Philosophy Discussion Forums | A Humans-Only Club for Open-Minded Discussion & Debate

[LovelyLau]

I think it is a necessity.
Because people who are sick will need help.
However is the cost a necessity..I'm not sure.
Like way does it cost..this I guess to keep hospitals funded as well as clinics and pay people.
They should have free clinics that people volunteer their time like once in a while iike doctors, nurses etc.
Countries where the cost of living is less then the healthcare is less. If the government pays a bit for the cost of healthcare which is as much as people rubbish Russia, i read they have free healthcare there and that is probably because the government makes it free.
But the cost of living there is cheap.

[Sushan]

Personally, I prefer the Oregon plan (which existed in the state before the Affordable Care Act). Basically that state took the total Medicaid money plus whatever the state would normally kick in, then gave every billing code a priority number (made a ranked list). Then the accountants drew a line (based on prior year's experience) such that the total money would cover the costs of the highest priority treatments and diagnostic tests for everyone without insurance BUT completely not cover those bills below the line (of lower efficacy value). Instead of the norm of covering every treatment (no matter how beneficial or not) for the extremely poor but nothing at all for say, the working poor (without insurance).

Thus using my example, liver transplants for alcoholics would be below the line ie. not paid for. Cosmetic surgery, below the line. Experimental "last ditch" cancer treatment for endstage disease, below the line. Expensive new treatments without a statistical effectiveness advantage over traditional treatment, below the line. Antibiotics for a cold, BTL.

So instead of covering any old thing for some folks and nothing for others, you'd cover the highest priority treatments for everyone.

Thank you for sharing information about the Oregon plan, which presents a unique approach to managing healthcare resources. It's enlightening to learn about systems that aim to allocate medical funding in a way that maximizes efficacy and fairness across the board. The strategy of ranking treatments by priority and drawing a financial line to determine what gets funded is an intriguing model that strives for efficiency and equity in healthcare provision. I appreciate the thoughtfulness behind such a system, as it attempts to ensure that the most crucial treatments are accessible to everyone, rather than providing comprehensive coverage to a few while leaving others without any support.

However, the ethical implications of this system, particularly regarding treatments that fall below the line, such as liver transplants for alcoholics or experimental cancer treatments, raise significant concerns. It's a challenging ethical dilemma: on one hand, the system seeks to use limited resources wisely, focusing on treatments with the highest efficacy and benefit. On the other hand, it inevitably leads to tough decisions about who gets treatment and who doesn't, which can feel like a judgment on the value of certain lives or conditions.

The example of denying liver transplants for alcoholics or withholding experimental treatments for end-stage cancer patients highlights a critical ethical question: How do we reconcile the need to allocate resources efficiently with the moral imperative to treat all individuals with compassion and dignity, regardless of their circumstances?

I'm curious about your perspective on this ethical dimension. How do you view the balance between efficiency and fairness in this system, especially when it comes to decisions that could mean life or death for individuals whose treatments fall below the line? Is there a way to address these ethical concerns within the framework of such a prioritized funding system, or are there alternative approaches that might better navigate these complex moral waters?

Well, typically the standard criticism of the Oregon plan is: "that's Healthcare rationing, I'm against that". However, anyone with a more in depth understanding of the topic realizes that the standard system also rations Healthcare, but instead of limiting the least efficacious treatments, it completely excludes whole sections of the population. Better IMO to exclude procedures than people.

I read a bit about the Oregon plan and the related discussions. References to the Oregon plan often highlight its attempts to maximize the overall health benefits within a fixed budget, which has sparked both admiration and critique. For instance, the plan's prioritization process, which ranks medical services based on cost-effectiveness and necessity, represents a concrete effort to ensure that the available resources do the most good for the most people.

Critics argue that such a system inevitably leads to difficult decisions about which treatments are deemed necessary and which are not, potentially leading to ethical dilemmas. Supporters, on the other hand, see it as a pragmatic approach to a problem faced by healthcare systems worldwide: how to provide the best possible care with limited resources.

I'm curious about your thoughts on the public's reception of the Oregon plan. Do you think the general understanding of healthcare rationing needs to be expanded to appreciate the nuances of systems like Oregon's? Additionally, how do you view the ethical considerations of rationing care based on the efficacy of treatments versus the financial cost?

I am sorry if this feels like I am asking the same question repeatedly. But I am quite interested in this concept.

