Health Care Cost Control: A Better Way

July 27th, 2010 at 2:25 pm | 45 Comments |

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Is rationing required to control healthcare costs? No. Not if you define rationing as denying care to a particular person with a specific illness. That is neither necessary nor even possible given our healthcare system or our legal system. Dr. Donald Berwick’s appointment as CMS Director may be a hoped-for step towards adopting the British system by some, but it won’t work.

Rather, we need a system that focuses on eliminating the moral hazard where neither patients nor doctors have a direct stake in the cost of care. This notion was widely discussed in the debate over Obamacare but seems to have fallen off the political radar screen.

What elements need to be in place to achieve this cost consciousness? First, physicians need to have some of the concerns about the cost of care be embedded in their clinical treatments. This need not pit physicians’ interests against patients’ interest, although clearly that risk needs to be closely monitored. Risk/benefit decisions now are almost entirely made on the concern of risk to the patient’s safety versus the possible uncovering of useful clinical information.

There are many excellent of examples of the common sense benefits of considering costs in clinical decision-making: Use of computed tomography of the head for minor trauma has been well studied and the data are quite clear that unless a patient has headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the collar bone, or a seizure, a CT of the head has a less than a 1% chance of uncovering a problem that would require any active intervention. It would be a mistake for a physician who still had some concerns about the patient despite the absence of these criteria from being enjoined to order the study. However, the physician should be not only free to follow these well documented guidelines but also free from the risk of a lawsuit if the guidelines are appropriately invoked. Right now, there is absolutely no economic reason for a physician to hesitate to order a CT scan in this setting. While many emergency room physicians are well aware of these guidelines and adhere to them, there are many who do not. Avoiding the CT scan would save costs and also lead to less radiation exposure. There are literally thousands of such examples.

The best way to have physicians concerned about the costs of their diagnostic tests and therapies is to create a competitive model in which both doctors and patients have to worry about how much they are spending.  In fact, it may be the only way. While it will take a long time to achieve this type of payment system, it is likely the single most logical approach. The main Obamacare plan model is not to promote such individual responsibility but rather to maintain the piecemeal approach of fee for service care with either price controls or, in progressive-world nirvana, a central administrator determining allowable care. These two approaches will create a nightmare for physicians and patients. Remember that these national healthcare schemes in Europe are fine as long as you are not too ill or not ill at all and really do not care about runaway government spending… Of course everyone loves a “free” system that treats your poison ivy rash and gets you right back to work. But if you have invasive skin cancer, be prepared to wait to see the specialist.

The recently described reorganization of the National Health Service in the UK is not a plan that would be acceptable in the US. They plan to turn the entire healthcare system into the province of primary care physicians. This is a political response favored by progressives who really do not favor real progress. A modern, technologically advanced healthcare system needs knowledgeable and skilled specialists to provide optimal care. Sure, it is good to have coordination of care and treatment for less complex problems but that kind of care should supplement the care of complex and critically ill patients. The latter is more efficiently and more effectively delivered by specialists. A “new age” healthcare system will focus on diet and vitamins and other lifestyle nostrums that have rarely been shown to matter all that much (except for smoking). There are 17.9 million or so patients with cancer in the U.S. They need more than a daily helping of fruit.

In order to make a prepaid system work, a very difficult but achievable reform of the delivery system is required. Obamacare does propose some demonstration projects that look into some aspects of this idea but the whole plan lacks the one element that could make physicians and hospitals aggressively pursue reform models that could work — incentives and competition. Plans with these characteristics can be designed and created but they put far more responsibility in the hands of doctors and patients than Mrs. Pelosi finds acceptable.



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45 Comments so far ↓

  • Rabiner

    Stanley Goldfarb:

    “Not unless our country is willing to accept a breast cancer survival rate that is some 30- 50% lower in the U.K. compared to the U.S and a slew of lawsuits that would go with such an outcome.”

    When you standardize detection rates I’ve read that survival rates are equal. The discrepancy comes from late detection not treatment for disease found at the same stage.

    “What elements need to be in place to achieve this cost consciousness? First, physicians need to have some of the concerns about the cost of care be embedded in their clinical treatments. This need not pit physicians’ interests against patients’ interest, although clearly that risk needs to be closely monitored. Risk/benefit decisions now are almost entirely made on the concern of risk to the patient’s safety versus the possible uncovering of useful clinical information.”

