.
Excellent post about the market disincentives to providing rural health care by Allen Perkins on his blog "Training Family Doctors". http://usafamilymedicine.wordpress.com/2011/04/14/health-care-and-the-market/
Dr. Perkins goes on to quote from President Obama, who quotes Abraham Lincoln, about the need to care for others; this is a core principle of social justice, and one that I have addressed explicitly in the past both from a principled point of view (Does the nation need a clear policy on a right to basic health care?, April 10, 2009) and from one of enlightened self interest (Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009).
The market, well-regulated, can serve many purposes and be of value, but it cannot, by its nature, be relied upon to serve social justice needs.
Showing posts with label social justice. Show all posts
Showing posts with label social justice. Show all posts
Friday, April 15, 2011
Friday, December 3, 2010
Matthew Freeman Memorial Lecture, Dec 6, 2010
This event is free and open to the public. For more information and to RSVP, contact Nancy Michaels at nmichaels@roosevelt.edu
Matthew Freeman LECTURE & SOCIAL JUSTICE Award
GENDER DIS-INTEGRATION AND THE DISCIPLINE OF “LGBT” A TRANSFEMINIST PERSPECTIVE -- Anne Enke
Monday, December 6 11 a.m. - 12:30 p.m.
Matthew Freeman LECTURE & SOCIAL JUSTICE Award
GENDER DIS-INTEGRATION AND THE DISCIPLINE OF “LGBT” A TRANSFEMINIST PERSPECTIVE -- Anne Enke
Monday, December 6 11 a.m. - 12:30 p.m.
Roosevelt University, Chicago, IL
430 S. Michigan Ave. Sullivan Room - 2nd Floor
Matthew Freeman was a Roosevelt student committed to working for a world with true justice, equality and fairness. Matthew died days before he would have received his degree. Through the support of his parents, his legacy continues with this annual lecture and award presentation. This year’s Matthew Freeman Social Justice Awards will be presented to Roosevelt students Oneka Ijeoma and Renee Farwell for their commitment to bettering our world through activism.
The Mansfield Institute for Social Justice and Transformation and the Department of Political Science and Public Administration present the annual Matthew Freeman Lecture and Social Justice Award Ceremony.
This year’s distinguished lecturer is Anne Enke, Professor of Gender and Women’s Studies, History and LGBT Studies at the University of Wisconsin. Professor Enke is the author of Finding the Movement: Sexuality, Contested Space and Feminist Activism (Duke University Press, 2007).
Matthew Freeman was a Roosevelt student committed to working for a world with true justice, equality and fairness. Matthew died days before he would have received his degree. Through the support of his parents, his legacy continues with this annual lecture and award presentation. This year’s Matthew Freeman Social Justice Awards will be presented to Roosevelt students Oneka Ijeoma and Renee Farwell for their commitment to bettering our world through activism.
The Mansfield Institute for Social Justice and Transformation and the Department of Political Science and Public Administration present the annual Matthew Freeman Lecture and Social Justice Award Ceremony.
This year’s distinguished lecturer is Anne Enke, Professor of Gender and Women’s Studies, History and LGBT Studies at the University of Wisconsin. Professor Enke is the author of Finding the Movement: Sexuality, Contested Space and Feminist Activism (Duke University Press, 2007).
Thursday, July 22, 2010
Improving quality and access still requires coverage for all
.
Now that the health reform law, PPACA, has passed into law, and while we wait for the years to pass that will usher in many of the changes, as well as the regulations that will actually guide how those laws will be implemented, policy people and pundits have resumed publishing articles about what other things should be / need to be done. Most of these were suggestions that had been made previously and are either being advanced because PPACA has included funding for them and the authors want to emphasize how beneficial they will be, and others are ideas for health improvement that may not specifically be in the law but that the authors feel are still important and should be advocated for. In addition, of course, there are the “flames” and attacks on “Obamacare” as “socialized medicine” (which it isn’t close to, unfortunately in many people’s opinions, including mine).