[Sushan]

T1D is currently a chronic illness because insulin treatment is available, just like AIDS is currently a chronic disease because antiviral medications exist. However, before insulin treatment was discovered half of diabetics died within 2 years of diagnosis. Nope, it was definitely an acute illness. You may not remember when AIDS splashed onto the scene in the 80s, it made the Covid pandemic stress seem trivial. Folks were (rightly) freaked out by the acute illness that was AIDS, people understand that but perhaps haven't stopped to reassess that currently (especially among the young) HIV is viewed as a chronic illness that is "managed" with pills or an occasional injection.

Thus the very chronicity of T1D (currently) is specifically because of Western medicine's turning it so because of it's efficiency against the acute illness that T1D started out as.

The World Health Organization (WHO) provides clear definitions to distinguish between acute and chronic illnesses, which can help clarify the discussion:

- Acute Illness: An acute condition is typically characterized by a sudden onset and is usually of short duration. Acute illnesses can range in severity from mild conditions requiring minimal intervention to severe, life-threatening emergencies. The key aspect of an acute illness is its transient nature.

- Chronic Illness: Chronic conditions, on the other hand, are long-developing syndromes, defined by WHO as requiring “long-term management over a period of years or decades”. They are often characterized by their persistent and prolonging effects on the individual's health, requiring ongoing medical attention or limit activities of daily living or both.

Based on your comment, it seems there might be a misunderstanding or a conflation of the terms "acute" and "chronic" based on the availability of treatment and the historical fatality rates of conditions like T1D and AIDS. It's important to note that the classification of an illness as acute or chronic typically does not hinge solely on whether it leads to quick death without treatment. Rather, it's about the duration and course of the disease - whether it's of short duration (acute) or persists for a long time, often for the person's lifetime (chronic), and requires long-term management.

However, I'm curious about your statement implying that an illness is considered "acute" only if it leads to a quick death in the absence of treatment. Could you clarify if this is your stance?

Considered by administrators? (who are those who sit in meetings at conferences to form committees to come up with definitions) As a clinician and a non administrator, I'm not an expert in the various lumping and splitting of diagnosis coding into semi arbitrary categories. Of course you're likely not one either.

But I'm sure at this point you understand the significant difference between being told your kid has a lethal diagnosis such that there's a 50% chance of dying in the next 2 years as opposed to your kid has a completely manageable lifelong illness that will require numerous, numerous clinic visits where we will do lifelong testing and use those results to adjust their treatment so that we avoid some serious long-term risks that may be significant in their elder years.

I happen to use the term "acute" to describe the former and "chronic" to describe the latter. However I'm not personally too impressed with labels except as a shortcut for communication. Since I've communicated this difference, my interest at this point in their label is miniscule.

As a clinician myself, and not an administrator, I find your commentary both insightful and humorous. The distinction between acute and chronic conditions, as you've described, is indeed fundamental in clinical practice, and while I might not sit in those meetings forming committees and definitions, the importance of accurate healthcare diagnosis categories and codings, such as ICD-11, cannot be overstated in specific clinical contexts. These systems, despite their limitations, play a crucial role in ensuring standardized care, facilitating research, and managing healthcare resources effectively.

I share your sentiment regarding the administrative penchant for 'lumping and splitting' diagnosis codes into categories that can sometimes seem arbitrary. It can indeed be challenging to navigate these classifications, especially when they don't always align with the clinical realities we face daily. Your use of 'acute' and 'chronic' to delineate between life-threatening immediacy and long-term management does capture the essence of these conditions, albeit in a way that's not typically articulated in the usual clinical vernacular.

Your candid expression about the repulsion towards administrative meetings, conferences, and the creation of definitions did bring a smile to my face. It's a world apart from the hands-on, patient-focused reality of clinical work. Yet, these definitions and categories do influence our practice in myriad ways, for better or worse.

I'm intrigued to hear more about your views on this disconnect between clinical practice and administrative definitions. Do you have any particularly memorable experiences or observations from interactions with the administrative side of healthcare that highlight this 'repulsion'?

[Sushan]

I think it is a necessity.
Because people who are sick will need help.
However is the cost a necessity..I'm not sure.
Like way does it cost..this I guess to keep hospitals funded as well as clinics and pay people.
They should have free clinics that people volunteer their time like once in a while iike doctors, nurses etc.
Countries where the cost of living is less then the healthcare is less. If the government pays a bit for the cost of healthcare which is as much as people rubbish Russia, i read they have free healthcare there and that is probably because the government makes it free.
But the cost of living there is cheap.

