With all the shouting going on about America’s health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it—people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they’ve encountered it, when people who’ve spent entire careers studying it (and I don’t mean politicians) aren’t sure what to do themselves.
Albert Einstein is reputed to have said that if he had an hour to save the world he’d spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.
Though I’ve worked in the American health care system as a physician since 1992 and have seven year’s worth of experience as an administrative director of primary care, I don’t consider myself qualified to thoroughly evaluate the viability of most of the suggestions I’ve heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.
THE PROBLEM OF COST
No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we’ve spent on health care has been rising.
Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we’ve been getting for each dollar we spend.
WHY HAS HEALTH CARE BECOME SO COSTLY?
This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can’t attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country’s GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).
Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.
Is it because of monstrous profits the health insurance companies are raking in? Probably not. It’s admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it’s unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren’t likely different by any order of magnitude).
Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it’s hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.
Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.
Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it’s hard to imagine it’s shrunk to any significant degree since then.
In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:
1. Technological innovation.
2. Overutilization of health care resources by both patients and health care providers themselves.
Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they’re treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don’t have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we’ve figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we’re great at doing in the United States is making technology available.
Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What’s not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies—but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn’t important—just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.
Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.
A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:
1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depending on their training and the intangible exercise of judgment.
2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.
3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.
4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).
5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.
Gawande’s article implies there exists some level of utilization of health care resources that’s optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).
How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient—the “sweet spot”—in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn’t mean every physician knows it or provides them. Data clearly show many don’t. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.
In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.
But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next—
WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?
According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families—Implications for Reform, growth in health care spending “can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care.” When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you’d be spending 60% of your income on health care but that as a result you’d enjoy, say, a 30% chance of living to the age of 250, perhaps you’d judge that 60% a small price to pay.
This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn’t what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?
People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don’t realize that we’re already rationing at least some of it. It just doesn’t appear as if we are because we’re rationing it on a first-come-first-serve basis—leaving it at least partially up to chance rather than to policy, which we’re uncomfortable defining and enforcing. Thus we don’t realize the reason our 90 year-old father in Illinois can’t have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn’t). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we’re so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).
So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980’s (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn’t want to give up.
But how do we decide whether we’re getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn’t provide great clinical benefit—demented patients score higher on tests of cognitive ability while on it but probably aren’t significantly more functional or significantly better able to remember their children compared to when they’re not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.
Who’s best positioned to judge the value to society of the benefit of an innovation—that is, to decide if an innovation’s benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public’s views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone’s imagination).
THE PROBLEM OF ACCESS
A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance—emergency rooms—which has significantly impaired the ability of our nation’s ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors’ appointments, long wait times in doctors’ offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.
GUIDELINES FOR SOLUTIONS
As Freaknomics authors Steven Levitt and Stephen Dubner state, “If morality represents how people would like the world to work, then economics represents how it actually does work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there’s always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.
Here then is a summary of what I consider the best recommendations I’ve come across to address the problems I’ve outlined above:
1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It’s harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn’t be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group’s higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory “open enrollment” period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that’s driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of “good” and “bad” insurance that’s currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a “public option” insurance plan open to all, I worry that if it’s significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another’s health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a “public option” remains comparable to private options, the very people it’s meant to help won’t be able to afford it.
2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn’t have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that’s true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let’s not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.
3. Decrease overutilization of health care resources by doctors. I’m in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what’s truly best for their patients? The idea that external bodies—whether insurance companies or government panels—could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients’ welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient’s consideration, as long as they’re careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn’t). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients’ welfare, meaning doctors’ salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn’t seemed to promote shoddy care when doctors feel they’re being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.
4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:
* Making available the right resources for the right problems (so that patients aren’t going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the “sweet spot” with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we’ve been seeing for the last decade).
* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don’t actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it’s just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should—we’d just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).
* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can’t have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current “pre-pay for everything” model does.
Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don’t have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don’t allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.