In the first group I would include articles that address Community Health Centers (CHCs), or more specifically Federally-Qualified Health Centers (FQHCs), the patient center medical home (PCMH), and increased primary care, for all of which there is enormous funding in the new law. “Health reform and primary care – the growing importance of the community health center” by EY Adashi, HJ Geiger, and MD Fine (NEJM, 3Jun2010;362(22):2047-10) addresses all 3. Dr. Geiger was central to the creation of the first two CHCs, Columbia Point in Boston and Mound Bayou, Mississippi, in 1965. The article talks about how CHCs are built on primary care and on the principles of the patient-centered medical home (before those principles were articulated under that name), and calls for expansion of CHCs as a key vehicle for caring for all Americans, not only the “underserved” and the use of CHCs as venues for demonstration projects for PCMHs. It also includes an excellent map showing the percent of people in each state currently served by CHCs (West Virginia is tops with over 15%), and another with dots showing the location of all of them (very dense over WV).
Other articles on these topics include JF Markuns, B Fraser, and JD Orlander on developing the skills needed for medical directors in CHCs, “The path to physician leadership in community health centers: implications for training”, (Family Medicine Jun2010;42(6):403-7). This is important because a poor relationship between physician and non-physician administrators, often born of unshared assumptions about who is responsible for what, has frequently been a major stressor in many CHCs. Other pieces look at the medical home in particular populations -- “Health care reform and the opportunity to implement a family-centered medical home for children” (D Laraque and CCJ Sia, JAMA 16Jun2010;303(23)2407-8)* and in educational settings – “Medical student exposure to components of the patient-centered medical home during required ambulatory clerkship rotations: implications for education” (JW Saultz, et. al, Acad Med Jun2010;85(6):965-73)*.
The second group of articles address issues that the authors feel remain to be dealt with. A major one is quality of care, obviously of great concern to everyone who receives (and provides) health care. Harold Sox and Sheldon Greenfield, in “Quality of care – how good is good enough?”* (JAMA 16Jun2010;303(2):2403-4) argue that setting threshold values for adherence to practice measures is not a very good way to measure quality as patient characteristics, individually and in populations cared for by different physicians, groups, and hospitals as well as in different regions, differ greatly. They suggest measures of the quality of the decisions made by physicians, and the degree to which they are based on the best evidence in the context of the actual patient. Marco D. Huesch, in “Payment policy based on measurement of health care spending and outcomes” (JAMA 2010 Jun 16;303(23):2405-6)*, further addresses the flaws of many of the assumptions on which “pay for performance” programs pay. In the measurement of quality, we have to be especially careful of the pitfalls of “streetlight research”(see my post of Feb 26, 2009, Defining "Streetlight" Research) and measure what we find easiest to measure, whether or not it is what we really want to know about.
In an area getting, in my opinion, much closer to the edge of a bad idea, Robert Brook, of the RAND Corporation writes in of “Rights and responsibilities in health care: striking a balance” (JAMA 9Jun2010;303(22):2289-90)*. He makes comparisons to car warranties, which are often invalid if the owner has not followed the prescribed maintenance schedule. All of us would agree that it would be better (mainly for their health, I hope, but also for the bottom line) if everyone would adopt only the best health behaviors; indeed, we might argue that individual responsibility is critical. Of course, such arguments are inherently classist (on a group, not individual basis, as in all population issues) and are usually made by those who have the resources (financial, educational, “values”) to be more likely to be able to adopt such behaviors (and we don’t all do it – there are actually white, prosperous people who are overweight, drink, use drugs, smoke, don’t exercise enough, etc.) He calls for “classes” in the workplace using “sophisticated adult learning materials” to educate people. Beyond the fact that this would leave out those who don’t have a workplace, or work in a business too small to afford such class, this construct misses the fact that the reason people do not adopt such behaviors has very little to do with their not knowing that they are good ideas, and very much to do with the other parts of their lives that make adopting such behaviors very difficult. Most important, people are not cars, and refusing to honor a warranty is not the same as refusing to cover health care costs; we are not (and should not) going to allow people to die in the streets because they didn’t behave well and don’t have the money to bail themselves out of these poor decisions by paying for their care out of pocket.