Reflecting on your thoughts, I find myself in a unique position to discuss the healthcare system from both ends of the spectrum: as a patient and a service-providing clinician within a system that offers healthcare free at the point of use. The idea of free healthcare, much like you've observed in countries like Russia, comes with its set of pros and cons.

On the pro side, free healthcare ensures that every individual, regardless of their financial status, has access to necessary medical services. This inclusivity is fundamental in promoting public health, preventing disease spread, and treating chronic conditions without the burden of cost leading to untreated illnesses. As a clinician, the ability to provide care without the barrier of cost fosters a more straightforward, ethical approach to medicine, focusing purely on the best interests of the patient.

However, the cons are also noteworthy. Funding such a system often comes from the public through taxes, which can be a contentious point. There can be issues with resource allocation, leading to longer wait times for certain treatments or procedures. From a clinician’s perspective, this can sometimes limit our ability to deliver timely care, impacting patient outcomes. Additionally, the high demand and limited resources can lead to burnout among healthcare professionals, challenging the sustainability of the system.

In your mention of free clinics and volunteer work, there’s a beautiful ideal of community and collective responsibility for health. Yet, this too requires a careful balance of volunteer engagement, professional oversight, and consistent quality of care, which can be challenging to maintain over time.

Considering these points, I'm curious about your perspective on the balance between free healthcare and the associated costs, both monetary and otherwise. How do you see the pros and cons playing out in practice, and what might be the ideal approach to addressing the cons while maximizing the benefits of a healthcare system that aims to be free at the point of use?

[LuckyR]

Well, typically the standard criticism of the Oregon plan is: "that's Healthcare rationing, I'm against that". However, anyone with a more in depth understanding of the topic realizes that the standard system also rations Healthcare, but instead of limiting the least efficacious treatments, it completely excludes whole sections of the population. Better IMO to exclude procedures than people.

I read a bit about the Oregon plan and the related discussions. References to the Oregon plan often highlight its attempts to maximize the overall health benefits within a fixed budget, which has sparked both admiration and critique. For instance, the plan's prioritization process, which ranks medical services based on cost-effectiveness and necessity, represents a concrete effort to ensure that the available resources do the most good for the most people.

Critics argue that such a system inevitably leads to difficult decisions about which treatments are deemed necessary and which are not, potentially leading to ethical dilemmas. Supporters, on the other hand, see it as a pragmatic approach to a problem faced by healthcare systems worldwide: how to provide the best possible care with limited resources.

I'm curious about your thoughts on the public's reception of the Oregon plan. Do you think the general understanding of healthcare rationing needs to be expanded to appreciate the nuances of systems like Oregon's? Additionally, how do you view the ethical considerations of rationing care based on the efficacy of treatments versus the financial cost?

I am sorry if this feels like I am asking the same question repeatedly. But I am quite interested in this concept.

The public's perception here in Oregon was not negative. Part of that was because the author of the plan was a physician who started as the head of the legislature then served two terms as governor. He was as well respected by his political adversaries as anyone could be in the Modern polarized era. Of course he was well liked by those in his party.

Thus most of the opposition was in the National media from outside of the state. Mainly because it challenged the status quo and essentially everywhere else (since no one else was using it). Docs in the state grumbled about having to jump through hoops to get things approved, but let's be honest there's going to be a certain amount of grumbling with any system.

As to the presence of criticism, I'm not moved by that since every other system currently in place is subject to equal (or more likely) worse criticism.

[LuckyR]

Considered by administrators? (who are those who sit in meetings at conferences to form committees to come up with definitions) As a clinician and a non administrator, I'm not an expert in the various lumping and splitting of diagnosis coding into semi arbitrary categories. Of course you're likely not one either.

But I'm sure at this point you understand the significant difference between being told your kid has a lethal diagnosis such that there's a 50% chance of dying in the next 2 years as opposed to your kid has a completely manageable lifelong illness that will require numerous, numerous clinic visits where we will do lifelong testing and use those results to adjust their treatment so that we avoid some serious long-term risks that may be significant in their elder years.

I happen to use the term "acute" to describe the former and "chronic" to describe the latter. However I'm not personally too impressed with labels except as a shortcut for communication. Since I've communicated this difference, my interest at this point in their label is miniscule.

