Showing posts with label health care delivery. Show all posts
Showing posts with label health care delivery. Show all posts

9/03/2012

A history of public health (MD monographs on medical history) Review

A history of public health (MD monographs on medical history)
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George Rosen's chronology of the development of public health in A History of Public Health is a MUST read for not only public health professionals, but clinicians, health administrators and any one even remotely interested in how mankind has responded to the threat of infectious disease. His very detailed presentation of the facts takes the reader back to the study of Hippocrates as he wrote the epic writings of EPIDEMICS I, EPIDEMICS II, and AIRS, WATERS AND PLACES. By placing the reader within the historical context of the period he is reviewing, the reader gains a better understanding and appreciation for the actions (or in some cases, IN-actions) of key individuals and governments. Mr. Rosen very eloquently describes how this area of PUBLIC HEALTH is actually a multi-disciplinary science, which consists of medicine, social science and others (such as engineering, public administration and economics). Rosen's unique style of presenting the facts is very direct, concise and full of detail. His thorough examination of the elements that contributed to what we know as PUBLIC HEALTH today, is thorough and informative. If there must be one weakness of the book, it is that this is a complete chronology of public health as viewed through a WESTERN, positivist view. Very little is mentioned on Eastern, traditionalist medicine in any form or fashion. However, one of the most comprehensive books on this subject ever written and one that is a MUST for all involved in the public health field.

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8/28/2012

Partners in Health: How Physicians and Hospitals can be Accountable Together (J-B Public Health/Health Services Text) Review

Partners in Health: How Physicians and Hospitals can be Accountable Together (J-B Public Health/Health Services Text)
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A review of the need for collaboration between hospitals and doctors to improve quality and safety while increasing cost. Demonstrates how the reimbursement and legal environment create skewed and inappropriate incentives, but leaves out nursing and addresses outpatient medicine only superficially. As far as it goes, it is timely and practical. Its insights are useful for physicians in particular, especially physician managers. It does give an impression of some of the successful institutions, but the discussions are dry and technical but leave one wishing for more depth and detail. Storytelling would have strengthened the arguments.

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7/12/2012

Managerial Epidemiology for Health Care Organizations (Public Health/Epidemiology and Biostatistics) Review

Managerial Epidemiology for Health Care Organizations (Public Health/Epidemiology and Biostatistics)
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My students find the book easy to read and understand but are frustrated by the multiple errors and missing data in Chapter five data examples and end of chapter questions.

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Managerial Epidemiology for Health Care Organizations provides readers with a thorough and comprehensive understanding of the application of epidemiological principles to the delivery of health care services and management of health care organizations. As health administration becomes evidence- and population-based, it becomes critical to understand the impact of disease on populations of people in a service area. This book also addresses the need of health organizations' to demonstrate emergency preparedness and respond to bioterrorism threats. A follow-up to the standard text in the field, this book introduces core epidemiology principles and clearly illustrates their essential applications in planning, evaluating, and managing health care for populations. This book demonstrates how health care executives can incorporate the practice of epidemiology into their various management functions and is rich with current examples, concepts, and case studies that reinforce the essential theories, methods, and applications of managerial epidemiology.

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5/04/2012

Tough Decisions: Cases in Medical Ethics Review

Tough Decisions: Cases in Medical Ethics
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Tough Decisions is an outstanding book made even better in this long awaited second edition.
Unlike most collections of case studies, this volume does not simply present a variety of vignettes to be analyzed and evaluated. Instead, the reader is required to actually make tough decisions and then follow up on the consequences. Decisions often lead to further decisions and then still further decisions. Different readers will thus follow different paths through the text. The situations themselves are realistically described and include multidimensional characters and well-written dialogue.
The cases will provide a rich basis for discussion if this is used as a classroom text, but this is also an engaging and readable book for anyone interested in the tough decisions faced in healthcare every day.