Why are Americans so worked up about health care reform? Statements such as “don’t touch my Medicare” or “everyone should have access to state of the art health care irrespective of cost” are in my opinion uninformed and visceral responses that indicate a poor understanding of our health care system’s history, its current and future resources and the funding challenges that America faces going forward. While we all wonder how the health care system has reached what some refer to as a crisis stage. Let’s try to take some of the emotion out of the debate by briefly examining how health care in this country emerged and how that has formed our thinking and culture about health care. With that as a foundation let’s look at the pros and cons of the Obama administration health care reform proposals and let’s look at the concepts put forth by the Republicans?
Access to state of the art health care services is something we can all agree would be a good thing for this country. Experiencing a serious illness is one of life’s major challenges and to face it without the means to pay for it is positively frightening. But as we shall see, once we know the facts, we will find that achieving this goal will not be easy without our individual contribution.
These are the themes I will touch on to try to make some sense out of what is happening to American health care and the steps we can personally take to make things better.
A recent history of American health care – what has driven the costs so high?
Key elements of the Obama health care plan
The Republican view of health care – free market competition
Universal access to state of the art health care – a worthy goal but not easy to achieve
what can we do?
First, let’s get a little historical perspective on American health care. This is not intended to be an exhausted look into that history but it will give us an appreciation of how the health care system and our expectations for it developed. What drove costs higher and higher?
To begin, let’s turn to the American civil war. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause ghastly results. Not generally known is that most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail’s pace and this caused severe delays in treating the wounded. Secondly, many wounds were subjected to wound care, related surgeries and/or amputations of the affected limbs and this often resulted in the onset of massive infection. So you might survive a battle wound only to die at the hands of medical care providers who although well-intentioned, their interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!
Let’s skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a “wait and see” approach. Medicine could handle bone fractures and increasingly attempt risky surgeries (now largely performed in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.
This very basic review of American medical history helps us to understand that until quite recently (around the 1950’s) we had virtually no technologies with which to treat serious or even minor ailments. Here is a critical point we need to understand; “nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in such a scenario costs are curtailed. The simple fact is that there was little for doctors to offer and therefore virtually nothing to drive health care spending. A second factor holding down costs was that medical treatments that were provided were paid for out-of-pocket, meaning by way of an individuals personal resources. There was no such thing as health insurance and certainly not health insurance paid by an employer. Except for the very destitute who were lucky to find their way into a charity hospital, health care costs were the responsibility of the individual.
What does health care insurance have to do with health care costs? Its impact on health care costs has been, and remains to this day, absolutely enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight a great pool of money became available to pay for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. More Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare and Medicaid (1965). In addition funding became available for expanded veterans health care benefits. Finding a cure for almost anything has consequently become very lucrative. This is also the primary reason for the vast array of treatments we have available today.
I do not wish to convey that medical innovations are a bad thing. Think of the tens of millions of lives that have been saved, extended, enhanced and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor’s offer and most of us demand and get access to the latest available health care technology in the form of pharmaceuticals, medical devices, diagnostic tools and surgical procedures. So the result is that there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). Add an insatiable and unrealistic public demand for access and treatment and we have the “perfect storm” for higher and higher health care costs. And by and large the storm is only intensifying.
At this point, let’s turn to the key questions that will lead us into a review and hopefully a better understanding of the health care reform proposals in the news today. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other industrialized countries spending on health care and is it even close to these numbers? When we add politics and an election year to the debate, information to help us answer these questions become critical. We need to spend some effort in understanding health care and sorting out how we think about it. Properly armed we can more intelligently determine whether certain health care proposals might solve or worsen some of these problems. What can be done about the challenges? How can we as individuals contribute to the solutions?
The Obama health care plan is complex for sure – I have never seen a health care plan that isn’t. But through a variety of programs his plan attempts to deal with a) increasing the number of American that are covered by adequate insurance (almost 50 million are not), and b) managing costs in such a manner that quality and our access to health care is not adversely affected. Republicans seek to achieve these same basic and broad goals, but their approach is proposed as being more market driven than government driven. Let’s look at what the Obama plan does to accomplish the two objectives above. Remember, by the way, that his plan was passed by congress, and begins to seriously kick-in starting in 2014. So this is the direction we are currently taking as we attempt to reform health care.
Through insurance exchanges and an expansion of Medicaid,the Obama plan dramatically expands the number of Americans that will be covered by health insurance.