As a clinician myself, and not an administrator, I find your commentary both insightful and humorous. The distinction between acute and chronic conditions, as you've described, is indeed fundamental in clinical practice, and while I might not sit in those meetings forming committees and definitions, the importance of accurate healthcare diagnosis categories and codings, such as ICD-11, cannot be overstated in specific clinical contexts. These systems, despite their limitations, play a crucial role in ensuring standardized care, facilitating research, and managing healthcare resources effectively.

I share your sentiment regarding the administrative penchant for 'lumping and splitting' diagnosis codes into categories that can sometimes seem arbitrary. It can indeed be challenging to navigate these classifications, especially when they don't always align with the clinical realities we face daily. Your use of 'acute' and 'chronic' to delineate between life-threatening immediacy and long-term management does capture the essence of these conditions, albeit in a way that's not typically articulated in the usual clinical vernacular.

Your candid expression about the repulsion towards administrative meetings, conferences, and the creation of definitions did bring a smile to my face. It's a world apart from the hands-on, patient-focused reality of clinical work. Yet, these definitions and categories do influence our practice in myriad ways, for better or worse.

I'm intrigued to hear more about your views on this disconnect between clinical practice and administrative definitions. Do you have any particularly memorable experiences or observations from interactions with the administrative side of healthcare that highlight this 'repulsion'?

Oh don't get me started, ha, ha. The reality is that Admin's job is to make policy decisions, and in a business (which US Healthcare is) the business must stay in business in order to create "product", which if course is patient care. To my view Admin should view their job as being the umbrella between the outside world (insurance companies and government payers, regulators, legal adversaries, vendors like med supply folks and Pharm people etc) and the clinicians who provide the product. Thus their role should be insulating clinicians from outside interference and running a tight fiscal ship as a balance. Generally clinicians will support an Admin who can articulate why potentially painful choices are a good business decision especially if that Admin has a good track record of supporting the clinical staff when it was not expedient to do so. Unfortunately, since there is both power and high compensation in Admin, the wrong types tend to be drawn to it. It is not new information that such individuals act in their own best interest at worst or simply abdicate their protective role towards the clinical staff and become yet another external adversary to the clinical mission.

[Kurumy]

I think it is a necessity.
Because people who are sick will need help.
However is the cost a necessity..I'm not sure.
Like way does it cost..this I guess to keep hospitals funded as well as clinics and pay people.
They should have free clinics that people volunteer their time like once in a while iike doctors, nurses etc.
Countries where the cost of living is less then the healthcare is less. If the government pays a bit for the cost of healthcare which is as much as people rubbish Russia, i read they have free healthcare there and that is probably because the government makes it free.
But the cost of living there is cheap.

Your perspective highlights a crucial aspect – the essential need for healthcare, especially for those who are unwell. The concern about the cost is valid, and you've touched on a key point regarding funding for hospitals, clinics, and healthcare professionals. The idea of free clinics with volunteer support is commendable, promoting accessibility to essential services.

The connection between the cost of living and healthcare expenses is significant. Countries with lower living costs often reflect more affordable healthcare. Your observation about Russia's healthcare system sheds light on the potential impact of government involvement in making healthcare more accessible.

It's an intricate balance between sustaining healthcare infrastructure and ensuring affordability. Your insights contribute to the ongoing conversation about creating a healthcare system that is both necessary and equitable.

[Sushan]

Well, typically the standard criticism of the Oregon plan is: "that's Healthcare rationing, I'm against that". However, anyone with a more in depth understanding of the topic realizes that the standard system also rations Healthcare, but instead of limiting the least efficacious treatments, it completely excludes whole sections of the population. Better IMO to exclude procedures than people.

I read a bit about the Oregon plan and the related discussions. References to the Oregon plan often highlight its attempts to maximize the overall health benefits within a fixed budget, which has sparked both admiration and critique. For instance, the plan's prioritization process, which ranks medical services based on cost-effectiveness and necessity, represents a concrete effort to ensure that the available resources do the most good for the most people.

Critics argue that such a system inevitably leads to difficult decisions about which treatments are deemed necessary and which are not, potentially leading to ethical dilemmas. Supporters, on the other hand, see it as a pragmatic approach to a problem faced by healthcare systems worldwide: how to provide the best possible care with limited resources.

I'm curious about your thoughts on the public's reception of the Oregon plan. Do you think the general understanding of healthcare rationing needs to be expanded to appreciate the nuances of systems like Oregon's? Additionally, how do you view the ethical considerations of rationing care based on the efficacy of treatments versus the financial cost?

I am sorry if this feels like I am asking the same question repeatedly. But I am quite interested in this concept.