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The Johns Hopkins Medical Institutions, Baltimore, MD. Places medical and non-medical readers in realistic situations where they experience difficulties of making tough medical decisions. Cases are composites of actual cases the authors have seen or managed. Concluding chapters discuss major theories of medical ethics. Hardcover, softcover also available. DNLM: Ethics, Medical.

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3/21/2012

Who Killed the Queen?: The Story of a Community Hospital and How to Fix Public Health Care (McGill-Queen's/Associated Medical Services Studies in History of Medicine, Health, & Society (Hardc) Review

Who Killed the Queen: The Story of a Community Hospital and How to Fix Public Health Care (McGill-Queen's/Associated Medical Services Studies in History of Medicine, Health, and Society (Hardc)
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This is a book that every Canadian should read. It provides new insights into the health care situation and how government is responding. Something every baby boomer needs to know!

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"Who Killed the Queen?" is the first sustained investigation ever attempted into the mass closures of hospitals and hospital beds in Canada during the mid-1990s, showing the effects that the loss of 20 per cent of beds has had on health care across the country. It provides very strong evidence as to who and what was responsible for bed losses that are unparalleled in the history of any other industrialized country. It also provides well-supported templates for saving and strengthening the entire Canadian health care system despite this attack. "Who Killed the Queen?" makes its arguments by means of a particularly dramatic and telling case-study. It investigates the life and death of the exemplary, 100 year-old Canadian community hospital, the Queen Elizabeth of Montreal, site of many national and international medical firsts, which nonetheless became a typical victim of the mass closures in the mid-1990s.

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2/08/2012

Who Killed Health Care?: America's $2 Trillion Medical Problem - and the Consumer-Driven Cure Review