To cover the cost of this expansion the plan requires everyone to have health insurance with a penalty to be paid if we don’t comply. It will purportedly send money to the states to cover those individuals added to state-based Medicaid programs.
To cover the added costs there were a number of new taxes introduced, one being a 2.5% tax on new medical technologies and another increases taxes on interest and dividend income for wealthier Americans.
The Obama plan also uses concepts such as evidence-based medicine, accountable care organizations, comparative effectiveness research and reduced reimbursement to health care providers (doctors and hospitals) to control costs.
The insurance mandate covered by points 1 and 2 above is a worthy goal and most industrialized countries outside of the U.S. provide “free” (paid for by rather high individual and corporate taxes) health care to most if not all of their citizens. It is important to note, however, that there are a number of restrictions for which many Americans would be culturally unprepared. Here is the primary controversial aspect of the Obama plan, the insurance mandate. The U.S. Supreme Court recently decided to hear arguments as to the constitutionality of the health insurance mandate as a result of a petition by 26 states attorney’s general that congress exceeded its authority under the commerce clause of the U.S. constitution by passing this element of the plan. The problem is that if the Supreme Court should rule against the mandate, it is generally believed that the Obama plan as we know it is doomed. This is because its major goal of providing health insurance to all would be severely limited if not terminated altogether by such a decision.
As you would guess, the taxes covered by point 3 above are rather unpopular with those entities and individuals that have to pay them. Medical device companies, pharmaceutical companies, hospitals, doctors and insurance companies all had to “give up” something that would either create new revenue or would reduce costs within their spheres of control. As an example, Stryker Corporation, a large medical device company, recently announced at least a 1,000 employee reduction in part to cover these new fees. This is being experienced by other medical device companies and pharmaceutical companies as well. The reduction in good paying jobs in these sectors and in the hospital sector may rise as former cost structures will have to be dealt with in order to accommodate the reduced rate of reimbursement to hospitals. Over the next ten years some estimates put the cost reductions to hospitals and physicians at half a trillion dollars and this will flow directly to and affect the companies that supply hospitals and doctors with the latest medical technologies. None of this is to say that efficiencies will not be realized by these changes or that other jobs will in turn be created but this will represent painful change for a while. It helps us to understand that health care reform does have an effect both positive and negative.
Finally, the Obama plan seeks to change the way medical decisions are made. While clinical and basic research underpins almost everything done in medicine today, doctors are creatures of habit like the rest of us and their training and day-to-day experiences dictate to a great extent how they go about diagnosing and treating our conditions. Enter the concept of evidence-based medicine and comparative effectiveness research. Both of these seek to develop and utilize data bases from electronic health records and other sources to give better and more timely information and feedback to physicians as to the outcomes and costs of the treatments they are providing. There is great waste in health care today, estimated at perhaps a third of an over 2 trillion dollar health care spend annually. Imagine the savings that are possible from a reduction in unnecessary test and procedures that do not compare favorably with health care interventions that are better documented as effective. Now the Republicans and others don’t generally like these ideas as they tend to characterize them as “big government control” of your and my health care. But to be fair, regardless of their political persuasions, most people who understand health care at all, know that better data for the purposes described above will be crucial to getting health care efficiencies, patient safety and costs headed in the right direction.
A brief review of how Republicans and more conservative individuals think about health care reform. I believe they would agree that costs must come under control and that more, not fewer Americans should have access to health care regardless of their ability to pay. But the main difference is that these folks see market forces and competition as the way to creating the cost reductions and efficiencies we need. There are a number of ideas with regard to driving more competition among health insurance companies and health care providers (doctors and hospitals) so that the consumer would begin to drive cost down by the choices we make. This works in many sectors of our economy but this formula has shown that improvements are illusive when applied to health care. Primarily the problem is that health care choices are difficult even for those who understand it and are connected. The general population, however, is not so informed and besides we have all been brought up to “go to the doctor” when we feel it is necessary and we also have a cultural heritage that has engendered within most of us the feeling that health care is something that is just there and there really isn’t any reason not to access it for whatever the reason and worse we all feel that there is nothing we can do to affect its costs to insure its availability to those with serious problems.
