Biopsy of Economy

The economy continues to dominate our thinking. Really dominate- how truly sad when the focus should be on advancing medicine and technology, not on whether your biotech start-up will make it through the end of 2009. I see a pick up in VC financing and even a rare IPO- perhaps things are beginning to turn. We've been bouncing along the boulder field of the cliff the economy fell off Sept 2008 for long enough. But here's the rub- how are we going to have a sustained recovery when the focus is on reforming health care instead of helping business? Obviously reforming health care is center stage for political reasons. It is highly likely the Democrats will loose dozens of seats in the House and several in the Senate in the mid-term election. A turnover in the House is not out of the question; the number of seats that are in contention in the Senate makes a turn-over there unlikely in 2010. The unemployment and Under-employment rate will only slowly improve by the fall of 2010 and the Dow will likely be over 10,000- but the number of middle-class voters still affected by this economy will be significant. Hence the urgency to institute a comprehensive health care reform while Obama still has super-majorities in the House and Senate and can push through a public option. Or a public mandate- who are we really kidding here? As a physician, I understand the attraction of a single payer system. Frankly the multitude of private insurances was a real nuisance from a billing perspective. But competition is always the best way.
Regarding the economy- why not institute an investment tax credit as has been done in the past? Accelerated depreciation, expensing of otherwise long term capital assets and the ability to fully write-off purchases for your business this year. Why does the present administration seem to believe that it can government-spend its way out of this deep recession when the only way out is to grow the private economy? And that means improving the business climate, not raising taxes and expecting business to somehow pick up the slack. It means letting go- not taking over more industries as has already been over done.
By early 2011 the Obama agenda will have run it's coarse. Let's hope it will somehow help sustain the life sciences, not stand on top of them.

Healtcare Reform- Now or Never?

Indeed it does seem that change is imminent.
In order to have something in place before the next election cycle we may see a 3rd government run program slipped inbetween Medicaid and Medicare. This is the administration's opportunity to introduce a program that will eventually displace most private insurance for healthcare. Initially people will have a choice- but eventually few employers will want to pay for a more expensive, although responsive, private insurance plan. Fundamentally a 3rd program is the only way to actually dictate healthcare costs from the government's perspective. One can incentivize, cajole, extract promises, seek greater efficiency, but in the end if it is in the hands of private companies to set fees and approve procedures, the government does not control those costs. Obama also wants a legacy to his presidency he can point to and say 'I did this'. Just expanding private coverage does not provide that capstone. Look at the Massachusetts model: no one really got 'credit' for the program, it's still having problems, it's working but expensive. A 3rd government program can be implemented immediately,likely through CMS, and will result in additional hires to address unemployment- another one of Obama's associated promises. Private insurance cannot be relied upon to hire immediately. All the effort getting input from the stakeholders may ultimately just be a screen for implementing such a 3rd program. Obama has the votes in congress, he has Ted Kennedy to rally the country- I'm sure his team sees this as 'now or never'. We will see..

Health Insurance Turned Upside Down

I believe we need to move away from a health model that rewards procedures and disease and towards a model that promotes wellness. In order to accomplish an abstract, long term goal involving multiple stakeholders it is best to allow them to solve the problem themselves. But when each stakeholder is fighting to maintain status quo and surrender as little as possible it creates stagnation. Rather than regulate heavily- which is where the current administration is heading- my suggestion is to adjust the playing field to incentivize the stakeholders. Rather than a level playing field with a tug-of-war pulling on 'healthcare' , tilt the field so that all the players end up on the same side and are pulling in the same direction- not against one another. An initial step would be to adjust the insurance company's relationships with one another so that their interests align with making people healthier.

In order to promote wellness and get the health insurance industry focused on keeping people 'well' as opposed to treating illness after it occurs, then something fundamental needs to be done. Why should an insurance company receive premiums for months or years and rarely pay a claim because of 'luck' ? And is it not the 'fear' of being stuck with an enormous bill for a patient that drives the process of 'underwriting'? Underwriting is expensive, labor intensive, slow and wasteful.

I suggest that the insurance company which has been covering the person for the longer time should pay a portion of the claims that occurs after the person changes insurances. That would make the insurance company that received the most monthly premiums contribute more fairly when an illness occurs. If the first insurance company was responsible for a portion of any claim for a period of time after their coverage ended - let's say one or two years- then they would have a stronger interest in keeping that patient healthy in the long run. During their own coverage period they would make more of an effort to do so. And the second insurance company would know that even if there were underwriting concerns ( more than average # of claims or the person having a certain disease) that any new claims would be proportionately paid by the first insurance company. This would mitigate the new insurance company's risk. Perhaps the first insurance company would pay 90% first three months and decreasing 10% each month there after so at the end of a year it would be totally on the new health insurance company.

Without many fundamental changes to healthcare in the US the entire system will become unaffordable. The population is aging, technology is increasing, drugs are more expensive. This type of 'insurance sharing model' is only one change that could lead to new thinking and progress toward wellness.

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