Who Killed Health Care: America's $2 Trillion Medical Problem - and the Consumer-Driven Cure
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According to information released by the Centers for Disease Control and Prevention on June 24, 2007, about 43.6 million people in the United States, or 14.8 percent of the population, had no health insurance in 2006. The finding, based on a survey of 100,000 people, is lower than previous federal estimates of 46 million. The estimate is based on those who did not have insurance at the time of the interview. About 54.5 million people in the country, or 18.6 percent of the population, had no insurance for at least part of 2006. Whatever the exact numbers, there is obviously a very serious problem with health care provision in the U.S. In fact, dozens.
In her previously published book, Consumer-Driven Health Care, Regina Herzlinger explains that consumer-driven health care is "fundamentally about empowering health care consumers - all of us - with control, choice, and information." Such control will "reward innovative insurers and providers for creating the higher-quality, lower-cost services we want and deserve." What would be the role of government? She asserts that "government will protect us with financial assistance and oversight, not micromanagement." The material in this substantial volume is organized within five Parts. Herzlinger wrote the first, "Why We Need Consumer-Driven Health Care," then edited the contributions by others that comprise Parts Two-Five. She also wrote Chapter 78, "A Health Care SEC: The Truth, the Whole Truth, and Nothing But the Truth." For most of us who are not health care professionals, this volume provides about as much information as we could possibly need, much less process. I especially appreciate the fact that Herzlinger and her associate contributors make a conscious effort to avoid jargon, vague theories, oblique hypotheses, etc. They obviously believe that major health care issues are too important to be packaged as flimflam, swamp gas, and flapdoodle. Hence their rigorous focus on explaining (from a variety of perspectives) why consumer-driven health care is needed, and, how to establish and then sustain it.
In this volume, Herzlinger focuses her attention on what she describes as "America's $2 trillion medical problem" (about the current size of the economy in China) and explains why consumer-driven initiatives offer a "cure." More specifically, she exposes "the iron triangle" of third parties (i.e. Congress, health insurers, and hospital administrators) that have opposed consumer-driven health care and thereby subordinated, if not totally ignored the welfare of patients as well as their personal physicians (if they have any). These third-parties are the ones who have "killed" health care for tens of millions of uninsured or under-insured people who, Herzlinger insists, have been deprived of power, information, and choice. She is a passionate and well-informed advocate of nothing less than major, extensive, and comprehensive health care reform.
"Four armies are battling to gain control [of health care]: the health insurers, hospitals, government, and doctors. Yet you and I, the people who use the health care system and who pay for all of it, are not even combatants. And the doctors, the group whose interests are most closely aligned with our welfare, are losing the war." What to do? Herzlinger's convincing, indeed compelling and eloquent response to that question is best revealed within her narrative. However, for present purposes, here are a few key recommendations:
1. Consumers must take back the money their employers and government now take from their salaries and taxes to buy health insurance on their behalf so they can make their own purchase decisions.
2. Physicians must be empowered to design better, cheaper health care.
3. The destitute must be subsidized by "the rest of us" so that can purchase health insurance "like everybody else."
4. The federal government must help subsidize the destitute, provide transparency (a key factor for all consumers, actually), and prosecute fraud and abuse.
In Parts 1 and 2, Herzlinger explains who is killing health care and how they are doing it. She identifies both "villains" and "heroes." In Part 3, she "lays out the principles as well as the specifics of consumer-driven health care - what it is, why it will work, what it offers to all of us - and analyzes the lessons from consumer-driven systems like Switzerland's." Then in Part 4, Herzlinger provides a step-by-step plan "of the carrots, the sticks, and the laws that will make this consumer-driven system happen."
Many of those who read this brief commentary of mine may ask "So what?" Perhaps they are satisfied with their current health care coverage. It is possible but unlikely that many (if any) of those who are destitute - who have no health care insurance coverage whatsoever - check out reviews of books, much less purchase and then read them. The fact is, those who are satisfied with their current health insurance coverage are probably paying too much for their share of its total cost. And a separate but related fact is that their employer is also paying too much for its share of the health care coverage that it is required by law to provide to its full-time employees.
Herzlinger has a crystal clear vision of what health care should be and do but she is also a pragmatist. She fully understands that unless and until, in a democratic capitalistic society such as the U.S., incentives and rewards are changed, there can be no reform of the current health care system. It is wholly understandable that "the iron triangle" of third parties (i.e. Congress, health insurers, and hospital administrators) oppose consumer-driven heath care, especially given the fact that about $2 trillion is involved and would be at risk if (huge "if") patients were entrusted with the power to decide how that money would be spent.
My concerns, frankly, are these: How many people will read this review and others, then purchase and read Herzlinger's book? Then what (if anything) will they do? All change initiatives inevitably encounter what James O'Toole has aptly characterized as "the ideology of comfort and the tyranny of custom." The power and resources of those who defend the status quo of "the iron triangle" must not be underestimated. All by herself, Regina Herzlinger cannot reform the current health care system. Who will join her in doing everything humanly possible to make consumer-driven health care a reality? If you think you wish to enlist in this "war" and help win it, I suggest you read and then re-read Pages 254-258, then contact your representatives in the House and Senate and insist - not request - that they read this book or at least have a staff member do so. Will that do any good? I have no idea. But I do know that by remaining silent and compliant, we empower "the iron triangle" rather than ourselves.

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1/23/2012

The Treatment Trap: How the Overuse of Medical Care Is Wrecking Your Health and What You Can Do to Prevent It Review

The Treatment Trap: How the Overuse of Medical Care Is Wrecking Your Health and What You Can Do to Prevent It
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I am a physician who specializes in geriatrics and palliative medicine. I work in a busy tertiary care teaching hospital where some of the world's best specialists practice. Miracles of cure and life prolongation occur every day- liver and heart transplants, for example. But much more common is patients caught up in a system- marketplace is a more accurate description- of interventions- interventions that our specialists spent years in training learning how to do, and that they strongly believe are beneficial to their patients; interventions that are generously compensated by insurers; interventions that are not coordinated with all the other interventions provided by all the other specialists; interventions that have not been studied in the patient groups who are being subjected to them; interventions with significant side effects and consequences for many of the patients receiving them. Yet the unexamined belief- almost an article of faith among doctors and their patients- is that it is always better to do something than nothing in health care. Paradoxically, the truth is often just the opposite. Much of the time it is better to follow a different set of assumptions- when uncertain "don't just do something-- stand there." The Treatment Trap brings this situation to life through stories of real people- real people and their well-intended and very well-trained doctors- all doing what they were taught was right. For patients- See a doctor- do what they recommend. For doctors- See a patient, do something to show the patient you care, to make your living, to keep your practice above water. Interestingly, in support of the thesis of this book- that overtreatment is hurting and killing us- an increasing body of research shows that patients who get palliative care and hospice actually live LONGER than control patients receiving usual care- the usual care that Gibson and Singh reveal by listening to patients and families who have been there.