    How can you argue for cost/benefit analysis only after criticizing it by mentioning different breast cancer survival rates which are the result of early detection and screening? That detection and screening has been shown to be highly inefficient and unreliable (mammograms come to mind).

    “a CT of the head has a less than a 1% chance of uncovering a problem that would require any active intervention”

    I hear that if you change recommendations so mammograms are for people after 50 and every 2 years after instead of at 40 and every 2 years after you reduce the false positives significantly and it has little impact on breast cancer killing anyone although that rate would increase.

    “Remember that these national healthcare schemes in Europe are fine as long as you are not too ill or not ill at all and really do not care about runaway government spending..”

    It isn’t a scheme, it’s a system.

  • mikewaz

    I see a lot of vague hand-waving as to the solution, but no actual description of what we should do. Just saying “physicians should follow the guidelines” doesn’t cut it; look at what happened when the U.S. Preventive Services Task Force recommended changing the starting age for routine mammograms from 40 to 50. Even when they specifically said that people who have significant risk factors like the breast cancer gene, extensive chest radiation exposure, or relatives who had breast cancer should still start at 40, people flipped out. Many doctors said they would not follow that directive. Thousands of ailments are treated differently across the country.

    The two Medicare pilot programs that I think have hope for reforming how we pay for health care are the bundled payment pilot that’s scheduled to start in 2013 and the pay-for-performance pilot that was started back in 2005 but appears to still be going. More than anything else we can do, those two changes would change the emphasis in health care from throwing everything against the wall and seeing what sticks to doing it right the first time.

  • LFC

    There are many excellent of examples of the common sense benefits of considering costs in clinical decision-making:

    Sounds great, but unfortunately they are currently politically impossible.

    Can you imagine if a gov’t organization like the NIH came up with an annual set of guidelines for health care professionals to follow? Since it’s highly inefficient for every medical professional to keep up on all of the literature and research that would go into this each year, it seems like a great idea, right? Well just wait for the right-wing shrill and shrieking voices screaming “DEATH PANELS!” in 3, 2, 1…

  • Madeline

    It isn’t a scheme, it’s a system.

    “Scheme” has a slightly different meaning in the UK. When I was working in London, my employer handed me some information on the “health care schemes” they offered. I was wondering what was so fishy about them until I realized the “health care scheme” meant the same thing as “health care plan”.

  • RedSonja2000

    “Not unless our country is willing to accept a breast cancer survival rate that is some 30- 50% lower in the U.K. compared to the U.S…”

    Mr. Goldfarb fails to mention that 10 European countries (according to the WHO) have lower breast cancer mortality rates than the US in spite of their “national healthcare schemes.”

    “But if you have invasive skin cancer, be prepared to wait to see the specialist.”

    Like a lot of right-wing apologists, Mr. Goldfarb appears to know nothing at all about medical triage. Every country in the world from Zimbabwe to Austria sees the most serious patients first. That’s even exactly how we do it here in the USA and there would be no reason at all to change the practice regardless of who was paying the medical bills.

    Oh, and mentioning Nancy Pelosi’s name in the last sentence made me run out the door screaming in terror just as it was supposed to.

  • Rabiner

    Madeline:

    ““Scheme” has a slightly different meaning in the UK. When I was working in London, my employer handed me some information on the “health care schemes” they offered. I was wondering what was so fishy about them until I realized the “health care scheme” meant the same thing as “health care plan”.”

    That may be so, but he’s writing for an American website. Scheme is very different in American English.

  • LFC

    Maybe I’m being incredibly naive about their purpose, but shouldn’t the AMA be pushing for a guide to basic standards as a service to their members?

  • Oldskool

    “if you have invasive skin cancer, be prepared to wait to see the specialist”

    Until the new plan goes into effect, you may not get your cancer treated at all unless you produce a boatload of cash or a top notch insurance plan. Suggesting that waiting for care would be something new is disengenuous.

  • GEValle

    The best, and proven way to lower healthcare costs is to get the government OUT of healthcare…PERIOD.

    This includes serious tort reform that limits the ability of trial lawyers to rape insurance companies and pharmaceutical companies. Gee…Now WHY was tort reform NOT in Obama’s “plan”???

  • msmilack

    Berwick has no interest in rationing.

