Congress Has Forgotten America’s Biggest Health Care Problem
The critical question is not who gets care and who doesn’t, but how it’s delivered. [1]
By Nisarg A. Patel [2]
Senate Majority Leader Mitch McConnell’s health care bill won’t do anything to incentivize states and health care organizations to deliver better, more efficient care.
Above, McConnell speaks at a fundraiser in Elizabethtown, Kentucky, on June 30.
Photo by Bryan Woolston/Reuters removed
We spend too much on health care in this country—U.S. health care spending has spiked to more than 17 percent of our gross domestic product [3]. Insurance has become outrageously expensive, which is one of the reasons we need health care reform. (We all utilize more when it’s free.)
To understand why the cost of health insurance continues to increase, we need to understand why the cost of overall health care spending is rising. Most health care over the past 20 years has been reimbursed under a fee-for-service model, a flat sum for each test or procedure provided to patients regardless of outcome. As a result, the U.S. both orders and spends more on medical tests and treatments per person than any other country. Yet, we show no better health outcomes [4] for patients. (Fee-for-service works only when the recipient pays the fee for the service.)
This lack of accountability for outcomes compounded with a model that rewards volume over value has created a bloated system. While an MRI in the U.S. costs four times more [5] than an MRI in France, increases in U.S. life expectancy have flatlined relative to Western Europe [6]. (The cost of a procedure or test paid by insurance is frequently three or four times as high as when a patient pays personally.)
There is no easy way for a patient to become “smarter” at purchasing health care. *(But the patient does not pay for health care. Only third parties—Medicare, Medicaid, BC, BS, Insurance.)
Physicians and business school professors often speak of “bending the cost curve”—decreasing the rate at which health care costs rise. If we can redesign health care delivery to reduce overall spending and improve patient outcomes, then the cost of providing health insurance becomes a much smaller problem. The flip side of that equation is that if we don’t tackle issues of quality and efficiency in the health care system, then whatever way Congress ends up choosing to provide health care coverage won’t matter; health care costs will become increasingly unaffordable and erode access to coverage as everyday Americans are priced out of the insurance market. (This applies to administrative design of health insurance which will always decrease the quality of care of physicians practicing on the basis of their prolonged training.)
Initiatives from the Affordable Care Act, including Accountable Care Organizations and Medicare’s bundled payment program, began shifting some health services from fee-for-service to fee-for-value, evaluating quality relative to cost. These included penalizing health systems for high readmission rates and linking physician payments to better patient health outcomes. (Value can only be achieved by allowing physicians to practice without bureaucratic control.) Recent evidence suggests that these programs may be linked with fewer readmissions [7], a good proxy for better outcomes, and reduced health care spending [8] respectively. (Not necessarily. Physicians will be able to order $20,000 worth of test even if a 4-day average stage is reduced to three-day stay. Administrators are unable to see the value of any individual tests—only physicians can see the value. Administrators only see costs without any perceived value.)
The Senate health care bill, on the other hand, has no theory of cost control. It simply cuts funding for health care without addressing the root cause of rising costs. Even the last-minute horse trading over health savings accounts and opioid funding [9] has largely focused on who pays for health care, rather than how we receive it. GOP proposals over the past year have largely placed the burden on health insurance companies to drive down the overall costs of care, calling for high deductibles and co-pays that shift costs directly to patients to make them “smarter buyers” of health services.
But there is no easy way for a patient to become “smarter” at purchasing health care. Insurance companies can experiment with financial incentives—or disincentives—all they want, but those can be dangerous for patients’ health. (Free medical care is more dangerous for patient’s health) People can’t compare and purchase health care the same way they do with apples or airline tickets. (People pay for a known product with apples and airline tickets. If they paid for clinical opinions, they would be comparable.) The cost of medical treatment is shrouded in mystery and runs tens of thousands of dollars. (The mystery is of Medicare and Insurance making. It is only a mystery to their administrators.) The choice of which service is right is dependent on expertise that the patients often don’t have. *(However, the patient with the guidance of a doctor would have.) When deductibles are too high, evidence suggests patients may opt to forgo care entirely [10]. *(How high is too high for deductibles? When it’s more than the average cost of the non-insurable portion of healthcare. This should be easy to calculate. But it would decrease the cost of insurance and thus no insurance company will implement it) That may lower costs in the moment, but it won’t make anyone healthier. And it won’t lower the financial burden in the long run.
Insurance companies fundamentally don’t have the clinical or managerial expertise to create the changes that health systems need to improve quality and reduce costs. Insurers won’t improve coordination between hospitals, streamline clinician workflows, or increase surgical safety standards. They won’t get patients to take their medications more often, come in for preventive care, improve health IT infrastructure, or reduce hospital infection rates. Those changes, the ones that truly drive efficiency and reduce overall spending in health care, will have to come from concrete changes in policy and the operational efforts of clinicians. Current policy changes are moving our health care delivery system in the opposite direction. (All the above improvements would be automatic if the patient was in charge of the cost and had some skin in the decision) Tom Price, our health and human services secretary and a staunch critic of Medicare’s bundled payment program, delayed [11] mandatory experiments that would have tested outcomes-based payments on a national scale, despite evidence [12] demonstrating cost savings. Similarly, with all eyes focused on the Senate bill, the Centers for Medicare and Medicaid Services released a proposed rule to exempt more than 100,000 physicians from a bipartisan program that would have shifted their services to a value-based care model. . . (ED: Clinical outcomes in living beings with free will can never be predicted. The value is also different for every person.)
Read the entire report at http://www.slate.com/articles/health_and_science/medical_examiner/2017/07/delivery_not_access_is_the_biggest_problem_in_health_care.html [1]
Editorial Comment:
The whole idea that we have to improve quality of care is a hostile anti-professional political diatribe. The entire medical profession has “quality of care” as their middle name. The very idea that self-appointed non-medical bureaucrats, who are essentially medical illiterates, can judge the quality of the profession that has 4-years of college, 4-years of medical school, 4-years of post-doctoral specialty training, and 2 to 4-years of subspecialty training is ludicrous.
Unfortunately, the whole idea of physicians needing help in appropriate managing of patients, was initially proposed by the Executive Directors of our own professional organizations, with poor understanding of political medicine by the hard-working rank-and-file physicians and surgeons.
The administrators were enamored with possible political power much as the professional organizations in other countries including the UK where the British Medical Association is essentially a Union rather than a professional organization. When the profession placed one of their own in these executive administrative positions, they gradually became more like administrators and less like practicing physicians. Most authorities are saying that the BMA and the HHS in the UK are in a tailspin to disaster.
Solution: Since Physician Administrators and Trained MBA Administrators ended up with our current healthcare conglomeration, the answer is the free non-constricted practice of medicine for any licensed physician who can then practice in any state without restriction, thus being able to utilize the internet and innovate without rules. Return the needed control to the professional societies.
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