Posts Tagged ‘tuition’

Health Reform- a few further thoughts

Monday, May 19th, 2008

UPDATE:The article here offers an interesting comparison between the French and British health care systems. Almost a controlled trial since the writer had one hip done in the NHS and the other in France. That article link is no longer valid but this one is interesting. Sound familiar ?

In recommending Medicare as the vehicle for the basic coverage in a national health plan modeled on the French system, I did not intend to suggest that Medicare, as that vehicle, would be a government agency. I was recommending a non-profit corporation funded by payroll or other contributions from beneficiaries. Medicare, in theory, is funded by the Medicare tax contributions of workers prior to retirement. A system for active workers would be called the same name and the two programs, plus Medicaid, would be rolled into one system. It would be funded, however, not by general tax receipts but by the assessment for health care, analogous to the French funds, the largest of which, CNAMTS, is for salaried workers. There are many other funds for other workers such as agricultural or managerial workers.

As far as the name is concerned, Medicare was the name for the health care program for military dependents when I was in the Air Force. The name was adopted for the retirement health plan in 1965 and the military then called its program “CHAMPUS,” and now calls it “Tricare.” The name is secondary.

My point is that this should be a non-profit corporation or foundation, sort of like CalPERS, the California pension program for government employees. Beneficiaries, employers, unions and providers should all serve on the board of directors. The retirement program, which is mostly funded by tax receipts now, can be represented by bureaucrats. Working people should be represented by their own members, elected or appointed, depending on the format chosen by members. This may be a very important part of the French system.

We have learned a lot about managing health care in the past 25 years. When I was in graduate school ten years ago, there were students in the same program from all over the world. This is a universal problem. I have consulted for the NHS when they adopted the “Fund Holding” reforms of Margaret Thatcher. The Labour government, once it took over from the Conservatives after Mrs Thatcher was no longer Prime Minister, made many disparaging remarks about Fund Holding, a reform with some similarities to American HMOs. However, they have kept most of the reforms in place.

In considering reforms, most critics of the US system look to Canada for ideas. This is because they are close to us and share our language and many of our institutions. They are not, however, a good model. I believe many mistakes were made and too much coercion was used in dealing with providers, a feature of our current treatment of doctors in the US. Because of language, few know much about the French health care system but those of us who have been working in health care, especially in surgery, are aware of the very high quality of care and innovation. We should also become aware of the similarities and of the very high level of satisfaction, both by patients and doctors.

Health Reform- the transition

Saturday, May 17th, 2008

I have been reviewing the details of the French health care system, as it was established in 1945, and how it has evolved in a history somewhat similar to our own. The Second World War marked the divergence between the two countries. Wartime labor shortages left us with an employer-based system that has become too expensive and rigid. France, in the social upheaval of defeat, had the chance for radical reform and took it. Britain took a similar opportunity and went another way with single payer, tax supported health care in the NHS. The pre-war differences in the three countries made some of this probable, if not inevitable.

What do we do now ? Why is it necessary to reform the US system ?

Our system is very expensive and does not have universal coverage. Those are the two features most listed by critics. People who are covered are largely satisfied with the care they receive but are often uneasy about the cost and the possibility of being left without coverage if they develop a serious chronic illness or lose a job. Our system has evolved away from community rating, in which everyone paid the same premium based only on age and sex. Now we have experience rating, in which a history of illness can make us uninsurable.

One of my patients 20 years ago had had a thyroid cancer, a form of cancer that is 100% curable when properly treated. A couple of years later, she needed a breast biopsy for what was almost certainly a benign lump. Her insurance excluded coverage because she had had thyroid cancer, totally unrelated to the present condition.

Recently, it has been reported that almost all medical groups in California are financially insolvent. For decades, the American system relied on cross-subsidies as insured patients paid for those without insurance by funding hospitals and doctors’ practices, which, in turn, cared for the poor and uninsured for free. The development of managed care and HMOs has eliminated the cross subsidy by squeezing out of the system the resources to provide uncompensated care. No one ever went without acute care in our system. Chronic illness has been another matter, but many of the patients who rely on emergency rooms and charity hospitals would probably not have availed themselves of chronic care anyway. Now, acute care is in jeopardy as public health systems, like that of Los Angeles County,  are being bankrupted by the demand from illegal aliens.

How do we proceed ?

