) Berenson concludes that ACOs have “great potential to transform the healthcare system.” But, he says, the apt cliché is that “you can’t make an omelet without breaking eggs.”
We can certainly have a large ACO program that providers support. It just may not do anybody else much good. Or, we can attempt to create a program that actually saves money and improves quality. Is that a political nonstarter?
What does free, full-text, electronic, desktop access to academic publications mean to me? In a word, everything. I’m keenly aware of that right now because some technical problem or bureaucratic decision at Boston University has temporarily disabled that access. In effect, I’m flying blind, trying to advance my research without a key navigational instrument. It’s irritating and a drag on productivity.
What does it mean to you? To most readers, nothing at the moment. I’ve got enough posts in the queue and papers in my files to keep my stack of reading full and typical research-based blogging going for a week or two. If the problem isn’t straightened out in that time span, then you’ll suffer with me.*
To a few of you it may mean a tad bit more. I might ask you to send me papers. Now you know why.
If you haven’t read the introduction, go back and read it now. That introductory post also includes links to all the posts in this series on how we can rate the quality of the US health care system. Each of these pieces will discuss another way to look at quality, and how the US compares to comparable countries in that domain.
We wouldn’t have a complete series without some mention of physicians and their practices. They are, after all, an essential component of the health care system. Some measures of their capacity, and their perceptions of quality deserve to be recognized in this series.
Mail, phone, and e-mail survey of primary care physicians from February to July 2009 in Australia, Canada, France, Germany, Italy, Netherlands, New Zealand, Norway, Sweden, United Kingdom, and United States
Samples: 1,016 Australia, 1,401 Canada, 502 France, 715 Germany, 844 Italy, 614 Netherlands, 500 New Zealand, 774 Norway, 1,450 Sweden, 1,062 United Kingdom, and 1,442 United States
Core Topics: System views and satisfaction, access to care, managing chronic illness, teams, information technology, measuring practice performance, and financial incentives
So let’s begin. First up, how well prepared are physician offices with respect to modern technology for quality improvement and practice management?
It should come as no surprise to anyone paying attention that the US is surprisingly deficient when it comes to electronic medical records. While I am not convinced of the cost savings of EMRs in all settings, many studies have shown that they increase the potential for quality improvement.
But records are only one part of how technology can be used in practice. The survey also addressed specific tasks. In fact, the survey asked about fourteen specific functions:
electronic medical record; electronic prescribing and ordering of tests; electronic access test results, Rx alerts, clinical notes; computerized system for tracking lab tests, guidelines, alerts to provide patients with test results, preventive/follow-up care reminders; and computerized list of patients by diagnosis, medications, due for tests or preventive care
Here are measures of how many practices reported having at least 9 of these 14 functions:
Still not so good. Very much towards the bottom.
How satisfied are physicians with their practice? It’s not a perfect measure, but it’s an important one:
Given the rhetoric of how much physicians hate reform, you would think doctors were very happy before reform passed. You’d be wrong. With the exception of Austria and Germany, fewer doctors were satisfied with practicing medicine than any other surveyed country.
Let’s look at how doctors feel about the quality of care that patients are getting in the system:
Here, the US is more towards the middle. Only about a quarter of physicians in the US think that the quality their patients have been experiencing has worsened in the last three years.
That doesn’t mean that doctors judge the quality of the system to be good, though. That was asked as well:
With the exception of Germany, more US physicians felt that the system needed to be completely rebuilt than physicians in any other country. And the US tied with Germany for last in numbers of physicians who thought the system needed a total reboot or fundamental changes.
So how do physicians and practices make our system look? We’re pretty deficient in terms of information technology, physicians are unsatisfied with their work, and their views of the quality of patient care and the health care system range from mediocre to terrible. Not a ringing endorsement.
Here’s your sixth scorecard:
And here’s the running total for the series:
A further explanation of these charts can be found here.
Austin and Aaron are participants in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com.
10/28/2010
Austin Frakt