The public's perception here in Oregon was not negative. Part of that was because the author of the plan was a physician who started as the head of the legislature then served two terms as governor. He was as well respected by his political adversaries as anyone could be in the Modern polarized era. Of course he was well liked by those in his party.

Thus most of the opposition was in the National media from outside of the state. Mainly because it challenged the status quo and essentially everywhere else (since no one else was using it). Docs in the state grumbled about having to jump through hoops to get things approved, but let's be honest there's going to be a certain amount of grumbling with any system.

As to the presence of criticism, I'm not moved by that since every other system currently in place is subject to equal (or more likely) worse criticism.

Your insight into the public perception of the Oregon plan is enlightening, especially considering the respect garnered by its architect, John Kitzhaber. The plan indeed represented a novel approach to healthcare rationing, aiming to extend coverage rather than exclude individuals. Your mention of the plan facing more scrutiny nationally than locally highlights the tension between innovative local initiatives and the broader status quo.

The Oregon Health Plan attempted to balance coverage expansion with cost containment by prioritizing treatments based on effectiveness and cost. This approach, while logical and transparent, encountered challenges, particularly in controlling the costs of treatments above the priority line and the political complexities of healthcare reform. The necessity of dropping condition-treatment pairs to save costs led to difficult medical and moral decisions, showing the plan's limitations as a sustainable cost containment strategy.

Critics argue that while the plan's intentions were commendable, its execution revealed the difficulties in managing healthcare costs through prioritized lists. The economic downturn further strained the system, demonstrating the vulnerability of such reforms to broader economic forces.

(https://www.bmj.com/bmj/section-pdf/186 ... e.full.pdf)

Considering your perspective and the historical context of the Oregon Health Plan, I'm interested in hearing more about your thoughts on the balance between innovation in healthcare policy and the practical challenges of implementation. How do you perceive the evolution of healthcare reform, especially in light of economic and political fluctuations?

[Sushan]

Considered by administrators? (who are those who sit in meetings at conferences to form committees to come up with definitions) As a clinician and a non administrator, I'm not an expert in the various lumping and splitting of diagnosis coding into semi arbitrary categories. Of course you're likely not one either.

But I'm sure at this point you understand the significant difference between being told your kid has a lethal diagnosis such that there's a 50% chance of dying in the next 2 years as opposed to your kid has a completely manageable lifelong illness that will require numerous, numerous clinic visits where we will do lifelong testing and use those results to adjust their treatment so that we avoid some serious long-term risks that may be significant in their elder years.

I happen to use the term "acute" to describe the former and "chronic" to describe the latter. However I'm not personally too impressed with labels except as a shortcut for communication. Since I've communicated this difference, my interest at this point in their label is miniscule.

As a clinician myself, and not an administrator, I find your commentary both insightful and humorous. The distinction between acute and chronic conditions, as you've described, is indeed fundamental in clinical practice, and while I might not sit in those meetings forming committees and definitions, the importance of accurate healthcare diagnosis categories and codings, such as ICD-11, cannot be overstated in specific clinical contexts. These systems, despite their limitations, play a crucial role in ensuring standardized care, facilitating research, and managing healthcare resources effectively.

I share your sentiment regarding the administrative penchant for 'lumping and splitting' diagnosis codes into categories that can sometimes seem arbitrary. It can indeed be challenging to navigate these classifications, especially when they don't always align with the clinical realities we face daily. Your use of 'acute' and 'chronic' to delineate between life-threatening immediacy and long-term management does capture the essence of these conditions, albeit in a way that's not typically articulated in the usual clinical vernacular.

Your candid expression about the repulsion towards administrative meetings, conferences, and the creation of definitions did bring a smile to my face. It's a world apart from the hands-on, patient-focused reality of clinical work. Yet, these definitions and categories do influence our practice in myriad ways, for better or worse.

I'm intrigued to hear more about your views on this disconnect between clinical practice and administrative definitions. Do you have any particularly memorable experiences or observations from interactions with the administrative side of healthcare that highlight this 'repulsion'?