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1/16/2012

Doctors' Marriages: A Look at the Problems and Their Solutions Review

Doctors' Marriages: A Look at the Problems and Their Solutions
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My husband and I are both physicians; I work part time to take care of our 1 year old. He is still building his practice; so you can imagine our lives are a bit hectic. The book gave us a better perspective on what each other is going through in terms of stressors. Highly recommended reading for all professionals in a committed relationship whether or not you have any issues with the relationship.


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12/01/2011

Pursuing Excellence in Healthcare: Preserving America's Academic Medical Centers Review

Pursuing Excellence in Healthcare: Preserving America's Academic Medical Centers
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A well written, comprehensive and logical overview of the issues that face academic medical centers. If you work with or at a AMC, you need to read this book. If you are interested in the special role played by AMCs and want to learn how to improve how they work, this is a must read.

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For over 100 years, academic medical centers (AMCs) have been the bastion of medicine; providing outstanding care, incubating the discoveries that have improved health care around the world, and training the next generation of doctors and scientists. Delineating the issues that have lead to the current crisis in AMCs, this book provides a radically different model for achieving success. The model presents four intersecting spheres of action, each of which is necessary but none of which can stand alone. The book presents an in depth analysis of the issues and challenges facing AMCs and offers recommendations that allow them to achieve their core mission - the delivery of outstanding patient care.

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10/05/2011

Exploring Social Insurance: Can a Dose of Europe Cure Canadian Health Care Finance? (School of Policy Studies) Review

Exploring Social Insurance: Can a Dose of Europe Cure Canadian Health Care Finance (School of Policy Studies)
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I picked up this book as an after thought because right of the bat it seems dense and wordy (which it is). I was thinking I'd skim through the chapters to catch the gist of what was written - however I was pleasantly surprised at the quality of writing (this book has been well edited). This is a great collection of individual work created by various academics/contributors. The basic premise of the book is an investigation into the question of : "Can social insurance be made a part of the Canadian health care financing framework ? ".
The book has arguments for and against this question. Reading well researched and clearly expressed opinions from both sides of the debate was a refreshing change from the usual text of this nature which only talks about one point of view (the authors) ! The book does not give a definite answer , rather I felt it was allowing the reader to create his own opinion (at least I was inspired look at other debates in the US and UK systems).
Great book and highly recommended.

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Sustainability, quality, and accessibility are vital questions in health care. All Canadian governments, concerned about the growing share of the public budget absorbed by health care, are questioning the sustainability of the present system. How can we maintain and improve access to health care services of appropriate quality while ensuring sustainability? If there is one consolation to Canadian governments as they wrestle with the future of Medicare, it is that sustainability concerns are not unique to Canada but affect all countries, regardless of the level of private financing in a system. Some countries, however - particularly social insurance countries in Northern Europe such as Germany and France - manage to achieve universal access without wrestling with waiting lists, while providing a wide range of services. This book examines whether the grail of sustainability, quality, and accessibility could be better achieved through a marriage of the traditional Canadian model with elements of a European system.