  • Rabiner

    GEValle:

    “The best, and proven way to lower healthcare costs is to get the government OUT of healthcare…PERIOD.

    This includes serious tort reform that limits the ability of trial lawyers to rape insurance companies and pharmaceutical companies. Gee…Now WHY was tort reform NOT in Obama’s “plan”???”

    umm, can I have what you’re smoking?

  • easton

    RedSonja, absolutely right:

    “Remember that these national healthcare schemes in Europe are fine as long as you are not too ill or not ill at all and really do not care about runaway government spending..”

    Is a baseless and unsupportable assertion, in other words a damnable lie. And why the focus always on England is beyond me… look around your house and see how many things say “Made in England.”
    How about compare our system to Japan or Germany? The reason Republicans don’t is because they know it will only make them look like fools. Japan pays 60% of our health care costs, have better outcomes (highest life expectancy), and has universal coverage. Has Mr. Goldfarb ever heard of Japan? How about a detailed contrast between our two systems and see what we can learn from them? What about Germany, which at less than 11% is far below the US 16% and which also has better outcomes than the United States. In fact by life expectancy the US is down at 38, much, much lower than Japan at 1 and Germany at 23. In fact, most European nations are above the US. Does Mr. Goldfarb believe Europeans or Japanese do not get sick?

    Selective statistics (find one area where the US is slightly better than extrapolate it to the whole) and baseless assertion. Rubbish. The worst thing is I agree with his central thesis of cost consciousness, sad he had to throw in baseless opinion.

  • easton

    GEValle, then how do you explain how all of the countries that have much more Government involvement spend less and have longer life expectancies? Seriously. You can’t, so you will ignore it.

  • msmilack

    I think this article raises many good points about cost consciousness but the doctors I know feel it puts them in a bind not just because of a fear of lawsuits but because they care about the patients and use some of these expensive tools for diagnostic purposes. In other words while what you say sounds practical, I’m not sure how many physicians would agree with you that under those circumstances they can still provide the best care.

    To everyone who thinks tort reform will make such a big difference: from all the reading I’ve done since the campaign and up until today, it seems clear that the majority of experts agree that tort reform is unlikely to make a dent in healthcare costs; the highest number I’ve seen is 2 percent at most. Now, 2 percent is still an improvement — and by the way, Obama for one has no objection to tort reform which he has explained since the campaign — but I would be willing to bet that if Obama creates legislation to that effect, the GOP will vote no. Why? Well, have they voted yes on any other domestic policy?

    You may recall that the health care bill was largely based on Republican ideas which the Republicans nonetheless automatically rejected because it came from the Democrats. I don’t believe for a second that the Republicans currently in office care at all about poor people in this country; the plan they came up with only addressed 3 million people instead of 300 million. I’m still waiting for the GOP to come up with a plan that truly addresses the people who elected them to office.

  • seeker656

    “Remember that these national healthcare schemes in Europe are fine as long as you are not too ill or not ill at all and really do not care about runaway government spending..”

    As T.R. Reid details in his book “The Healing of America” there is no example in the world of a free market health care system that provides adequate health care to the general population of a given nation. The runaway “government spending” in Europe is still 50% t0 60% of what we spend in the United States on health care when measured on a per capita or percentage of GDP basis.

  • msmilack

    easton // Jul 27, 2010 at 4:36 pm
    You wrote: “GEValle, then how do you explain how all of the countries that have much more Government involvement spend less and have longer life expectancies? Seriously. You can’t, so you will ignore it.”

    In fairness to GEValle (and others), while I know that what you say is factually true, it is not easy to understand. I don’t think it’s so much that people ignore that reality as that they simply don’t understand the economics of it. In America, we are used to believing that you get what you pay for so how is it that we pay more and get less? It’s confusing to most Americans, myself included though I absolutely know that other civilized countries have figured out how to do it right.

  • mikewaz

    GEValle:

    “The best, and proven way to lower healthcare costs is to get the government OUT of healthcare…PERIOD.

    This includes serious tort reform that limits the ability of trial lawyers to rape insurance companies and pharmaceutical companies. Gee…Now WHY was tort reform NOT in Obama’s “plan”???”