OK, this article was not intended to be an exhaustive study as I needed to keep it short in an attempt to hold my audience’s attention and to leave some room for discussing what we can do contribute mightily to solving some of the problems. First we must understand that the dollars available for health care are not limitless. Any changes that are put in place to provide better insurance coverage and access to care will cost more. And somehow we have to find the revenues to pay for these changes. At the same time we have to pay less for medical treatments and procedures and do something to restrict the availability of unproven or poorly documented treatments as we are the highest cost health care system in the world and don’t necessarily have the best results in terms of longevity or avoiding chronic diseases much earlier than necessary.
I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens – health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don’t need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.
Let’s go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don’t exercise but we offer a lot of excuses. We don’t eat right but we offer a lot of excuses. We smoke and/or we drink alcohol to excess and we offer a lot of excuses as to why we can’t do anything about managing these known to be destructive personal health habits. We don’t take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because “health care is there” and somehow we think we have no responsibility for reducing our demand on it.
It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement personalized preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.
There are a huge number of free web sites available that can steer us to a more healthful life style. A soon as you can, “Google” “preventive health care strategies”, look up your local hospital’s web site and you will find more than enough help to get you started. Finally, there is a lot to think about here and I have tried to outline the challenges but also the very powerful effect we could have on preserving the best of America’s health care system now and into the future. I am anxious to hear from you and until then – take charge and increase your chances for good health while making sure that health care is there when we need it.
If you have a child, you know how easily their bedrooms can get out of control. Toys strewn about, clothes out of drawers, books on the floor; it can almost be a hazard sometimes just to enter. Think about new corner sofa bed with storage where you can put all toys and clean up kid room. But getting your child’s room organized can be rewarding and fun, especially if your child is actively involved in the process.
Never attempt it without their permission, input and most importantly their active participation. Don’t surprise your child and go ahead and organize their room for them. Just as you expect your privacy and possessions to be respected, so should theirs. Teach your child as soon as possible the importance of keeping their room tidy and orderly, so they’ll have a strong appreciation for neatness and order as they grow. With a little patience and cooperation, even the youngest can be taught this habit early on, simply by learning how to put toys and other belongings like books and art supplies away after use. When organizing your child’s room, make sure it’s fun and creative, so they are interested in maintaining it. And as we all know, children grow and change rapidly, so their rooms should have the room to grow with them. Make sure your organizational method has room to grow and change as well. And above all, make sure you get their ideas about what they think will work the best for them. Make sure that all their favorites are well within reach and easy to put away.
Place things that they use on an infrequent basis on the top shelves in their closet, and devise a workable system for hanging and organizing clothes and grouping favorite outfits together add cheap corner sofa bed to your kid room. When it comes time to put laundry away, ask if they need your help, but try to give them the space when possible to do it themselves, and it will grow into a good habit as they grow older. Hanging storage closet systems are ideal for kids. They are bright and colorful and are able to contain closet items in a way that enhances visibility for a child. Designed with roomy pockets they hold an array of shoes, toys, and clothes, and hang over any standard closet rod. Their front openings make it simple and quick for any child to use.
Also consider a desk with drawers or other filing system for your child’s school work, art work, awards, report cards, and other papers. There are many brightly-colored and durable storage bins, desks and organizers available for your child’s room, so take them shopping with you so you can both select the best option. And most importantly, keep your room neat and organized, and maintain it on a daily basis. Don’t expect your child to maintain a nice, tidy room if you’re not doing the same. The best teacher is your example.
Why Property Owners Should Practice Periodic Trimming and Removal of the Trees in Their Outdoor Spaces Do you have trees in your outdoor spaces? Is is tiresome and challenging to regularly cut its branches and leaves? For those who are experiencing similar situation, then the best thing that they can do is to get the expert services of tree trimming and removal companies. If you haven’t hired one and you want to know more about these service providers and their services, then you are advised to continue perusing this article. Who They Are? Well, these are the service providers who are adept when it comes to the provision of tree trimming, cutting and removal services. These practitioners make use of quality and advanced tools for maintain, cutting as well as trimming of trees. No matter how tall or hard these branches are, they know of ways to cut it devoid of disturbing the surrounding properties as well as the cables nearby. Having a regular trimming and pruning service is one habit that should be kept and formed by property owers. Other than the ones showcase a while ago, what are the other perks of regularly trimming and cutting the branches and maintaining trees?