The United States is much larger than France with a much larger population, 300 million compared to 64.5 million. Our economy is much larger and healthier with an unemployment rate of 5% vs 10% or higher in France. Our people tend to work longer hours and produce more per worker. Some of the French problems with health care are, in fact, problems with their economic model, which is more protectionist and less productive with huge agricultural subsidies (even larger than ours) and excessive vacation time and early retirement. The French health care system would fit our economy better than a British or Canadian model and the relative cost would be tolerable. Ours is already based on payroll deductions rather than general tax revenues and this could be continued. Workers already pay FICA taxes to fund Social Security and Medicare. In addition, they pay health insurance premiums. Combining the two would allow some cross subsidy for the Medicare deficit we face in the next few decades as “Baby Boomers” retire.

The US has 50 states and there have been a few attempts to use states as “laboratories of democracy” to test health care reform experiments. These do not work (except, perhaps, for Hawaii, which is relatively isolated) because states are not large enough and people will move around to acquire benefits. Any real reform has to be national. What I propose is to move to a universal Medicare program which would pay 80% of health care costs. The co-payment would be paid by private insurance, just as is done in France. Costs would be subject to “Evidence-based Medicine” criteria for reimbursement. If people want chiropractic treatment or acupuncture or massage, let them pay for it without subsidy. This may, in fact, be the most difficult part of the problem to solve as our state regulation is highly politicized and influenced by lobbies of various health care organizations.

I would also strongly recommend that the Workers Compensation system be integrated into the health plan, as is done by France. I work with the Workers Compensation programs in multiple states, reviewing claims,  and find that many of these workers have no private insurance. Integrating workplace injury treatment would avoid costly duplication and help reduce fraud, rampant in workers comp.

What do we do with illegal aliens ? They dominate public care in Los Angeles and fill emergency rooms of private hospitals. Since the Federal Government chooses to allow them to come into the country, they should pay for care of illness and injury. They are already eligible for workers compensation care.

What about nursing homes and treatment of the disabled? Medicaid is already the principle source of funding for care of the elderly and disabled poor. Integrating this into a national health plan would relieve a huge burden on the states and might reduce some of the gamesmanship in state-federal relationships.

What about a fee schedule, like that of France ? Doctors’ incomes have been eroding steadily the past 30 years as HMOs gained power and the FTC has prosecuted doctors’ groups for any attempt to negotiate fees with them. They should be allowed to represent members as a union and negotiate fees and terms. The Los Angeles County Medical Association has disappeared as members found themselves without the means to support it and it was dissolved with its magnificent library dispersed.

New doctors are heavily burdened with debt. USC medical school, where I teach, now has a tuition rate of $40,000 per year. The average medical student leaves with loan balances of $250,000. New young doctors must earn enough to repay loans. The problem has become so severe that a new medical school organized by the Cleveland Clinic and Case Western University has decided to grant 100% scholarships to all students accepted, in hopes of encouraging more to choose academic medicine. The military services offer full scholarships to medical students who agree to serve a minimum time as military physicians. What if we offered all new doctors, who agreed to accept the national fee schedule as payment in full (after co-payment), a full scholarship to medical school ? If later, they decided to shift to the equivalent of Sector 2 in the French system and charge higher fees, they would have to repay their scholarships. A system to forgive existing loans could even be introduced. Each year a new doctor participated in the Sector 1 equivalent, part of the loan was forgiven.

There are many permutations of a program like this and I offer these suggestions only for discussion. What about it ? One additonal advantage of a system like this is adminsitrative savings. Doctors offices have severe overhad problems trying to deal with the many HMO and IPA contracts plus Medicare paperwork. When I was in practice 13 years ago, I had 246 different contracts with various insurance groups, most with different requirements for pre-authorization and the like. I finally bought a computer system for the office to deal with the complexity. A card reader system like the carte vitale would be a godsend to doctors’ offices. The savings alone would make a lower fee schedule more acceptable. I know pediatricians whose capitation payment for HMO patients is no higher than the French Sector 1 fee. I am not an accountant but I think this could work. Something has to.

Is the blog the next education methodology ?

Friday, May 9th, 2008

I have been told by my students that some do not attend class because the class material is posted on the school web site (the password protected one) and there are students who are discourteous enough in class to distract others who are serious about study. I was shocked by the last statement but I now hear about students who talk during lectures in medical school. When I was a student, only an idiot would pay so little attention to lectures, which were the backbone of the course. Textbooks were sometimes of marginal value because, in being complete, they failed to discriminate between key facts and minutiae.  I did have one such idiot in my class so, even then, there were those who had trouble with impulse control.

This article also stimulates some thought about tuition. Universities are incredibly inefficient economic units. When I wrote a grant proposal 13 years ago for a study that would be conducted mostly by computer analysis of Medicare billing records, the overhead factor that had to be added for the university (Dartmouth) was over 40%. Now, we have medical students paying $40,000 per year tuition who do not attend class but essentially take the course online. Of course, that doesn’t apply to clinical study with patients and hospital wards but there is a lot of simulation going on there, too. My student group spent a day at the Surgical Skills Center at USC a couple of weeks ago, practicing tying knots and suturing pigs’ feet back together.