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10/04/2011

The Logic of Health Care Reform: Why and How the President's Plan Will Work; Revised and Expanded Edition (Whittle) Review

The Logic of Health Care Reform: Why and How the President's Plan Will Work; Revised and Expanded Edition (Whittle)
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The Logic of Health Care Reform is like countless other books, which is what makes it so depressing to read. Its subtitle -- Why and How the President's Plan Will Work -- refers not to the current president, but to Bill Clinton. It came out in 1992, came out with revisions in 1994, is available for a penny used on Amazon, and stands as a very sad reminder of the hopes with which people greeted Clinton's plan.
What is hopeful about The Logic of Health Care Reform is that Paul Starr laid the groundwork for a new progressive media. He cofounded The American Prospect in 1990; it's a breeding ground for some of the brightest lights in progressive media, among them Ezra Klein, Jon Cohn, and Josh Marshall. The hope, looking backwards with some trepidation, is that Clinton's failure arms us for success now. Of course we can't know. If health reform succeeds under Obama, a long cast of protagonists will be adorned with floral wreaths and paraded before the townspeople; if it fails, it will be painted as inevitable, and those same protagonists will be painted as pusillanimous and ultimately valueless. Where I stand right now, it could go either way.
In any case, Starr's book came out in the thick of the debate over the Clinton plan, and the blurb describes him as "one of the plan's architects." It contains the same litany that we've read countless times before: the insured population shrinking precipitously; small businesses as victims because of their limited bargaining power; health care costs growing much faster than the overall rate of inflation; health-insurance costs rising while wages remain stagnant, and indeed rising health insurance probably accounting for immobile wages. Firms have a finite bucket of money, after all.
I've come to realize that The American Prospect and its derivatives tend to be wonkish. They focus on the economics of health reform, instead of the moral urgency that impels us, as a just society, to help out those who are less fortunate than we are. A glorious exception here is Jon Cohn's book Sick. You should probably read Starr's book and Cohn's back to back; that would give you a picture of why health reform is not only the morally right thing to do, but makes economic sense.
The centerpiece of the Clinton plan was "managed competition." First, there's competition: some organization, called the "sponsor" -- typically an employer -- offers a menu of competing insurers to its members. Members choose their insurer once per year, when they're not expected to be sick and can choose with a sound mind.
The second piece corresponds to the word "managed". Unmanaged insurers could undercut their competitors by offering plans that cover less, or by only insuring healthy people. Regulation, then, would require that insurers compete on a standard plan, and must offer it to everyone regardless of health. The plans would be required to be "community-rated," which is to say that they'd offer the same rates to all their subscribers. This would mean that plans which ensure an older or sicker customer base would tend to have higher premiums. Hence the sponsor would reimburse plans more if they have a sicker customer base, less if they have a healthier base.
Starr does a good job laying out the various moving parts in health-insurance reform. One of these days I'll sit down and map out exactly how those moving parts interact. If we want universality, for instance, insurance must be required; otherwise adverse selection kicks in, and the healthiest patients drop out of insurance, leading to a downward spiral where only the sickest are insured. Then it becomes a question of who should be required to pay (e.g., employers, employees, the government, ...). Some people will not be able to afford coverage at any price, though; these people will need financial help, which then forces us to ask how to help those people. Then there's the question of how to separate health coverage from employment status: whether you find and treat your heart disease shouldn't depend upon who your employer is. Tweaking any one of these moving parts causes adjustments in the others, but the total number of moving parts does seem rather small.
Starr's book is another tool in the armamentarium. At this point in my education, it seems deeply foolish, when it's not actively harmful, to reject a government role in regulating the health-insurance market. Doing so would almost certainly make the market function better for consumers. People have been talking a lot lately about having a health-care "conversation." By all means, let's have that conversation. The first question is: do you believe that it is even a problem that 1/6 of your fellow-Americans are uninsured? If not, there's not much to talk about. If you do think it's a problem, the onus is on you to explain why the government shouldn't require insurance of all Americans. Let's start that discussion, and let's use The Logic of Health Care Reform as a starting point.

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The Pulitzer Prize-winning author of The Social Transformation of American Medicine reveals that President Clinton's plan for health care reform will work because it was devised by taking the best ideas from a variety of proposals that reflect the full range of the political spectrum.