Oh don't get me started, ha, ha. The reality is that Admin's job is to make policy decisions, and in a business (which US Healthcare is) the business must stay in business in order to create "product", which if course is patient care. To my view Admin should view their job as being the umbrella between the outside world (insurance companies and government payers, regulators, legal adversaries, vendors like med supply folks and Pharm people etc) and the clinicians who provide the product. Thus their role should be insulating clinicians from outside interference and running a tight fiscal ship as a balance. Generally clinicians will support an Admin who can articulate why potentially painful choices are a good business decision especially if that Admin has a good track record of supporting the clinical staff when it was not expedient to do so. Unfortunately, since there is both power and high compensation in Admin, the wrong types tend to be drawn to it. It is not new information that such individuals act in their own best interest at worst or simply abdicate their protective role towards the clinical staff and become yet another external adversary to the clinical mission.

I completely agree with your perspective on the role of administrative staff in healthcare. The recent situation in Sri Lanka, where former health minister and officials have been jailed due to corruption, starkly illustrates the global challenge of maintaining integrity and accountability in healthcare administration. Such examples highlight the critical need for robust systems that prevent misuse of power and ensure that healthcare administration genuinely supports the clinical mission.

In the Sri Lankan context, the corrupted healthcare system has led to a loss of public trust, inefficiencies, and a decline in the quality of patient care. This scenario is not unique to Sri Lanka; similar issues can be found in various parts of the world where the healthcare system's administrative arm fails to prioritize patient care and support clinicians adequately.

To avoid such situations, there must be a system of checks and balances that ensures transparency and accountability in healthcare administration. Regular audits, whistleblower protection policies, and strong legal frameworks are essential to deter corruption and malpractice. Furthermore, the selection process for administrative roles in healthcare should prioritize candidates with a proven track record of ethical behavior and a genuine commitment to supporting clinical staff and patient care.

What are your thoughts on implementing such measures, and do you think they would be effective in maintaining the integrity of healthcare administration globally? What other steps do you think should be taken to prevent the kind of administrative failure and corruption?

[Sushan]

I think it is a necessity.
Because people who are sick will need help.
However is the cost a necessity..I'm not sure.
Like way does it cost..this I guess to keep hospitals funded as well as clinics and pay people.
They should have free clinics that people volunteer their time like once in a while iike doctors, nurses etc.
Countries where the cost of living is less then the healthcare is less. If the government pays a bit for the cost of healthcare which is as much as people rubbish Russia, i read they have free healthcare there and that is probably because the government makes it free.
But the cost of living there is cheap.

Your perspective highlights a crucial aspect – the essential need for healthcare, especially for those who are unwell. The concern about the cost is valid, and you've touched on a key point regarding funding for hospitals, clinics, and healthcare professionals. The idea of free clinics with volunteer support is commendable, promoting accessibility to essential services.

The connection between the cost of living and healthcare expenses is significant. Countries with lower living costs often reflect more affordable healthcare. Your observation about Russia's healthcare system sheds light on the potential impact of government involvement in making healthcare more accessible.

It's an intricate balance between sustaining healthcare infrastructure and ensuring affordability. Your insights contribute to the ongoing conversation about creating a healthcare system that is both necessary and equitable.

I agree with your sentiment that healthcare should be accessible to all, reflecting the fundamental belief that every individual deserves the right to health and well-being. The notion of free healthcare, as seen in countries with government-funded systems, is indeed an ideal approach to ensuring that no one is denied medical treatment due to financial constraints.

However, the downside of free healthcare systems can sometimes be observed in the form of misuse and a lack of appreciation for the services provided. In my clinical practice, I have witnessed instances where patients discard medications or fail to follow through with treatments, perhaps because they do not directly bear the cost. This behavior not only leads to wastage of resources but can also undermine the effectiveness of healthcare delivery.

The challenge, therefore, lies in designing a healthcare system that balances accessibility with responsible usage. Educating the public about the value of healthcare resources, implementing systems to reduce waste, and perhaps introducing minimal charges for certain services to discourage misuse could be potential strategies to address these issues.

In your view, how can we strike a balance between making healthcare universally accessible while ensuring that the services are valued and used appropriately?

[LuckyR]

Considering your perspective and the historical context of the Oregon Health Plan, I'm interested in hearing more about your thoughts on the balance between innovation in healthcare policy and the practical challenges of implementation. How do you perceive the evolution of healthcare reform, especially in light of economic and political fluctuations?

To me, the primary conundrum within US Healthcare is reconciling two incompatible mindsets. The first is the idea of "equal" access for all, or at least not denying care to anyone. The second one is, the staunch unwillingness to pay for care either in the form of increased taxes, or bellyaching about copays, deductibles or whathaveyou.

Given that, the best psychological way forward is to have a two tiered system. Thus everybody knows everyone, regardless of their ability to pay, will get "care". And the costs of the second tier will be such that tax revenues can handle it with less of an increase (than a single tier system).

