Obama’s Bold New Economic Ideas and Health Care

With all the Obama hype, we remained starved for information on what Obama would actually do as President. With this vacuum of information, I’m forced to review articles such as this from Bloomberg which reviews some of the ideas of his economic advisers even though it is unclear how much these really represent Obama’s beliefs. I’m hoping that this article doesn’t fully represent Obama’s thinking on health care.

Pay for Performance

Under a pay-for-performance system devised by Cutler, doctors would be reimbursed not for the services they provide but for the improvements they make to patients’ health. Patients would be encouraged to take better care of themselves through preventive care and comparison shopping for medical cost savings.

“It can help us get past the ideological battles,” said Mark McClellan, who served as Medicare and Medicaid Services administrator and commissioner of the Food and Drug Administration under Bush.

The plan isn’t without problems. Henry Aaron, a health-care expert at the Brookings Institution in Washington, questioned how widely it could be turned into practice, given the difficulties involved in measuring the worth of many procedures.

Costly Software

It’s also costly. Cutler has suggested the government spend anywhere from $115 billion to $156 billion on information- technology equipment and software for the medical industry.

Adding an element of pay for performance might be of value, but only to supplement current payment. It concerns me when this article (which possibly does not accurately represent Obama’s views) states this as an alternative to paying  “for the services they provide.” I sure hope they don’t think that payment based upon performance could replace payment for services provided. As the article notes, it is difficult to measure the worth of many procedures. It is also difficult to evaluate how well each physician is performing. A couple weeks ago I received one report, which conceivably might be used to pay for performance in the future. The report totally left out the data on my own patients, and instead extracted data from the hospital on patients I read EKG’s on but otherwise did not treat. The EKG population had much poorer numbers than the patients in my own practice, and needless to say I have a meeting scheduled to complain about this methodology.

At present the software used is both expensive and inaccurate. While this is a technical issue which might be fixed, there are many difficulties in determining payment based upon performance. When I get a new diabetic patient, they are typically out of control, and I wouldn’t mind receiving extra payment for the effort it takes to get their sugars under tight control. In this case, payment for performance would be fairly clear. However, it is inevitable, regardless of how well I care for these patients, that sooner or later they will develop serious problems as they age. When they are sicker, and more difficult to treat, would I receive less pay because having patients with more complications would make it appear that my performance is not as good? Would an Oncologist have difficulty receiving payment because their performance does not appear very good when they have patients whose tumors metastasize? How do you measure performance, as opposed to simply paying for the service, when a patient runs in with the common cold?

I also have concerns about relying on patients using comparison shopping for cost savings. Patients are in a poor position to evaluate the effects of cost. It costs more for me to achieve tight control of diabetic patients as compared to other physicians who might only see a diabetic patient every few months leaving thier sugars poorly controlled. In the short run, such care is less expensive, but there are many benefits to a more expensive regimen which achieves tight control and reduces the risk of heart attacks, strokes, and renal failure.

Payment for medical care based upon fee for service has its problems, but so far every attempt to tinker with the system, from HMO’s to Health Savings Accounts, has resulted in far worse problems. While this article gives the impression that Obama wants to get away with the status quo and promote exciting new ideas, sometimes simply improving upon old ideas that work is the best course of action. While to be conservative might  mean to oppose change, to be liberal does not mean change simply for the sake of change.

Rudy Giuliani: The Abortion, OxyContin, and Death Tax Fantasy Candidate

Rudy Giuliani is finally figuring out that you can’t be both “pro-choice” and “pro-life” at the same time, and has decided to simply admit he supports abortion rights.This will harm him with much of the GOP base, but it might be better than looking dishonest in trying to play it both ways. At least this might give Republicans something of substance to debate as opposed to a contest over who loves Ronald Reagan the most.

It might be possible to survive being a pro-choice candidate, but also being the pro-OxyContin candidate might not help, beyond increasing the chances at receiving endorsements from Oxy-Contin addicts such as Ruch Limbaugh. Giuliani, who has already had problems with his firm’s clients, now turns out to have worked for Purdue Frederick. That’s the company which sent reps into my office, and the offices of any physician who would let them in, claiming that OxyContin was preferable to short acting narcotics such as Vicodin as there is less potential for addiction. Apparently Rush Limbaugh’s doctor believed that line, as did many other doctors, resulting in an epidemic of addiction to the drug.

It gets worse for Rudy. If all he did was help a company present their side of the story, this might be forgiven. However, it also appears that Rudy tried to bribe the FDA:

According to the book “Painkiller,” by New York Times reporter Barry Meier, both Giuliani and his then-partner Bernard Kerik “were in direct contact with Asa Hutchinson, the administrator of DEA.”

Hutchinson told the Blotter on ABCNews.com today that Giuliani asked for a meeting, “and we gave him a meeting.” Hutchinson says he was aware the company was under investigation at the time, and “any time a company is under investigation I like to give them a chance to make their case.”

Kerik told New York Magazine at the time that Giuliani had raised $15,000 in donations for a “traveling museum operated by the DEA.”

Some officials told ABC News there were questions inside the agency of whether the donations were an attempt to influence the DEA.

Meier wrote that “with Giuliani now in the mix, the pace of DEA’s investigation into Purdue’s OxyContin plant in New Jersey slowed as Hutchinson repeatedly summoned division officials to his office to explain themselves and their reasons for continuing the inquiry.”

