A Second Opinion (Audible Audio Edition) Arnold S Relman Stephen McLaughlin Audible Studios Books
Download As PDF : A Second Opinion (Audible Audio Edition) Arnold S Relman Stephen McLaughlin Audible Studios Books
A world-renowned physician traces the rise of the medical-industrial complex that has made a disaster of our health care system and tells us incisively what we need to do to change it.
The U.S. health care system is failing. It is run like a business, increasingly focused on generating income for insurers and providers rather than providing care for patients. It is supported by investors and private markets seeking to grow revenue and resist regulation, thus contributing to higher costs and lessened public accountability.
Meanwhile, 46 million Americans are without insurance. And health care expenditures are rising at a rate of 7 percent a year, three times the rate of inflation.
Dr. Arnold Relman is one of the most respected physicians and health care advocates in our country. This book, based on 60 years' experience in medicine, is a clarion call, not just to politicans and patients, but to the medical profession to evolve a new structure for health care, based on voluntary private contracts between individuals and not-for-profit, multi-specialty groups of physicians.
Physicians would be paid mainly by salaries and would submit no bills for their services. All health care facilities would be not-for-profit. The savings from reduced administrative overhead and the elimination of billing fraud would be enormous. Healthcare may be our greatest national problem, but the provocative, sensible arguments in this book will provide a catalyst for change.
A Second Opinion (Audible Audio Edition) Arnold S Relman Stephen McLaughlin Audible Studios Books
Arnold Relman is an insightful elder health care policy statesman. Born in 1923, he was 84 when he wrote this book. He has been engaged in formulating health care reform policies for decades. He wrote an earlier book on the subject: "The Choices for Healthcare Reform" back in 1992. He graduated from med school in 1946 nearly twenty years before Medicare and Medicaid were created in 1965. From 1977 to 1991, he was an editor of The New England Journal of Medicine (NEJM). He was a professor at Harvard Medical School, a research scientist, a clinician, a doctor, and a consultant to government.Relman's main thesis is that for profit medicine has never worked. It has caused skyrocketing health care costs, as we have by far the most expensive health care cost worldwide (at 16% of GDP). And, our quality of care does not compare well with many OECD countries (shorter lifespan, higher infant mortality rates, and highest % of population being uninsured at 15%). The profit imperative dictates that a business grows its revenues and profits. This means overcharging, overutilization of health care services, and lower quality of care.
Relman's thesis, besides being now self evident, is supported by a seminal paper written in 1963 by a Nobel prize winning Stanford economists, Kenneth Arrow. The latter stated that health care services have no price transparency and no price competition. The demand for services is generated not by the customer (the patient) but by the vendor (the doctor) who makes the purchasing decision for the customer. Half a century later, Arrow's analysis is still spot on.
Back in 1980, Relman wrote a seminal article in the NEJM about "the New Medical-Industrial Complex." Emerging investor-owned health care insurers and providers reshaped the culture of health care services away from a vocational profession and towards entrepreneurship. This commercialization caused the tremendous rise in health care costs and a commensurate deterioration in its quality.
Relman brings an abundance of historical evidence to support his thesis. In 1986, Relman participated in a study conducted by the Institute of Medicine called "For-Profit Enterprise in Health Care" that compared for-profit vs not-for-profit hospitals. They uncovered that investor owned health care facilities steadily charged a lot more and incurred much higher overhead than their non-profit counterpart. They also restricted more access to health care by readily turning down patients who could not afford the care. This study readily concluded the advent of for profit medicine would lead to rapidly rising health care costs. Relman refers to another study in 1997 that found that for profit hospitals charged 10% more than their nonprofit counterparts because their overhead was nearly 10% higher (34% vs 25% respectively). A 2002 study comparing quality of care found that mortality risk was 2% higher at for profit hospitals vs nonprofit ones. A study on dialysis centers found that the mortality rate at for profit ones was 20% higher, and the likelihood of being placed on a waiting list for transplantation was 26% lower than for nonprofit dialysis centers. Similar studies on nursing homes found that the cost of care was higher and the quality lower at the for profit ones vs the nonprofit ones. For profit insurers are also much less efficient than public ones as they spend typically 25% of premiums on overhead (marketing, underwriting, management salaries) vs only 3% for Medicare.
When comparing the US with Canada, Relman notes that until the 1960s both country had a very similar health care system run mainly by nonprofit entities. In 1965, both countries spent 6% of GDP on health care. As the US went on a commercialization binge, it now spends 16% on health care vs only 10% for Canada who used instead a single payer publicly funded system. Thus, the US increased its health care spending by 10 percentage points of GDP vs only 4% for Canada over the same period. Yet, Canada covers everyone with its Medicare-for-all; while the US covers only 85% of its population. And, the overall quality of care does not favor the US. Similar comparison with most Western European countries would be even more detrimental to the US.