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What Are the Benefits of Regular Cutting, Maintaining and Trimming of Trees?
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1. Should you be among the numerous men and women out there who intend to have a beautiful outdoor spaces containing beautifully shaped and designed plants, shrubs and trees, then you definitely hire these tradesmen. 2. When you regularly prune your trees, then you can treat the damage, molds and fungi. 3. It is also important for your trees to be regularly maintained if you want them to remain healthy and fit at all times. Hiring these people is deemed as the most effectual method of ensuring the functionality as well as the looks of your trees. Trees not only provides the needed shade from the harsh rays of the sun but they also furnish oxygen, fruits, flowers and protection from winds, floods and storms. 4. Periodic cutting and trimming of trees are surefire ways of keeping your lawn, garden and outdoor spaces beautiful and appealing at all times. 5. When the trees are maintained by regular pruning and cutting, then you can keep danger at bay. Old and diseased branches are prone to falling off and risky to the individuals passing by. Trees with low hanging branches posed great risks in driveways as well as in the nearby roads. The moment these low-lying branches are not trimmed and removed, then there is great possibility that you will get bumped by it. 6. Trimming and cutting of these unwanted branches are effectual in controlling your house’s visual access. Since these tradesmen showcase lots of benefits to us, then we must be careful when selecting and hiring these people.
Importance of Hiring a General Contractor One of the things that can give excitement to people is the prospect of building their own homes or renovating their current one. People think that they can single handedly manage home construction activities but they will soon realize that they don’t want to be in that place. If you think that you are good enough to be your own contractor, you need to pause awhile and thing hard about this decision, and make sure that you will commit to the project until it is done and be able to face some technical issues and demands and face complications as they come. If you want to do yourself a favor, then better hire a good general contractor to do these things for you. It is great to be a home owner, but if you have no skills or experience in home construction, don’t make it your ambition to be your own home contractor as well. If you are not a contractor, you can find it difficult to find that handy men that you need for tasks that need to be done for your home construction and you also need to manage them so that they can do that work correctly. A general contractor is able to get professionals needed to complete your home construction or home improvement project because he is within the network of professionals. If you hire a general contractor who has been in the business for many years will assure you that he will be able to get qualified and reliable sub contractors. It is beneficial to hire a general contractor with connections to subcontractors because with the years of experience that he has, he will know whom to choose to help the project proceed in a fast and efficient way. When a general contractor has a well established relationship with subcontractors, you can be sure that your project will have a priority when it comes to scheduling, you will have more competitive bids and great service. This saves a lot of time because your don’t have to do screening and hiring and the time can be used to working on the actual job.
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Home construction has many challenges but the general contractor is able to face these challenges in a fast and proficient manner. IF you don’t want to face the challenges and problems on your own, then don’t attempt to do your home improvement project by yourself. You can very well be clueless on what to do next.
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Building codes and regulations are mandated to ensure public safety and health. There is a need to get permits for your specific project and other requirements which a general contractor can easily do for you. General contractors also have proper insurance in case of liability and also compensation for workers. With a general contractor you are assured that he will be there al the days of the week working everyday to ensure that your project is finished at the agreed time.
Video Production Process and the Stages Involved Video Production has got three stages Each and every video production project will have to pass through these three stages. Video production is the process of several short recorded videos, editing unnecessary parts and joining them together. It is a daunting task which can take several months or even years. A team known as the film crew which consists of the director, costume and makeup artist, continuity team, camera operator, visual effects supervisor and may others. Their names appear at the end of the video being credited for the work they did. Those who appear in front of the camera are known as actors and actresses. They are visible on the screen. The quality of a video is determined by the three production stages. Pre-Production stage is the first stage in video production process. Planing of the video shooting takes place in this stage. It involves officials in charge of the video that is to be produced. Selection and development of a script is done at this stage. Then a storyboard of the script will be worked on by a storyboard artist. Research and scouting of locations for shooting will be done. Casting of actor actresses and supporting cast is done Finance matters are handled, choosing a production company and film crew is chosen. The second stage of production is known as the production stage. It involves both the chosen crew and cast. It is done on the chosen locations which are referred to set. The locations are designed to the desired look by set designers and then cameras will start rolling. Video recording then starts During this stage lighting, framing and composition of the video is done. At the end of this stage they should be having raw footages that that will be used in the third stage of production. A lot of time and money is spent on this stage.