While Rudy tried to defend claims that OxyContin is safe, he has also been trying to prove a conservative fantasy. Republicans argue for elimination of inheritance taxes, while trying to hide fact that it is to benefit the ultra-wealthy, by claiming their goal is to protect small family farms which are torn apart by the “death tax.” Finding the farmers who are affected in this manner has been as elusive as Bigfoot, the Loch Ness Monster, and Richard Nixon’s secret plan to end the Vietnam War. Rudy’s campaign staff thought they found this elusive farm family and requested that they host a rally for Giuliani. They subsequently found that the family wouldn’t be affected by the inheritance tax, and dumped them:

On Tuesday Deb received a call from Giuliani’s Des Moines office and was asked to call New York.

“They wanted to know our assets,” she revealed, and added that she and Jerry have a modest 80 acre farm and raise cattle.

Later she received a call from Tony Delgado at the Des Monies location.

“Tony said, ‘I’m sorry, you aren’t worth a million dollars and he is campaigning on the Death Tax right now.’ then he said they weren’t going to be able to come,” Deb continued.

The Death Tax is a federal version of the Iowa Inheritance Tax.

The VonSpreckens then called Delgado back and told him how upset they were that the event had been cancelled, how much work they had done and that they had been expecting 75-100 people at their farm.

“I invited him into my home,” Deb said of Giuliani, fighting back tears.

It wasn’t a total loss for this family. The campaign offered to have Rudy pose for a picture with them, but they didn’t accept the offer:

She said she then got a call from New York later the same day asking her to introduce Giuliani at a rally in Cedar Rapids, also scheduled for May 4. They offered her one-on-one time with Giuliani and to have her photo taken with him.

“My feeling is that they’re trying to cover their butts,” said Jerry.

Maybe they are holding out for Rudy to pose with them in drag, which would make for a much more amusing picture.

Bush Administration Covered Up E-Mails Incriminating Rove in US Attorney Scandal

If there’s a scandal in Washington, you can count on Karl Rove being involved. He somehow managed to escape indictment in the Valerie Plame case. The White House tried to cover up his involvement in the politically-motivated firing of the US attorneys, but Murray Waa of The National Journal has exposed this:

The Bush administration has withheld a series of e-mails from Congress showing that senior White House and Justice Department officials worked together to conceal the role of Karl Rove in installing Timothy Griffin, a protégé of Rove’s, as U.S. attorney for the Eastern District of Arkansas.

The withheld records show that D. Kyle Sampson, who was then-chief of staff to Attorney General Alberto Gonzales, consulted with White House officials in drafting two letters to Congress that appear to have misrepresented the circumstances of Griffin’s appointment as U.S. attorney and of Rove’s role in supporting Griffin.

In one of the letters that Sampson drafted, dated February 23, 2007, the Justice Department told four Senate Democrats it was not aware of any role played by senior White House adviser Rove in attempting to name Griffin to the U.S. attorney post. A month later, the Justice Department apologized in writing to the Senate Democrats for the earlier letter, saying it had been inaccurate in denying that Rove had played a role.

Alberto Gonzales has been accused of inappropriately withholding the email:

Several of the e-mails that the Bush administration is withholding from Congress, as well as papers from the White House counsel’s office describing other withheld documents, were made available to National Journal by a senior executive branch official, who said that the administration has inappropriately kept many of them from Congress.

The senior official said that Gonzales, in preparing for testimony before Congress, has personally reviewed the withheld records and has a responsibility to make public any information he has about efforts by his former chief of staff, other department aides, and White House officials to conceal Rove’s role.

“If [Gonzales] didn’t know everything that was going on when it went down, that is one thing,” this official said. “But he knows and understands chapter and verse. If there was an effort within Justice and the White House to mislead Congress, it is his duty to disclose that to Congress. As the country’s chief law enforcement official, he has a higher duty to disclose than to protect himself or the administration.”

Howard Fineman on 2008 As Year of the Third Force

Howard Fineman sees 2008 as possibly being the year of the “Third Force.” With the possibility that the major party candidates will be determined by February, there is plenty of time for buyer’s remorse, and for people to look at any third party candidates who might decide to run in early 2008.

If I were a GOP strategist – or a Democratic one – I would be worried by Arnold’s body language. He and other major independent actors on the political scene – New York Mayor Michael Bloomberg and former Vice President Al Gore, chief among them – comprise a Third Force that could upset two-party politics as we know it in the 2008 presidential race.

Indeed, although there is no formal alliance, Schwarzenegger, Bloomberg and Gore have formed a mutual admiration society that has huge potential implications for 2008. They have come to share similar visions on the urgency of the global warming and health care crises, and a similar impatience with politics as usual.

One problem with many articles on the possibility of a third party candidate is that they predict a desire for another choice, but fail to take into account the different views amont those seeking alternatives. Desiring a third choice does not mean there is agreement what the alternative choice should be. The media looks at third parties from a horse race perspective, ignoring the fact that people choose third parties based upon what they support.

Feinman suggests that Gore might support a third party bid by someone else as opposed to running himself. Besides Gore, Schwarzenegger, and Bloomberg, Feinman suggests others could be involved:

Other key players who could be part of this Third Force include Sen. Joe Lieberman of Connecticut, a man without a comfortable home in his own party any more. And Sen. Chuck Hagel of Nebraska, an anti-war activist who was on the verge of announcing for the GOP nomination, but changed his mind at the last minute.

If you hear that Lieberman and Hagel are getting together to hash out a common position on Iraq – not an easy thing to achieve, to be sure – then you know something is up.

I don’t see that this group would make for a third party which would excite very many people. Gore’s views on the war are so different from those of Lieberman. While Hagel might differ from Repubicans on the war, he is conservative on other issues. If Gore has any interest, he’d be better off running as a Democrat than running with those whose views differ so much from his. If he is looking to back a third party bid, I would not expect him to back one involving Lieberman or Hagel.