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10/01/2011

Best Care Anywhere: Why VA Health Care is Better Than Yours Review

Best Care Anywhere: Why VA Health Care is Better Than Yours
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Philip Longman makes the case that current U.S. healthcare is a fragmented, market driven system that lags behind much of the industrialized world in both quality and access of healthcare. According to Longman, the problem with our healthcare system is that it isn't really a system and that it doesn't reward the one thing that it should - health improvement. In fact, he offers proof that in the U.S. doctors and hospitals are rewarded for providing treatment, but not necessarily providing health to their patients. To illustrate this, he offers examples from two of the nation's premier hospitals - Beth Israel and Duke Medical Center. Both initiated programs that were so successful at improving health that they became unprofitable and were ultimately terminated.
This book is filled with understandable, but often shocking statistics. For example, every year in the United States 98,000 people die due to medical errors while in the hospital, another 90,000 die due to infections that they get while in the hospital, and 126,000 needlessly die because their doctor failed to use evidence-based protocols for just four of the most common conditions.
The solution? Longman speaks effusively about the VA healthcare system. And rightfully so. It is the only fully functioning, evidence-based healthcare system in the country. The book explores the history of the VA and speaks honestly about some of the warts that mar the VA's reputation. But the truth of the matter is that the VA has turned all of that around and is currently at the front of the healthcare revolution.
Longman's book contains sections on safety, quality improvement, the concept of lifetime healthcare, and the Kizer Revolution at the VA, which dramatically improved quality and altered forever the course of veterans' healthcare.
The section on VistA, the software program that is revolutionizing healthcare, is worth the price of the book. This open source software program is really a bundle of 20,000 programs written in open source code. Surprisingly, it is being adopted extensively around the world - but not right here at home.
Longman proposes a reform of the U.S. healthcare system that incorporates the best of VistA and many other VA best practices and innovations. If you are interested in the healthcare debate and what is possible in future U.S. healthcare, I highly recommend this book.
For those interested in learning more about the healthcare debate and want to explore other opinions, I would also recommend the following three books: A Second Opinion: Rescuing America's Health Care; Who Killed Health Care?: America's $2 Trillion Medical Problem - and the Consumer-Driven Cure; and Redefining Health Care: Creating Value-Based Competition on Results.

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The long-maligned Veterans Health Administration has become the highest-quality healthcare provider in the United States. This encouraging change not only has benefited veterans but also provides a blueprint for salvaging America's own deeply troubled healthcare system. "Best Care Anywhere" shows how a government bureaucracy, working with little notice, is setting the standard for best practices and cost reduction while the private sector is lagging in both areas. Author Phillip Longman challenges conventional wisdom by explaining exactly how market forces work to lower quality and raise prices in the healthcare sector, and how U.S. medical practices have a weak basis in science. The book, expanded from a widely praised article in the "Washington Monthly," mixes hard facts with author Philip Longmans' compelling human story of the loss of his wife to cancer. Part manifesto, part moving memoir, "Best Care Anywhere" offers new hope for addressing a major problem of contemporary society that affects all of us.

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9/27/2011

Healthy Competition: What's Holding Back Health Care and How to Free It Review

Healthy Competition: What's Holding Back Health Care and How to Free It
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I enjoyed the book and found it presented a well organized argument for why it is so critical to allow the markets and consumers to experiment with new methods of controlling health care costs and improving access. I also appreciated the author's acknowledgement that health care is a special service that is critically important in our lives. That is what makes reforming the system so challenging.
The book makes clear that market based proposals to reform health care are designed to lower the cost of care and increase coverage. These are proposals that are critical to all Americans.

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9/03/2011

Why Obama's Government Takeover of Health Care Will Be a Disaster (Encounter Broadsides) Review

Why Obama's Government Takeover of Health Care Will Be a Disaster (Encounter Broadsides)
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Excellent short book on all that's wrong with ObamaCare. Dr. Gratzer is a former Canadian psychiatrist who has had exposure to both Canadian and US health care systems. He provides evidence that many health outcomes are significantly better in the US on average. The major tenets of Obama's health care reform are provided and critiqued. The book also provides a much needed reminder of how we got into our current situation. In the 1940s, as a result of wage and price controls, employers started offering health insurance when they couldn't offer higher salaries. Then the IRS made insurance premiums paid by employers non-taxable. Gradually, most services became covered by employment based health plans, thus separating the cost of the service from the consumer. This could only lead to rising costs, leaving those without employer based coverage unable to afford care. It has been government intervention, not the free market, which has lead to many of our current problems. The book offers a useful quick summary to anyone concerned about the current health care reform.