In the pre-Medicare era, two thirds of doctors were engaged in primary care and one third were specialists. Now, those ratios have flipped in favor of specialists. As a result, health care costs a lot more while its quality has suffered. The Dartmouth Medical Center publishes maps of health care costs comparison within the U.S. They found that costs correlate most with the percent of specialists within the medical staff of a geographical area. Thus, medical costs do not track the demand. They track the supply (% of specialists).
Relman policy recommendation is to adopt a publicly funded single-payer insurance system that would pay for health care services, on a prepaid per patient basis, provided by not-for-profit privately managed medical groups where doctors would be salaried employees instead of volume driven entrepreneurs. Think of a Medicare-for-all paying for services delivered through a not-for-profit Kaiser Permanente Group.
Plain arithmetic demonstrates Relman's recommendation cost savings. Medicare spends 3% on overhead. Private insurers spend 25%. For profit hospitals spend 34% on overhead. Nonprofit ones spend 25%. The for profit fee-for-service causes huge overutilization of services vs prepaid per patient compensation. When combining those factors you can readily see how you could reduce US health care spending by at least a third which would bring it in line with other OECD countries.
If you find this subject interesting, I also recommend the following excellent books: The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care,Overdiagnosed: Making People Sick in the Pursuit of Health, and Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.
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A Second Opinion (Audible Audio Edition) Arnold S Relman Stephen McLaughlin Audible Studios Books Reviews
Dr. Relman calls for health care reform based on prepaid group practices, regulated and paid by the federal government. His objective, gradually developed in Chapters 1 through 4, is high quality health care for everyone at reasonable cost. In Chapter 5, he offers ideas on how prepaid group practices might best work. Nowhere, however, does he provide an organized case for this approach to reform, comparing it point-by-point with pertinent alternatives, citing evidence to show who benefits and who suffers and how much, under different alternatives.
Dr. Relman offers more a personal memoir than a policy analysis. His data are mostly broad-brush points and big-bucket numbers offered in editorial mode "I reject," "I agree," "I believe" and "I envision." From a writer as eminent as Dr. Relman, that might be tolerated for an introduction and a postscript, but the book goes on in such a vein for 175 pages.
Dr. Relman probably has some sense of how his program might be achieved. However, Chapter 6 of the book comes down to this elect more Democrats and appeal to the moral conscience of physicians (as he tries to do in Chapter 8). As he clearly knows, there have been times when we had more Democrats in office and times when we had a more vigorous climate of concern among physicians, but we still got little progress.
Dr. Relman's objectives appear worthy, and his approach to reform may be reasonable, but someone else will need to make the case. It will probably take a longer book, certainly one that is more focused and critical.
At the beginning of my medical career, physicians feared inroads from socialized medicine. Three decades later we were pawns of capitalized medicine as insurers dictated what drugs to use, tests to order, and how long to keep a patient in the hospital. HMOs tout preventive care, and there are actually billing codes for this, but they are largely not reimbursed. During this time Dr. Relman held many prestigious positions that puts him near the top of the list of the most important physicians of our era. In this small book he succinctly outlines the history of patient care and the doctor-patient relationship over five decades. He reproves the entrepreneurial spirit that overtook physicians in the 1950s and how it created conflicts of interest. He describes how Medicare and Medicaid may have helped many patients, but almost destroyed the concept of a physician or surgeon giving free care to the poor. As insured health plans became more common in the 1970s and 80s, he castigates the unconscionable profit motive that effectively restricts health care to those who need it most. He outlines the socialized systems in Great Britain and Canada, good aspects and bad. Finally, he proposes a single payer plan for the United States.
It's hard to disagree with Relman when the current system is in such a mess. Nevertheless I maintain that any new or revised system should not eliminate entrepreneurship. Socialism has already demonstrated that if you fail to reward excellence and ambition, you only reap mediocrity.
Too liberal. Socialized medicine. Pro Obamacare
This is a healthcare plan for today. The USA should be following Relman.
Dr. Relman was editor of New England Journal of Medicine for 14 years, a practicing physician, and on a variety of health care boards. His health care reform ideas offers the best or equal to the best plan for affordable, universal health care (at a basic level of care). He recommends single payer system, that physicians work in non-profit multi-speciality clinics for better comprehensive care of patients, that physicians receive bonus for going above a standard level of patient load.
