I totally agree with Barbara.
Best,
Shirley
Shirley Johnson-Lans
Chair
Department of Economics
Vassar College
----- Original Message -----
From: Barbara Starfield <[log in to unmask]>
To: [log in to unmask]
Sent: Thu, 8 Jan 2009 14:34:01 -0500 (EST)
Subject: Re: Reform - from Joe White
I beg to differ. We know a fair amount about many features of health care delivery. We know, for example, that a primary care oriented health system is better all around (effectiveness, efficiency, equity) than a specialty oriented system (which the US has in spades) and we also have good cluese as to why that is the case. The problem is that an extraordinary array of vested interests greatly prefer a specialty oriented system because they gain a lot from it----just the kind of situation that Professor Normand refers to. The vested interests are so strong that no one wants to even mention what they are!
Barbara
-----Original Message-----
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Adam Oliver
Sent: Thursday, January 08, 2009 2:22 PM
To: [log in to unmask]
Subject: FW: Reform - from Joe White
________________________________
From: Joe White [mailto:[log in to unmask]]
Sent: Wed 07/01/2009 5:08 PM
To: Oliver,AJ
Subject: FW: Reform
Hi Adam,
Nobody ever knows what the public thinks "major reform" means.
But I would disagree with Professor Normand. It depends a lot on what
you're trying to change, and on the consequences of disruption.
When the United States implemented its Medicare program that was certainly
major reform. Yet it went fairly smoothly. It went smoothly in part
because the reform was designed to change as little as possible at the
operational ground level. This also meant it did not control costs
immediately. But costs weren't controlled before, either. The goal of
reform was to get people insured, and it worked quite well, quite quickly.
Professor Normand's rule is roughly right for "reorganization," such as
creating the U.S. Department of Homeland Security. But, for example,
putting all of the uninsured into Medicare would be much less complicated.
It's an add-on, not a change-over. Creating a regulatory structure to
transform the private insurance market would be more difficult. But it is
highly unlikely to make things worse for the first three years, simply
because the status quo is so egregiously bad. What could the consequence of
reform be? That some people slip through the cracks and don't get insured?
That insurers overcharge some people? Get away with risk-rating? Get away
with cherry picking? Those wouldn't exactly be changes.
Where Professor Normand's concerns apply most clearly is delivery reform.
Delivery is a lot more complicated than finance. It involves many more
activities. They are much harder for outsiders to observe and so to manage
(for example, it's easy to monitor what is charged for a service; much
harder to monitor the course of care). It is much harder to decide what
activities are appropriate (As an operating matter even though economists
won't agree in theory, it's easy to decide whether a fee is appropriate: you
set the fee and if they charge more that's inappropriate). The activities
interrelate in much more complicated ways. They are entrenched in
organizational structures in much more complicated ways. And, by the way,
we don't have good data about better ways to deliver care, while we have
compelling evidence about how financing can be done better than it is done
in the United States. For all these reasons, if reform means delivery
reform, Professor Normand could be right. Increments could be the way to
go. But reform of insurance, and even some cost controls (e.g. reasonable
fee restraints) are much easier and less complicated.
Cheers,
Joe White
-----Original Message-----
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On
Behalf Of Charles Normand
Sent: Wednesday, January 07, 2009 4:34 AM
To: [log in to unmask]
Subject: Re: Reform
Adam
I am not sure either what major reform is meant in this context, but my fear
is always that the effect of major reform is to make so many changes so fast
that the whole system takes years to recover. The three year rule is that
it takes at least this long for the system to be no worse than it was before
the changes began. In some cases this makes things so much worse that a need
is perceived for another major reform. If the new team has an ounce of
sense between them they will opt for a Norwegian style of problem solving
rather than system reform - the main difference is that this is based on a
clear understanding of the usefulness of each element of change and almost
no fanfare.
Charles Normand
Edward Kennedy Professor of Health Policy & Management
University of Dublin
Trinity College
3-4 Foster Place
Dublin 2
+353 1 896 3075
-----Original Message-----
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On
Behalf Of Adam Oliver
Sent: 22 December 2008 19:09
To: [log in to unmask]
Subject: Reform
Fyi, although can someone tell me what 'major reform' is? I have no idea -
good job no-one rings me to ask these types of questions. I suspect for most
people it means "I want cheaper health care coverage for me, now", or "I
want the Government to do obviously good things so long as I don't have to
pay for it.". But perhaps I'm being too cynical.
OBAMA: Majority Supports Major Reforms to Health Care System
A majority of U.S. adults believe that President-elect Barack Obama should
make major reforms to the health care system, according to a recent
Washington Post-ABC News Poll, the Post
<https://exchange.lse.ac.uk/exchweb/bin/redir.asp?URL=http://www.washingtonp
ost.com/wp-dyn/content/article/2008/12/20/AR2008122001498.html> reports
(Cohen/Agiesta, Washington Post, 12/21). The poll, conducted by telephone
between Dec. 11 and Dec. 14, included responses from a random sample of
1,003 adults. The poll has a margin of error of plus or minus three
percentage points. Seventy-seven percent of adults believe that Obama should
make major reforms to the health care system, compared with 20% who believe
that he should not, the poll found. According to the poll, among adults who
believe that Obama should make major reforms to the health care system, 51%
believe that he should seek to make such changes immediately after he takes
office, and 26% believe that he should wait until later in his presidency.
Sixty-eight percent of adults believe that Obama will have the ability to
make major reforms to the health care system, compared with 28% who believe
that he will not have the ability, the poll found. Almost three-fourths of
adults believe that Obama should increase federal funds for health insurance
for children, compared with 23% who believe that he should not, according to
the poll. Among adults who believe that Obama should increase federal funds
for health insurance for children, half believe that he should address the
issue immediately, compared with 24% who believe that he should wait,
according to the poll. In addition, 52% percent of adults believe that Obama
should increase federal funds for embryonic stem cell research, compared
with 42% who believe that he should not, the poll found (Washington Post
graphic
<https://exchange.lse.ac.uk/exchweb/bin/redir.asp?URL=http://www.washingtonp
ost.com/wp-dyn/content/story/2008/12/21/ST2008122100258.html> , 12/21).
Please access the attached hyperlink for an important electronic
communications disclaimer:
http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
Please access the attached hyperlink for an important electronic communications disclaimer: http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
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