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8/23/2011

The Healthcare Fix: Universal Insurance for All Americans Review

The Healthcare Fix: Universal Insurance for All Americans
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Book Review: The Healthcare Fix
Laurence Kotlikoff is an economics professor at Boston University. Mr. Kotlikoff thinks he's the Man with the Plan for universal healthcare in the U.S. The book he's written is a short, fast read which presents a straightforward message:
Medicare and Medicaid, because of their billing policies are bankrupting the country by feeding healthcare inflation. The fix, according to Kotlikoff is to scrap the two federal programs and replace them with universal health adjusted medical insurance vouchers. A young healthy individual would receive a small voucher say $5000 per year while an older less healthy individual would get a voucher of say $50,000 to buy a full private insurance policy.
This would incentivize private insurers to write policies for these insured as follows. If the oldser only needed $10,000 in health spending for the year the insurer profits by $40,000. OTOH if the youngster was hit with a $30,000 medical expense the insurer would take a -$25000 hit. The latter is less likely than the former. Also, the vouchers would be health history adjusted so that the older patient might get a lower voucher for having a good year.
What's attractive about Kotlikoff's fix is that the voucher system has a built in mechanism for monitoring spending, it eliminates cherry picking of patients and it's universal. However, as is the case with a short somewhat glib book Kotlikoff glosses quite a bit. He even glosses in error.
In one example he mischaracterizes Mitt Romney's role in signing a law that charges $300 per employer annually to fund health insurance for all in Massachusetts. The $300 fee was passed OVER Romney's line item veto. The main part of the bill is a punitive mandate that requires all taxpayers* acquire health insurance. Those who don't face monthly penalties enforced by Massachusetts' version of the IRS. The MA health insurance law funding comes in part from the $300 fee but mostly from shifting uncompensated healthcare funds to subsidizing premiums for poor and lower wage workers. The Massachusetts law does little to contain the soaring costs of the commonwealth's pet industry.
This kind of glossing is what troubles me about this otherwise interesting and provocative book. Kotlikoff is hardly naive about the economic and political realities facing his proposal. Libertarians don't like government programs. Healthcare professionals feel entitled to unlimited compensation. Patients want the best healthcare others' money can buy. Hospitals love their high tech profit centers. Then there are the miriad of big and small suppliers that profit from over priced products, waste and techno-churn.
America's healthcare problem is not the lack of universal healthcare. It's the lack of universal fairness in health insurance. Employer ensured workers, especially high income professionals, have their premiums paid. But they pay no taxes on this imputed income. An uninsured taxpayer showing up at the hospital had better have a bunch of high balance credit cards and be prepared for bankruptsy. Yet his taxes compensate for the lower taxes of his fortunate and better paid neighber. Kotlikoff would do away with this asymmetry and use the 'higher taxation' to help fund his scheme. One could expect Republicans to rail agaist this while Democrats knee-jerk against vouchers. He also suggests savings and thus funding could be found in reducing administrative costs in the healthcare system. Good luck on reducing hospital fat and red tape. One other loose end in Kotlikoff's plan is where do the insurer's profits go? Shareholders? High CEO pay? Into lower premiums?
Notwithstanding its holes and loose ends Kotlikoff has made a provocative case that is a must read piece of food for thought. Regardless what you think of his proposed fix, Kotlikoff is right about one thing ... Our profligate healthcare industrial complex is threatening our fiscal future.* In Massachusetts a young tax cheat can earn buy one of the special subsidized young person's
policies which doesn't require proof of income.


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