The real problem is that all of these ideas, whether good (CHCs, primary care, the PCMH, emphasis on quality) or not is that under the new PPACA law, as before it, not everyone has adequate access to health care. Our reimbursement systems continue to reward providers (physicians, hospitals, health plans, and the drug and device manufacturers who sell to them) for doing more, using more technology, doing more procedures – for those who (or, mainly, whose insurance) can pay. And many people are still not covered. Medicaid will be expanded (for a while) but not yet, and will only pay (for 2 years) Medicare rates (and even this is rejected by many providers). Undocumented people will not be covered at all, although they will be here and get sick and need care. CHCs are neat, but as I have noted before, they have an incentive to locate where there are lots of Medicare and Medicaid patients, for whom they receive cost-plus reimbursement, not where there are uninsured and undocumented people. We need more primary care providers, we probably would benefit from true medical homes, and for goodness sake we need better quality, but without a health system that is actually universal, covers everyone, and has systematic means of cost-control, they are relatively less important, the cart before the horse, whistling past the graveyard. Even quality.
In 1994, Schiff, Bindman, and Brennan wrote “There is a profound and inseparable relationship between access and quality: universal insurance coverage is a prerequisite for quality care. Because quality must be population based, traditional definitions of quality should be broadened to include the gravest of quality deficits—denial of care. The most important prerequisite for access is health insurance.” (“A Better-Quality Alternative Single-Payer National Health System Reform”, JAMA 14Sep1994;272(10):803-80).
Denial of care and lack of access are still the greatest quality deficit. Discussions of quality that include only those “inside the tent” and ignore all others are specious and offensive; all discussions of quality must start from “everyone needs access”.
*Hyperlinks are not provided to these articles as they are not available free on line.
.
Now that the health reform law, PPACA, has passed into law, and while we wait for the years to pass that will usher in many of the changes, as well as the regulations that will actually guide how those laws will be implemented, policy people and pundits have resumed publishing articles about what other things should be / need to be done. Most of these were suggestions that had been made previously and are either being advanced because PPACA has included funding for them and the authors want to emphasize how beneficial they will be, and others are ideas for health improvement that may not specifically be in the law but that the authors feel are still important and should be advocated for. In addition, of course, there are the “flames” and attacks on “Obamacare” as “socialized medicine” (which it isn’t close to, unfortunately in many people’s opinions, including mine).
In the first group I would include articles that address Community Health Centers (CHCs), or more specifically Federally-Qualified Health Centers (FQHCs), the patient center medical home (PCMH), and increased primary care, for all of which there is enormous funding in the new law. “Health reform and primary care – the growing importance of the community health center” by EY Adashi, HJ Geiger, and MD Fine (NEJM, 3Jun2010;362(22):2047-10) addresses all 3. Dr. Geiger was central to the creation of the first two CHCs, Columbia Point in Boston and Mound Bayou, Mississippi, in 1965. The article talks about how CHCs are built on primary care and on the principles of the patient-centered medical home (before those principles were articulated under that name), and calls for expansion of CHCs as a key vehicle for caring for all Americans, not only the “underserved” and the use of CHCs as venues for demonstration projects for PCMHs. It also includes an excellent map showing the percent of people in each state currently served by CHCs (West Virginia is tops with over 15%), and another with dots showing the location of all of them (very dense over WV).
Other articles on these topics include JF Markuns, B Fraser, and JD Orlander on developing the skills needed for medical directors in CHCs, “The path to physician leadership in community health centers: implications for training”, (Family Medicine Jun2010;42(6):403-7). This is important because a poor relationship between physician and non-physician administrators, often born of unshared assumptions about who is responsible for what, has frequently been a major stressor in many CHCs. Other pieces look at the medical home in particular populations -- “Health care reform and the opportunity to implement a family-centered medical home for children” (D Laraque and CCJ Sia, JAMA 16Jun2010;303(23)2407-8)* and in educational settings – “Medical student exposure to components of the patient-centered medical home during required ambulatory clerkship rotations: implications for education” (JW Saultz, et. al, Acad Med Jun2010;85(6):965-73)*.