    Wrong (at least on the tort reform side). Specifically, see Sec. 10607. State demonstration programs to evaluate alternatives to current medical tort litigation. Also, in case you’re wondering, Harvard released a study showing that the current tort system is exceedingly effective at policing out cases with no injury and no error. The press release for the article can be found at http://www.hsph.harvard.edu/news/press-releases/2006-releases/press05102006.html. Another study looked at states that capped damages. They found that in states with caps, malpractice premiums increased on average by 48% over ten years. In comparison, states without caps saw premiums increase by 36% on average. The study can be found at http://www.bmpllp.com/publications/articles.php?action=display_publication&publication_id=28.

  • forgetn

    GEValle:

    If lower cost derive from lower government participation the US healthcare system should be the world’ cheapest and most efficient. Since America’s health care system has the lowest level of government intervention.

    Your assertion is completely wrong, since America’s health care system is by any measure the world’s most expensive.

  • msmilack

    mikewaz
    One program that has already gone into effect is the pooling of people who are unable to get health insurance because of pre-existing conditions.

  • forgetn

    Msmilack:

    You ask a very good question. How do France and Germany achieve better results out of their health care system for less than 1/3rd of what Americans pay (as a portion of GDP)?

    Three issues dominate the US healthcare system:

    (1) Administrative costs are a huge drag on costs in America — this includes everything for the profit element to the insurance for lawsuits, to much higher salaries for physicians in the U.S. than elsewhere (not making a value judgment — stating a fact).

    (2) Americans have poorer health habits, yes the smoke less, but they do face other constraints such as obesity which most foreigners don’t face at the same level (A day at Disney is a huge wake-up call on the scale of the problem).

    (3) More is better, the example of mammography is an excellent point of reference. Early test will give rise to false positive — leading to either aggressive surgery or radiotherapy. However, operations carry very heavy risks that can dramatically reduce quality of life, and don’t change the overall survivor rate for those who do have cancer in their 40s. In general, the issue is that if you have heart surgeons (again an example) they will operate on heart patients — America’s medical practice is over specialized (because the incentives are there!)

    These factors have a definite impact on the cost of America’s healthcare you don’t see in other jurisdictions. This of course a massive over simplification of the differences — there are many others.

  • msmilack

    mikewaz
    Tort reform is not something Obama has ever objected to; his point has always been that it amounts to such a small percentage of the overall healthcare costs (2 percent savings at most) that to focus on it instead of coming up with more creative solutions that make a bigger dent was often used by the Republicans as a distraction and an attempt to look like they were making a big difference when in fact it was a tiny difference.

  • msmilack

    forgetn
    Thanks for explaining that. I do recall Obama discussing the administrative costs and wasteful spending and we know the white house is focused on Americans living a healthier lifestyle. I personally do not object to physicians earning large salaries because they go to school for so many years to become specialized; if I have to go in for a heart operation, I’d like to know that in a competitive environment, the student who worked the hardest and got the best grades is operating on me. I think that financial incentive is necessary to producing the best doctors. Just my opinion.

  • easton

    forgetn, yes, thanks for that. Insurance companies also have massive advertising budgets.

    I also noticed how GEValle never did bother to even attempt to rebut anything.

  • forgetn

    Mismack:
    I didn’t say wasteful, the costs are simply there, not better or worse. With a largely private health care system, the profit element has to be there. America’s tort (and insurance premiums) are not about to disappear, these are part of the “American way of life”.

    You nail one aspect in your latest comment: “The best doctors” is a major issue, American doctors are overspecialized — fewer general practitioners than almost anywhere else in the world (excluding Canada — which has its own wacky problems).

    Again, its important to not look at anyone aspect as the culprit; the profit element is important if private healthcare is going to be part of the system. lawsuits are a good way or re-establishing justice for patients who have faced harm from doctors’ negligence. America is not about to police what people eat.

    An average hospital in North America offers more than 6,000 services to its patients. Few business anywhere in the world offer than kind of diversity of services. Healthcare is a complicated service to offer in any country.

  • msmilack

    easton

    With your point about the origin of costs: not only do insurance companies spend massive amounts on advertising; they also spend massive amounts on lobbyists. Lobbyists may be their biggest expenditure — at least it seemed so during the health care debate. I don’t suppose we can ever get rid of lobbyists though . . .

