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My brain is sprained from trying to figure out the big White House
meeting today between medical/insurance industry execs and President
Obama. One upside: The execs who went onstage with Obama, nodding about
the need for reform, won't be able to walk away easily later. The broad
cost-cutting ideas mentioned--more efficiency, less paperwork, better
preventive and chronic care--are worthy. But the lack of detail or
accountability--or really, of anything new--shows the distance to go
and loopholes to be opened.

The insurance lobby is still intent
on leveraging its "cooperation" to kill any nonprofit "public insurance
option" that would siphon off business from for-profit insurers. And
the five (white male) executives on stage with Obama were symbolic of
the lack of real consumer or patient representation in designing
national health reform.

Yet even in the emptiness of today's
proposals (for instance, "fight obesity" was the only specific
"wellness" proposal) there are opportunities for holding the
medical/insurance industry--and Washington--to account.

The New York Times story struggled to sum up that possibility:

By
giving such prominence to a promise that lacks many specifics, or any
sort of enforcement mechanism, the president appeared eager to give the
pledge greater substance through his strong embrace, while building
momentum for his broader ambition to make health care available to
every American.

Here are the four vague bullet points in the letter sent to Obama by
the leading lobbies for insurers, hospitals, doctors, drug makers and
medical device makers (think pacemakers, hip replacements) and one
union, the Service Employees International, that has cozied up to
industry in the health reform fight. 

• Implementing proposals in all sectors of the health care system, focusing on administrative simplification, standardization, and transparency that supports effective markets;
• Reducing over-use and under-use of health care by aligning quality and efficiency incentives among providers across the continuum of care so that physicians, hospitals, and other health care providers are encouraged and enabled to work together towards the highest standards of quality and efficiency;
• Encouraging coordinated care, both in the public and private sectors, and adherence to evidence-based best practices and therapies that reduce hospitalization, manage chronic disease more efficiently and effectively, and implement proven clinical prevention strategies; and,
• Reducing the cost of doing business by addressing cost drivers in each sector and through common sense improvements in care delivery models, health information technology, workforce deployment and development, and regulatory reforms.

After
boring any reader of the letter to death, most of the groups followed
up with a PR release, sometimes revealing specific aims:

Here, for instance, is the only specific statement in the follow-up news release of the insurance lobby, "America's Health Insurance Plans," or AHIP:

"We are committed to ensuring that no one in America falls through the
cracks of our health care system. We are committed to providing
efficient, cost-effective service to individuals, families, and
employers. We are committed to streamlining health care administration
so physicians can focus on treating their patients."

In the insurance wish list, that would translate to:

We
want everyone to be required to show coverage by a private insurer or
HMO, either with a government subsidy or their own money. And by
"cost-effective service," we mean that insurers should be free to sell
bare-bones, high-deductible policies riddled with exclusions that would
appeal to the young, single and healthy but shift costs to families and
seniors.

And all of the streamlining of billing in
the world (which doctors do desperately desire) won't begin to bring in
the $2 trillion in savings the new industry coalition is promising. 

The pharmaceutical makers' letter boasts
largely about how using more drugs can reduce overall costs, but makes
no suggestion about how to reduce the price of the drugs themselves.
And it calls for making sure that patients with chronic problems take
their drugs on time and in the prescribed amounts. That idea rings a
bell: the drug companies are pushing a mail reminder service
to patients to take their drugs--with the companies paying pharmacies
for the info about the drugs you already take and advertising other
drugs that they want you to take. Aside from the privacy invasion, that
would raise, not lower, drug costs. Consumer Watchdog helped kill the idea in California, but it's still alive nationally.

Even
the American Medical Association letter, which largely talks about
better communications between doctors and providing appropriate care
(sure, absolutely!) rings an oft-heard bell of warning to consumers:

"Defensive medicine continues to be a major factor in rising costs. We
need medical liability reforms that help physicians provide the best
care without needing to order additional services to guard against
possible lawsuits."

So
the doctors' most specific single aim for cost-cutting is to eliminate
lawsuits for even the most deadly and blatant medical malpractice.
Notice they say "guard against possible lawsuits," without adding the
usual "frivolous."

Yet solid evidence from hospitals
shows that transparency about mistakes, including a sincere apology and
payment of costs incurred by the error, drastically reduces lawsuits.
And as for why the right to sue is important, insurance companies
privately acknowledge that they're more responsive to complaints by
patients with the legal right to sue them than by those who mostly
don't have that right (employees of large corporations, because of the
federal ERISA law).

The Service Employees International Union,
which doesn't "represent labor" overall, no matter what President Obama
said, declared in its comment that today's get-together was

"...a sign of how committed industry leaders are to reforming our
healthcare system that these groups were able to come together and
offer proactive proposals on cutting healthcare costs." 

Yet
the SEIU also has a monetary stake in the outcome: it represents
unionized employees mostly in the health care field, from low-paid home
care workers to physician assistants: basically, everyone below
registered nurses on the skill scale. One of the cost-cutting proposals
in the current mix is shifting more care to lower levels, such as
having physician assistants, not nurses, do "routine care" like
vaccinations. No matter what the reform outcome, the SEIU gets
thousands of new memberes.

In the final paragraph of its press
release, the SEIU reiterates its support for a "public option" to
private insurance, but leaves open the idea of what that could be. Most
patient advocates want to expand Medicare or build something like it.
But it could end up as nothing more than a handful of private plans
overseen by government, like the pricey benefits offered to members of
Congress. The SEIU would gain more members from having private HMOs
administer a "public" plan.

The American Hospital Association cautiously
said no more than "[we] stand ready to work with President Obama and
Congress," and the device makers didn't post any kind of news release
(though they have a big issue: whether Congress might overturn a Supreme
Court ruling saying device makers may not be sued for defective
products.)  

So
everyone has skin in this game. Without a committed consumer presence
in the D.C. negotiations, we have to fight from the outside. But as
this newly cooperative stance in the medical-insurance industry is
fleshed out, we'll all be more able to aim before firing.