I liken both the problem and the solution to the psychologically universally accepted issue of transportation. Everyone has access to public transportation. But it's a bus, not a Toyota.

[LuckyR]

I completely agree with your perspective on the role of administrative staff in healthcare. The recent situation in Sri Lanka, where former health minister and officials have been jailed due to corruption, starkly illustrates the global challenge of maintaining integrity and accountability in healthcare administration. Such examples highlight the critical need for robust systems that prevent misuse of power and ensure that healthcare administration genuinely supports the clinical mission.

In the Sri Lankan context, the corrupted healthcare system has led to a loss of public trust, inefficiencies, and a decline in the quality of patient care. This scenario is not unique to Sri Lanka; similar issues can be found in various parts of the world where the healthcare system's administrative arm fails to prioritize patient care and support clinicians adequately.

To avoid such situations, there must be a system of checks and balances that ensures transparency and accountability in healthcare administration. Regular audits, whistleblower protection policies, and strong legal frameworks are essential to deter corruption and malpractice. Furthermore, the selection process for administrative roles in healthcare should prioritize candidates with a proven track record of ethical behavior and a genuine commitment to supporting clinical staff and patient care.

What are your thoughts on implementing such measures, and do you think they would be effective in maintaining the integrity of healthcare administration globally? What other steps do you think should be taken to prevent the kind of administrative failure and corruption?

Oh, the answer is pretty easy (in concept). Administrators should be on the same payscale as top clinicians and (more importantly) have the same benefits and retirement as clinicians. This ensures that no one is going to seek Administrative work for financial reasons. Rather because they enjoy the business of medicine more than the clinical aspect (which is a win/win, since they're likely lousy clinicians). Also they will keep the retirement plans viable since they're going to actually need it.

Of course, the board will grumble that you can't attract "stars" in Admin with such paltry compensation, which is true. But does every single system need a "star"? Their work is actually more akin to a Caretaker or Gardener who maintains a system than the CEO of Apple who is going to revolutionize the entire field. Great Admin is more about avoiding huge errors than accomplishing victories.

[Sushan]

Considering your perspective and the historical context of the Oregon Health Plan, I'm interested in hearing more about your thoughts on the balance between innovation in healthcare policy and the practical challenges of implementation. How do you perceive the evolution of healthcare reform, especially in light of economic and political fluctuations?

To me, the primary conundrum within US Healthcare is reconciling two incompatible mindsets. The first is the idea of "equal" access for all, or at least not denying care to anyone. The second one is, the staunch unwillingness to pay for care either in the form of increased taxes, or bellyaching about copays, deductibles or whathaveyou.

Given that, the best psychological way forward is to have a two tiered system. Thus everybody knows everyone, regardless of their ability to pay, will get "care". And the costs of the second tier will be such that tax revenues can handle it with less of an increase (than a single tier system).

I liken both the problem and the solution to the psychologically universally accepted issue of transportation. Everyone has access to public transportation. But it's a bus, not a Toyota.

Thank you for the public transport analogy, which elucidates the situation effectively.

In my country, although we don't have a two-tier system, we operate a completely free healthcare system. This system, paradoxically, compels individuals to either somehow access the second tier you proposed or to abandon treatment altogether. Often, those with limited financial resources opt for the latter. This system is financed by taxpayer money, yet financially stable individuals typically disregard the free service.

If a two-tier system were introduced in the US, how would it be financed, especially if there is resistance to paying higher taxes or out-of-pocket expenses? Furthermore, how could it prevent individuals from forgoing treatment, the dilemma we currently face in my country?

[Sushan]

I completely agree with your perspective on the role of administrative staff in healthcare. The recent situation in Sri Lanka, where former health minister and officials have been jailed due to corruption, starkly illustrates the global challenge of maintaining integrity and accountability in healthcare administration. Such examples highlight the critical need for robust systems that prevent misuse of power and ensure that healthcare administration genuinely supports the clinical mission.

In the Sri Lankan context, the corrupted healthcare system has led to a loss of public trust, inefficiencies, and a decline in the quality of patient care. This scenario is not unique to Sri Lanka; similar issues can be found in various parts of the world where the healthcare system's administrative arm fails to prioritize patient care and support clinicians adequately.

