Sunday, April 10, 2016

My healthcare credo to date

As an amateur healthcare student, every now and then I like to pause and take stock of the convictions I've picked up by osmosis -- by deciding, consciously and unconsciously, what (and whom) to credit in what I read and hear. Here's a short set of hypotheses (and suspicions).

1. The single most important means of healthcare cost control is uniform or at least coordinated pricing: single payer, all-payer, or, maybe in the U.S., private as a fixed percentage of public. The U.S.'s  unique every-payer-for-itself system is the main reason Americans pay far more per procedure than citizens of any other developed country.

2. The evils of market consolidation are likely to outstrip the virtues of coordinated care.

3. Which treatments and drugs are covered by insurance, and to what level (ideally by all payers in concert, and. by Medicare and Medicaid in our current system) should be informed by outcomes research and price/benefit calculations.

4. The wisest words ever spoken by a public health official: "We cover everybody, but not everything."*

5. Payment incentives probably work best when they're negative -- penalties for high infection rates, or possibly high discharge rates, or for not using checklists, or for overprescribing certain treatments.

6. Positive incentives are likely to a) not measure what really matters and b) be gamed (I'm most open to being convinced I'm wrong on this one, and hope I am).

7. Significant new investment in the social determinants of health -- decent affordable housing, equitable education, environmental protection (e.g., against lead), new mother home visits -- might be the most effective way to bring down healthcare costs.

8. Consumer-directed health insurance is a scam -- a tax shelter for the wealthy, a barrier to physical and financial well being for the not-wealthy.

9. Narrow networks are only necessary in a dysfunctional system where it's every payer for itself.

10. Balance billing is a sign of deep societal dysfunction.

* Former British health minister John Reid, as quoted in T.R. Reid's (no relation) The Healing of America (Penguin Press, 2009, p. 221).


  1. Collegial and friendly comments:

    #6: What do you mean by positive incentives?

    #9: Dysfunctional system? Narrow networks could be appropriate in a functional system. If your vision is one IDS per city/MSA, I get it. But not realistic I think--and using networks seems like a sensible strategy.

    #10: Deep dysfunction? We designed our system to get us the intended result. I dont see it as societal dysfunction.

    Add #11: Medicaid as all things to all people will accelerate its demise in current form. Unsolved LTC needs and underfunding cannot persist indefinitely.

    1. Collegial and friendly responses:

      #6: Some incentives in PQRS (Physician Quality Reporting System, the basis for CMS's incentive programs) for example, are process-oriented; some are patient safety measures, and some measure outcomes. Some complain on general principle about process measures because they *don't* require evidence of better outcomes, but I worry generally about outcomes measures -- like, say, the results of cataract or retinal detachment surgery or post-stroke treatment. Perhaps the condition of patients prior to treatment can be massaged. A frequent counterargument against "test results will be gamed" worries in all fields is that you have to measure, and do the best you can to guard against cheating or gaming, and that's true to a degree.

      #9: If pricing were more or less uniform, different plans/insurers could conceivably shape networks on the basis of quality, but that might boil down to just weeding out really subpar performers. I suspect hat at present, there's a lot of lip service to selecting for quality but it's 97% about price.

      #10 We didn't exactly design our system; a lot happened by accident, and a lot didn't happen because powerful lobbies prevented it. No other developed country exposes patients at an in-network hospital to balance billing by out-of-network providers at that hospital. We allow it because of the power of (mainly) physicians' groups and (secondarily) insurers, and because the tug-of-war between them is uncontrolled. That's dysfunctional in my book.

      #11: Agreed that LTC is another major mess, where your choices, if you're not destitute, are unreliable private insurance or a riks of spending down till Medicaid kicks in.

  2. I, too, would like you to clarify. I don't know what you mean by #2. I find your blog consistently useful.

    1. Thank you, Unknown. The ACA provides a raft of incentives for physician groups and hospitals to provide "coordinated care" that have accelerated existing momentum for hospital mergers and hospital buy-ups of physician groups. Historically, hospital mergers have led to higher prices, and recent research points toward physicians charging more once they're acquired by hospitals or health systems.

  3. Thanks as always for your forthrightness.

    I do not agree with three items:

    #7 - Social determinants of health

    Vast sums are spent on dialysis and cancer and CHF and COPD for perfectly normal happy people who just live a hell of a long time.

    9. Narrow networks in some form will be with us even in an equitable single payer system.

    Let us say that an America single payer system set the price of bypass surgery at $20,000.

    Mayo Clinic or Cleveland Clinic wants to charge $40,000.

    The single payer system says, "We will not pay Mayo's charges/"

    That is in effect a narrow network.

    10. Balance billing

    Undisclosed balance billing is a monstrous testimony to medical greed, I agree with you there.

    But transparent price quotes are not an evil thing.