The second group of articles address issues that the authors feel remain to be dealt with. A major one is quality of care, obviously of great concern to everyone who receives (and provides) health care. Harold Sox and Sheldon Greenfield, in “Quality of care – how good is good enough?”* (JAMA 16Jun2010;303(2):2403-4) argue that setting threshold values for adherence to practice measures is not a very good way to measure quality as patient characteristics, individually and in populations cared for by different physicians, groups, and hospitals as well as in different regions, differ greatly. They suggest measures of the quality of the decisions made by physicians, and the degree to which they are based on the best evidence in the context of the actual patient. Marco D. Huesch, in “Payment policy based on measurement of health care spending and outcomes” (JAMA 2010 Jun 16;303(23):2405-6)*, further addresses the flaws of many of the assumptions on which “pay for performance” programs pay. In the measurement of quality, we have to be especially careful of the pitfalls of “streetlight research”(see my post of Feb 26, 2009, Defining "Streetlight" Research) and measure what we find easiest to measure, whether or not it is what we really want to know about.
In an area getting, in my opinion, much closer to the edge of a bad idea, Robert Brook, of the RAND Corporation writes in of “Rights and responsibilities in health care: striking a balance” (JAMA 9Jun2010;303(22):2289-90)*. He makes comparisons to car warranties, which are often invalid if the owner has not followed the prescribed maintenance schedule. All of us would agree that it would be better (mainly for their health, I hope, but also for the bottom line) if everyone would adopt only the best health behaviors; indeed, we might argue that individual responsibility is critical. Of course, such arguments are inherently classist (on a group, not individual basis, as in all population issues) and are usually made by those who have the resources (financial, educational, “values”) to be more likely to be able to adopt such behaviors (and we don’t all do it – there are actually white, prosperous people who are overweight, drink, use drugs, smoke, don’t exercise enough, etc.) He calls for “classes” in the workplace using “sophisticated adult learning materials” to educate people. Beyond the fact that this would leave out those who don’t have a workplace, or work in a business too small to afford such class, this construct misses the fact that the reason people do not adopt such behaviors has very little to do with their not knowing that they are good ideas, and very much to do with the other parts of their lives that make adopting such behaviors very difficult. Most important, people are not cars, and refusing to honor a warranty is not the same as refusing to cover health care costs; we are not (and should not) going to allow people to die in the streets because they didn’t behave well and don’t have the money to bail themselves out of these poor decisions by paying for their care out of pocket.
The real problem is that all of these ideas, whether good (CHCs, primary care, the PCMH, emphasis on quality) or not is that under the new PPACA law, as before it, not everyone has adequate access to health care. Our reimbursement systems continue to reward providers (physicians, hospitals, health plans, and the drug and device manufacturers who sell to them) for doing more, using more technology, doing more procedures – for those who (or, mainly, whose insurance) can pay. And many people are still not covered. Medicaid will be expanded (for a while) but not yet, and will only pay (for 2 years) Medicare rates (and even this is rejected by many providers). Undocumented people will not be covered at all, although they will be here and get sick and need care. CHCs are neat, but as I have noted before, they have an incentive to locate where there are lots of Medicare and Medicaid patients, for whom they receive cost-plus reimbursement, not where there are uninsured and undocumented people. We need more primary care providers, we probably would benefit from true medical homes, and for goodness sake we need better quality, but without a health system that is actually universal, covers everyone, and has systematic means of cost-control, they are relatively less important, the cart before the horse, whistling past the graveyard. Even quality.
In 1994, Schiff, Bindman, and Brennan wrote “There is a profound and inseparable relationship between access and quality: universal insurance coverage is a prerequisite for quality care. Because quality must be population based, traditional definitions of quality should be broadened to include the gravest of quality deficits—denial of care. The most important prerequisite for access is health insurance.” (“A Better-Quality Alternative Single-Payer National Health System Reform”, JAMA 14Sep1994;272(10):803-80).
Denial of care and lack of access are still the greatest quality deficit. Discussions of quality that include only those “inside the tent” and ignore all others are specious and offensive; all discussions of quality must start from “everyone needs access”.
*Hyperlinks are not provided to these articles as they are not available free on line.
.