To avoid such situations, there must be a system of checks and balances that ensures transparency and accountability in healthcare administration. Regular audits, whistleblower protection policies, and strong legal frameworks are essential to deter corruption and malpractice. Furthermore, the selection process for administrative roles in healthcare should prioritize candidates with a proven track record of ethical behavior and a genuine commitment to supporting clinical staff and patient care.

What are your thoughts on implementing such measures, and do you think they would be effective in maintaining the integrity of healthcare administration globally? What other steps do you think should be taken to prevent the kind of administrative failure and corruption?

Oh, the answer is pretty easy (in concept). Administrators should be on the same payscale as top clinicians and (more importantly) have the same benefits and retirement as clinicians. This ensures that no one is going to seek Administrative work for financial reasons. Rather because they enjoy the business of medicine more than the clinical aspect (which is a win/win, since they're likely lousy clinicians). Also they will keep the retirement plans viable since they're going to actually need it.

Of course, the board will grumble that you can't attract "stars" in Admin with such paltry compensation, which is true. But does every single system need a "star"? Their work is actually more akin to a Caretaker or Gardener who maintains a system than the CEO of Apple who is going to revolutionize the entire field. Great Admin is more about avoiding huge errors than accomplishing victories.

I believe that is a viable option. In this manner, only individuals truly interested in administration (or those too indolent for clinical duties ) will gravitate toward the administrative sector.

However, what if we bolster the rules and punitive measures, expelling the black sheep from the system with significant publicity? This approach could deter potential wrongdoers from becoming black sheep. Wouldn't this be more effective, feasible, and rapid?

[LuckyR]

I completely agree with your perspective on the role of administrative staff in healthcare. The recent situation in Sri Lanka, where former health minister and officials have been jailed due to corruption, starkly illustrates the global challenge of maintaining integrity and accountability in healthcare administration. Such examples highlight the critical need for robust systems that prevent misuse of power and ensure that healthcare administration genuinely supports the clinical mission.

In the Sri Lankan context, the corrupted healthcare system has led to a loss of public trust, inefficiencies, and a decline in the quality of patient care. This scenario is not unique to Sri Lanka; similar issues can be found in various parts of the world where the healthcare system's administrative arm fails to prioritize patient care and support clinicians adequately.

To avoid such situations, there must be a system of checks and balances that ensures transparency and accountability in healthcare administration. Regular audits, whistleblower protection policies, and strong legal frameworks are essential to deter corruption and malpractice. Furthermore, the selection process for administrative roles in healthcare should prioritize candidates with a proven track record of ethical behavior and a genuine commitment to supporting clinical staff and patient care.

What are your thoughts on implementing such measures, and do you think they would be effective in maintaining the integrity of healthcare administration globally? What other steps do you think should be taken to prevent the kind of administrative failure and corruption?

Oh, the answer is pretty easy (in concept). Administrators should be on the same payscale as top clinicians and (more importantly) have the same benefits and retirement as clinicians. This ensures that no one is going to seek Administrative work for financial reasons. Rather because they enjoy the business of medicine more than the clinical aspect (which is a win/win, since they're likely lousy clinicians). Also they will keep the retirement plans viable since they're going to actually need it.

Of course, the board will grumble that you can't attract "stars" in Admin with such paltry compensation, which is true. But does every single system need a "star"? Their work is actually more akin to a Caretaker or Gardener who maintains a system than the CEO of Apple who is going to revolutionize the entire field. Great Admin is more about avoiding huge errors than accomplishing victories.

I believe that is a viable option. In this manner, only individuals truly interested in administration (or those too indolent for clinical duties ) will gravitate toward the administrative sector.

However, what if we bolster the rules and punitive measures, expelling the black sheep from the system with significant publicity? This approach could deter potential wrongdoers from becoming black sheep. Wouldn't this be more effective, feasible, and rapid?

Yes, but we used a slightly different setup, which has worked extremely well for us. We had a version of the compensation package I mentioned. Historically our CEOs were drawn from our own clinician pool (not carpet baggers from elsewhere). This made the practice clinician centered, perhaps at the expense of the business. Then after a couple of decades, we attracted a "star" from the largest group (California) within our system which is known for high profitability but less clinician focus. He came in, cut a lot of the deadwood that had accumulated, which put the business on excellent footing but really upset a lot of clinicians who had carved out cushy practices (we are not compensated by productivity, rather hours worked). After a couple of years he had accumulated a critical mass of criticism and was forced out by the board. By then a homegrown successor had been groomed to take over and we reverted to a clinician centric focus, but on a much better financial footing. Win/win.