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Post-Production Stage is the third stage of video production. This begins after the footages are captured during shooting. Most of the work here is done by the editors. Editors do the cutting of videos, joining them together and blending the shots. An editor intention is to make sure that the story being told is continuous When editing, there will be an addition of graphics, soundtracks, sound effects, music, and control lighting to make it more believable and interesting to those viewers who will watch the video. Pace, mood and tone is created by these sound and music This is the stage that involves the least number of people. The director and producers are the ones who visit the editors to check on them, they also make sure that the video standard is what they desire.Learning The “Secrets” of Services
The Importance of Obtaining A Seamless Gutter It may sound a cliche but surely, “there is no place like home”, hence it is important that you only get what is best for it, you can start by asking yourself if there is a need to obtain new rain gutters. The moment you found out that it is no longer functional, you must carefully weigh your options as to what kind of gutter system are you going to obtain. There are a lot of gutters you can choose from, but seamless gutter is surely the best option for you, the following section will acquaint you with the reasons why you should choose it. There are a lot of advantages in using the seamless gutter system unlike the conventional types, hence it is best if you are going to read further the following information stipulated below. The number one advantage you can get from it is already present in their name which is seamless, since they don’t have a lot of joints it is quite easy in keeping them clean. In addition, there are not gaps seamless gutters hence it is more effective in preventing or avoiding water leaks. You are probably wondering for a more specific reason why is it advantageous if there are no gaps or breaks found in gutters. It was already made mention that if there are no gaps or breaks water leakage can be prevented or minimized. Most of the time the typical gutter system is made up of different sections that are connected with each other. There is a high probability that as time passes by these connected sections will form leaks. If you are not keen in observing these kind of problems then more likely the wood foundations in your house will start to decompose or rot which might cause more physical damage to your property.
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There are a lot of things that composes the seamless gutters like aluminum, copper, and galvanized steel. If you are worried as to how it can affect the exterior look of your house, you actually don’t need to worry for they come in different styles and colors.
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Seamless gutters are a bit expensive but you can be sure that it is very functional and physical damage to your property can be avoided. If you have already decided to use this kind of gutter then the next step that you need to do is to look for a reputable gutter installation agency. Most of the time people don’t worry with the additional charges in the whole installation. Despite of its high price the important thing is you can be sure that you don’t need to replace the gutter in your house regularly and your house will look more beautiful. With the advent of technology, surely you will be able to search in the internet for stores that are selling seamless gutters,
Consider the Benefits of Seamless Gutters Gutters are installed to provide sufficient house protection because you can avoid water damages caused by the accumulation of water from rain, ice and snow. However, leaves and other debris can accumulate also into the gutters that cause clogging and overflowing. Consequently, several parts of the house are also affected and get damaged. When you intend to install gutters, one of the best choices is to have the seamless gutters rather than the traditional ones. Here are the vital factors and benefits to think through with these superior gutters. Seamless gutters have no divisions and demarcation so they are extremely functional and effective in the maintenance of hygiene and cleanliness in your home. The absence of these sections avoid water leakages so your house will be protected from potential water damages. You can save a huge amount of money and time once you use seamless gutters. There will be less maintenance of the roof, walls, and other parts of your house for it is no longer exposed to water damages as a result of water leakages from malfunctioning gutters. Without the divisions and demarcations, maintaining cleanliness will be easier also as they do not permit the entry of dirt, debris, insects, birds and other small animals. There will be less hassle and effort needed compared to cleaning them regularly. They are very affordable as well, particularly with the installation, since the materials used, like steel, aluminum, copper, vinyl, etc. are easily available in the market.
A Simple Plan: Homes
The design of seamless gutters can be customized in accordance with the necessities of the individual homes and the preferences of customers. This avoids any sort of inaccurate measures, which makes the installation completely flawless.