This piece in Inside Higher Ed discusses the role of blogs in law schools and legal education. Online education is coming and high tuition is pushing it faster. I worked on a program to teach medical students to listen to heart sounds a few years ago. My skills at programming animation were not good enough but it is coming and we will be better for it.

What is a college education worth today ?

Sunday, December 2nd, 2007

This post was stimulated by a recent article in the Harvard Crimson. The absence of historical understanding is breathtaking but the willingness to rely on an all-powerful government is no surprise. College education seems to be a matter of indoctrination these days. Somebody even made a movie about it. At the University of Delaware, the effort to indoctrinate students was even an official policy. Those with a suspicious nature have been wondering about what is going on in universities these days. Tuition seems to be climbing at a rate well above inflation. What about knowledge ? Well, the results don’t look good. Note that some of the students tested are from elite, very high tuition universities.

UPDATE: Yale University thinks it knows the solution More diversity ! Let’s hire another 120 diversity experts. What else are African American Studies majors to do ? Or Native American Studies majors ? Or…

Note in the table that Ivy League university seniors score well above (64.1%) state university (47.4%) seniors, but look closely. Ivy League seniors score only 0.1% higher than Ivy League freshmen ! State university seniors score 2.9% higher than state university freshmen. I have been advocating a program to eliminate waste in college education. Harvard and Yale and Princeton are brands. There is intense competition to obtain admission. It is almost considered a sure-fire path to a successful career in investment banking in New York City. These elite universities should award a degree to the student admited once the payment of four years tuition is received. There should be no need to actually waste four years and hundreds of hours of professors’ time on an education that adds only 0.1% to a high school senior’s knowledge of the world. I’m sure most of the faculty of those “research universities” would appreciate being allowed to devote themselves to important tasks. They spend so little time on undergraduate education as it is, they would appreciate the end of hypocrisy.

I make an exception for science education, in which serious information is exchanged between student and teacher. High schools have their own set of problems but at least public high schools aren’t charging tuition and thereby implying that they are worth something. A few years ago, the culture of Yale rejected a $20 million donation rather than establish a program in Western Civilization. From the linked speech (Given by a prominent Yale alumnus): “The unwillingness or inability of faculties to require, or even suggest, a basic common undergraduate curriculum in the humanities and the arts for all students is a central fact of University life today. It is a well-nigh universal phenomenon, certainly not limited to Yale. The causes are varied. One notable factor-which I have found singularly unpersuasive-has been the suggestion, by persons purporting to be concerned with the interests of minority groups, that a survey course or general education in the Western tradition represents a threat or an insensitivity to minorities. Of course, Yale had its defenders. The latter article ends; “As the curtain goes down, there are bodies lying all over the stage; one can’t help but think that everyone involved is worse off. Yet if I were to teach this drama, it would be as a comedy, not a tragedy; and surely the restorative moment, even in this act, is Yale’s refusal to cede control of faculty appointments to outside pressures.” Jonathan Lear is [of course] a professor of philosophy at Yale.

The Duke rape case is instructive in the matter of whether “political correctness” influences humanities faculty today in universities. Take a look at the famous “Group of 88” who accused the lacrosse team members of rape. What do you see ? I see three math and scence professors. The rest are humanities or African American Studies faculty members. I rest my case.

UPDATE #2 I have found an explanation for the Duke fiasco that sounds reasonable. Professor Borjas quotes Stuart Taylor and K.C. Johnson’s book.

“Duke sought to join the Ivies, Stanford, and MIT among the nation’s leading institutions. It chose to do so, however, on the cheap: bypassing the sciences (where the combination of salary and lab costs for a new hire ran around $400,000), the school focused on bringing in big-name humanities professors, for whom the only startup cost was salary. Politically correct leftist professors were in vogue nationwide, and the leftward slant of Duke’s humanities and social sciences faculty accelerated…” That sounds about right to me.

I can not see a justification for a humanities degree from an expensive elite university. Imagine what the parents of Duke humanities students are getting for their tuition. Lest one think that Duke might be ashamed of the radical agenda of its leftist humanities faculty, Duke philosophy chair Robert Brandon said “We try to hire the best, smartest people available,” Brandon said of his philosophy hires. “If, as John Stuart Mill said, stupid people are generally conservative, then there are lots of conservatives we will never hire.” If you are willing to pay a high price for something, what do you get ? More of the same.