Arnold Relman is an insightful elder health care policy statesman. Born in 1923, he was 84 when he wrote this book. He has been engaged in formulating health care reform policies for decades. He wrote an earlier book on the subject "The Choices for Healthcare Reform" back in 1992. He graduated from med school in 1946 nearly twenty years before Medicare and Medicaid were created in 1965. From 1977 to 1991, he was an editor of The New England Journal of Medicine (NEJM). He was a professor at Harvard Medical School, a research scientist, a clinician, a doctor, and a consultant to government.
Relman's main thesis is that for profit medicine has never worked. It has caused skyrocketing health care costs, as we have by far the most expensive health care cost worldwide (at 16% of GDP). And, our quality of care does not compare well with many OECD countries (shorter lifespan, higher infant mortality rates, and highest % of population being uninsured at 15%). The profit imperative dictates that a business grows its revenues and profits. This means overcharging, overutilization of health care services, and lower quality of care.
Relman's thesis, besides being now self evident, is supported by a seminal paper written in 1963 by a Nobel prize winning Stanford economists, Kenneth Arrow. The latter stated that health care services have no price transparency and no price competition. The demand for services is generated not by the customer (the patient) but by the vendor (the doctor) who makes the purchasing decision for the customer. Half a century later, Arrow's analysis is still spot on.
Back in 1980, Relman wrote a seminal article in the NEJM about "the New Medical-Industrial Complex." Emerging investor-owned health care insurers and providers reshaped the culture of health care services away from a vocational profession and towards entrepreneurship. This commercialization caused the tremendous rise in health care costs and a commensurate deterioration in its quality.
Relman brings an abundance of historical evidence to support his thesis. In 1986, Relman participated in a study conducted by the Institute of Medicine called "For-Profit Enterprise in Health Care" that compared for-profit vs not-for-profit hospitals. They uncovered that investor owned health care facilities steadily charged a lot more and incurred much higher overhead than their non-profit counterpart. They also restricted more access to health care by readily turning down patients who could not afford the care. This study readily concluded the advent of for profit medicine would lead to rapidly rising health care costs. Relman refers to another study in 1997 that found that for profit hospitals charged 10% more than their nonprofit counterparts because their overhead was nearly 10% higher (34% vs 25% respectively). A 2002 study comparing quality of care found that mortality risk was 2% higher at for profit hospitals vs nonprofit ones. A study on dialysis centers found that the mortality rate at for profit ones was 20% higher, and the likelihood of being placed on a waiting list for transplantation was 26% lower than for nonprofit dialysis centers. Similar studies on nursing homes found that the cost of care was higher and the quality lower at the for profit ones vs the nonprofit ones. For profit insurers are also much less efficient than public ones as they spend typically 25% of premiums on overhead (marketing, underwriting, management salaries) vs only 3% for Medicare.
When comparing the US with Canada, Relman notes that until the 1960s both country had a very similar health care system run mainly by nonprofit entities. In 1965, both countries spent 6% of GDP on health care. As the US went on a commercialization binge, it now spends 16% on health care vs only 10% for Canada who used instead a single payer publicly funded system. Thus, the US increased its health care spending by 10 percentage points of GDP vs only 4% for Canada over the same period. Yet, Canada covers everyone with its Medicare-for-all; while the US covers only 85% of its population. And, the overall quality of care does not favor the US. Similar comparison with most Western European countries would be even more detrimental to the US.
In the pre-Medicare era, two thirds of doctors were engaged in primary care and one third were specialists. Now, those ratios have flipped in favor of specialists. As a result, health care costs a lot more while its quality has suffered. The Dartmouth Medical Center publishes maps of health care costs comparison within the U.S. They found that costs correlate most with the percent of specialists within the medical staff of a geographical area. Thus, medical costs do not track the demand. They track the supply (% of specialists).
Relman policy recommendation is to adopt a publicly funded single-payer insurance system that would pay for health care services, on a prepaid per patient basis, provided by not-for-profit privately managed medical groups where doctors would be salaried employees instead of volume driven entrepreneurs. Think of a Medicare-for-all paying for services delivered through a not-for-profit Kaiser Permanente Group.
Plain arithmetic demonstrates Relman's recommendation cost savings. Medicare spends 3% on overhead. Private insurers spend 25%. For profit hospitals spend 34% on overhead. Nonprofit ones spend 25%. The for profit fee-for-service causes huge overutilization of services vs prepaid per patient compensation. When combining those factors you can readily see how you could reduce US health care spending by at least a third which would bring it in line with other OECD countries.
If you find this subject interesting, I also recommend the following excellent books The Healing of America A Global Quest for Better, Cheaper, and Fairer Health Care,Overdiagnosed Making People Sick in the Pursuit of Health, and Overtreated Why Too Much Medicine Is Making Us Sicker and Poorer.
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