Sunday, December 21, 2008
The financial sector, for a change…
Just a brief digression from health care and medicine to just social justice. The New York Times of Sunday, Dec. 21, is full of information. The right-hand column on page 1 (the most important story of the day) is: “In need of cash, more companies cut 401(K) match”. Not good for folks contemplating retirement, huh. Especially when the story on page 6 of the Business section is entitled “Maybe this time, it’s buy, buy, buy and hold”. A challenge for regular people who mostly “buy” (and “hold”) with their retirement money, which is now being cut. Hmm. There is also a very long piece beginning on page 1 and continuing with a full double-page spread detailing how the Bush administration housing policies encouraged, perhaps led the collapse. Oh, well, they’re soon gone, but have we learned anything? Frank Rich, in his column “Who wants to kick a millionaire?” details the continued irresponsible arrogance of the financial “leaders” and their enablers in the administration such as Henry Paulson:
“Last week ABC News asked 16 of the banks that have received handouts from the Treasury Department’s $700 billion Troubled Assets Relief Program the same two direct questions: How have you used that money, and how much have you spent on bonuses this year? Most refused to answer.
“Congress can’t get the answers either. Its oversight panel declared in a first report this month that the Treasury is doling out billions ‘without seeking to monitor the use of funds provided to specific institutions.’ The Treasury prefers instead to look at ‘general metrics’, indicating the program’s overall effect on the economy. Well, we know what the ‘general metrics’ tell us already: the effect so far is nil. Perhaps if we were let in on the specifics, we’d start to understand why.”
Let’s get this clear. The American people, who are actually financing this bailout, just as they financed the wealth accumulated by these “titans of banking”, think that they should not get any bonuses. In fact, they don’t even think they should have jobs. We think that the ones who can be convicted of anything should be imprisoned, and the rest should have to give up all their money[*] and be living on unemployment (if their companies were keeping up with the premiums!) in second-hand FEMA trailers, before their companies receive dollar one from the bailout! Can we be clearer?
Obviously hasn’t happened with the Bush administration, and don’t get your hopes up for the incoming administration, not with Citigroup’s Robert Rubin (“I’d do the same all over again”) and his disciples being appointed to Obama’s key financial advisory positions. Sorry, the same people are going to win, and the rest of us are going to keep losing.
[*] For those of you who wonder if we can take all the money they already “earned”, I acknowledge that I am not a legal expert. For those of you who are, here is my question on what seems a parallel set of circumstances: I break into your house and steal the $1000 cash you keep in your sock drawer. For the next week I “put it on the street” in short term, high-interest loans and now have $2000. Then the cops arrest me for my original crime. My question: Do I get to keep the whole $2000, or just the $1000 I “earned”?
“Last week ABC News asked 16 of the banks that have received handouts from the Treasury Department’s $700 billion Troubled Assets Relief Program the same two direct questions: How have you used that money, and how much have you spent on bonuses this year? Most refused to answer.
“Congress can’t get the answers either. Its oversight panel declared in a first report this month that the Treasury is doling out billions ‘without seeking to monitor the use of funds provided to specific institutions.’ The Treasury prefers instead to look at ‘general metrics’, indicating the program’s overall effect on the economy. Well, we know what the ‘general metrics’ tell us already: the effect so far is nil. Perhaps if we were let in on the specifics, we’d start to understand why.”
Let’s get this clear. The American people, who are actually financing this bailout, just as they financed the wealth accumulated by these “titans of banking”, think that they should not get any bonuses. In fact, they don’t even think they should have jobs. We think that the ones who can be convicted of anything should be imprisoned, and the rest should have to give up all their money[*] and be living on unemployment (if their companies were keeping up with the premiums!) in second-hand FEMA trailers, before their companies receive dollar one from the bailout! Can we be clearer?
Obviously hasn’t happened with the Bush administration, and don’t get your hopes up for the incoming administration, not with Citigroup’s Robert Rubin (“I’d do the same all over again”) and his disciples being appointed to Obama’s key financial advisory positions. Sorry, the same people are going to win, and the rest of us are going to keep losing.
[*] For those of you who wonder if we can take all the money they already “earned”, I acknowledge that I am not a legal expert. For those of you who are, here is my question on what seems a parallel set of circumstances: I break into your house and steal the $1000 cash you keep in your sock drawer. For the next week I “put it on the street” in short term, high-interest loans and now have $2000. Then the cops arrest me for my original crime. My question: Do I get to keep the whole $2000, or just the $1000 I “earned”?
Subscribe to:
Posts (Atom)