Looking On The Bright Side of Options
However, apart from the many advantages, seamless gutters have some concerns also that you ought to know ahead of installing them. They include several details that makes it hard to install for a layperson who does not have suitable knowledge, skills and training. That is why you need to hire professional technicians who have the training and skills to install them. For the reason that installation of seamless gutters cannot be done alone and you need to hire professionals, the process can commonly become expensive. However, even though the installation costs are somewhat high compared to the sectional ones, consider that they are very durable. You can still save with the maintenance expenses, unlike with the sectional gutters that need regular cleaning. Gutters are located at the roof of your house so they are constantly exposed to various elements that can result in being highly prone to corrosion. Although they are extremely durable and long lasting, they still need occasional maintenance. This will enable lengthen the life of your gutters while you keep your house clean and protected.
Find the Best Insurance Company For You and Your Family It is a fact that life is really uncertain and unpredictable and all of us have no knowledge and idea on what might occur or happen on the future. The reality of life is really difficult to each and every individual which is why a lot of people are doing their best in order to achieve this obstacles and trials in life and in the end would lead to their life’s stability, luckily, there are some people who are producing a lot of things and necessities that could help their fellow humans in facing life’s reality. Insurance products and contracts are one of the most essential things that has been produced and designed by people in order to help their fellow human beings in protecting their most prized possessions and their life, as well. An insurance contract is one of the most beneficial things that an individual has bought and possessed for themselves and for their families, it is basically a protection and security of an individual from financial loss and misfortune. A lot of various kinds of insurance are produced and offered by an insurance institution or company, like gap insurance, health insurance, automobile insurance, income protection insurance, casualty insurance, life insurance, burial insurance, property insurance, liability insurance, credit insurance, disability insurance, long-term care insurance and many more other types of designed insurance products. The most common insurance product is what we called as life insurance and it is designed to function when the insured or assured person has died and the insurer or insurer company is obligated to pay a specific amount to the beneficiary listed by the late insured or assured client. An insurance for disabilities is designed for the beneficiaries in insuring their earned income when there are some unfortunate events of disabilities that would create a barrier with their work or career. There are basically a lot of insurance companies situated all over the world and the state of California situated in the country of United States of America has the best insurance company situated in their locally, and the clients wo are in need of their services could always search the internet and get their details, list of products, contact details, address or they could also find them from local newspapers and magazines.
Qualities to Consider When Searching for an SEO Reseller
Finding an SEO reseller to grow your business is crucial. It involves reducing your business’s methods, since you and the SEO reseller will work as partner.
Searching for an ambitious reseller is time consuming, and working with inexperienced shops definitely signifies bad media for your business. Plenty of merchants are bent to achieve the selling path, however, you must take some time inspecting them, since one incorrect transfer may bring along your company. Most of them also want to try selling because they believe that it is simpler than network or MLM, that developing revenue through reselling is quicker than doing doorway-to-door direct jobs.
Many SEO suppliers sell their business online. Online applications that may be delivered through mail are normally utilized by most of them. Additionally, there are suppliers that only leave a contact detail on the Contact Us and About pages of their website and await the calls of driven resellers. These are two explanations why there are plenty of SEO reselling applicants. The availability of companies and applications’ contact information on the Net makes them genuinely believe that SEO reselling is easy.
Selling SEO involves significantly more than just developing income. Like a company, you ought not to be eager out looking at the inner characteristics of every merchant. Having a history in promotion and marketing happens to be a plus, but you also needs to appear beyond a merchant’s written qualifications.
One of the first things you should note is the consumer’s determination to complete the task. This makes up the main first impression each candidate makes. Ensure that the candidate has at least the dedication to sell the support.
Ambitious resellers’ dedication and enthusiasm often deteriorate once they learn how difficult SEO could be. Most of them wind up supporting out while these candidates find the period needed to achieve success within this area. SEO selling is similar to having a means reducing your time, and having your personal company.
Learning demands determination, time, and conviction. Some hopefuls believe SEO is a simple ‘site-standing sport’. Once they figure out that is not the case, they become persistent and they leave. Furthermore, individuals who believe realize everything they need to learn about SEO are people who don’t succeed. Exactly like in virtually any additional company, you will find in learning SEO limitations and no restrictions.
A great audience is also a great learner. People that hear understand issues that are new, analyze ideas, and study from problems. Although it is true that you will require to be personable to succeed in the company, learning how exactly to listen carefully might help SEO is resold by a client effectively.