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."*

For pharma and medical device makers, U.S. is The Big Rock Candy Mountain

The New York Times' Elisabeth Rosenthal is out with another front-page chapter in her incomparable epic detailing the dysfunction of the U.S. healthcare system. She's spotlighted (1, 2, 3) price-gouging by various physician specialties, hospitals, and now medical device makers and pharma.

Rosenthal focuses mainly on diabetes treatment. It really has improved radically over the past two decades, with ever-more sophisticated insulin pumps and accouterments, and synthetic human insulin.  But near-monopoly pricing power -- unmitigated, in the U.S. alone, by strong government pushback -- forces many patients to buy more sophisticated treatment than they need, at astronomical markups. As is de rigeur in Rosenthal's pieces, the contrast with other wealthy countries hurts most. The contrast with the U.K. highlights strengths and, to a lesser extent, weaknesses of a system that contrasts starkly with our own:

In Britain, each hospital negotiates for pumps for its patients, getting prices that are typically less than half those in the United States, Dr. Pickup said. The vial of insulin analogue that Ms. Hayley gets for $200 at an American pharmacy is typically bought by British pharmacists for under $30 and dispensed free....

A mantra for true health care reform

My takeaway from T.R. Reid's comparative look at national health care systems, The Healing of America, is distilled in this mantra from former British health minister John Reid:

We cover everybody, but not everything (p. 221).

That is the key to equitable, effective, sustainable health care delivery. As (T.R.) Reid's tour of successful health care systems makes clear, the very different systems at work in France, Germany and Japan (which channel payment through private but nonprofit insurers), Canada (single payer, Medicare model) and Britain (direct government funding) share these three elements:

1. Everybody has the same access to the same treatment
2. Every provider of each treatment (or of each patient, in a capitated system) gets the same pay as every other provider of that treatment.
3. One entity sets all treatment prices for the whole nation (or province, in Canada's case).

Establishing these conditions doesn't make cost control easy. It just makes it possible.

The health care reform bills pending in the U.S. won't create these conditions in one fell swoop. At best, they will establish adequate minimum insurance coverage standards and create viable nonprofit alternatives to the for-profit industry. Then, if we're lucky, those nonprofit options will indeed kill off for-profit insurance, exactly as AHIP fears.