  • msmilack

    forgetn
    Thanks for responding. B/w, I do think there is an element of waste in administrative costs that could be curtailed though you are right, that was not the point you were making, so thanks for pointing that out; you are right, I had misunderstood you. I nonetheless remember that detail being part of the overall discussion before the vote on health care though I admit I don’t recall the details now. I’ll have to educate myself on the subject.

  • buddyglass

    Big agree. Health care costs more on a per-procedure business in the U.S. for sure, but that doesn’t tell the whole story when it comes to total spending. We spend more because we get more. The question is whether the “more” we get is actually beneficial in any meaningful way.

    A perfect example of this is the flap last year over the change in mammogram guidelines from the U.S. Preventative Services Task Force:

    http://www.cnn.com/2009/HEALTH/11/16/mammography.recommendation.changes/index.html

    Essentially they recommended that women start getting routine mammograms starting at age 50 instead of age 40. Almost every other first-world country uses 50 as their guideline. The recommendation was based on the fact that starting routine mammograms at 40 (instead of 50) actually saves very few lives. Does it save some lives? Yes. Just not very many.

    What was the response? People went crazy. OMG RATIIONING!!!

    What galled me most about it was the fact that using a starting age of 40 is itself just as arbitrary as using 50. Or, for that matter, limiting routine mammograms only to women.

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  • Oldskool

    Not sure if it’s been mentioned but advertising drives up the cost of health care too. Drug companies spend more on it than they do research. And it probably costs more than lawsuits to boot.

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  • msmilack

    buddyglass
    “Or, for that matter, limiting routine mammograms only to women.”

    It is true that there is a significant increase in the number of men who get breast cancer but I do not think the number is high enough to warrant an automatic recommendation of a mammogram for a man. Rather, it is suggested if any lump is found. I’m not sure what the percentage of the population has to be to make it uniformly recommended to all but the number is surely higher than it is at present.

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  • buddyglass

    @msmilack:

    That’s my point. I don’t think men should be getting routine mammograms either. But the argument raised in support of women 40-50 getting them is that “more people will die if this group doesn’t get routine mammograms, cost be damned”.

    So if you’re going to push for routine mammograms for women aged 40-50, why not do the same for women aged 30-40? After all, this will save lives. Why not women aged 20-30? Why not men?

    They tend to set the age cutoff based on cost. Its a bean counting exercise. Recommend a lower age and you catch more cases early, thus removing the need for expensive treatment later. Plus, you know, less people die. Make the age later and you spend less doing preventative mammograms (the vast majority of which will reveal nothing), but more money treating cases that could have been handled at less expense if they’d been caught earlier.

    Bear in mind nobody’s saying that Jane Doe can’t go out and spend her own money to get routine mammograms when she turns 40. She can. The question is whether these mammograms should be subsidized (by everyone else on her insurance plan), given the fairly small likelihood they’ll actually do her any good.

  • gman

    “The best way to have physicians concerned about the costs of their diagnostic tests and therapies is to create a competitive model in which both doctors and patients have to worry about how much they are spending.” 820 words, and that one, non-specific sentence is the only hint of a proposal in the entire article. The country is desperate to get a handle on out of control healthcare costs, and that’s the best we’re getting? It’s no wonder Obama was able to pass his flawed healthcare proposal – nature abhors a vacuum. I also continued to be puzzled about the contention that European style healthcare leaves very sick people with long waits to see the doctors that they need. I don’t know whether that’s true or not, but somehow Canada, UK, France, Germany, Sweden, Italy, Spain, Norway, Greece, Jordan (!), Netherlands, Luxembourg, Belgium, Finland, Portugal, Ireland, etc, etc, ALL have longer life expectancies than the US. The US is 49th in the world, just ahead of Albania, Cuba & Panama. Sorry, I’m not buying that as a meaningful argument anymore.

  • msmilack

    buddyglass
    Now I totally get your point. Thank you for explaining. As I was reading your response, I was also calculating in my head how much more radiation women would be exposed to if they started younger.

    Gman
    I was very struck by what you wrote: that we are 49th in life expectancy. There has to be a moral in that story related to the quality of our healthcare system.

    I’d be curious how that number breaks down socio-economically because I have a feeling that at least right now, our healthcare system is better for some people than others i.e. people without healthcare die faster than people who can afford medical care — no question — so I wonder how many of those who die young are living in poverty in this country. Maybe that number is less in those other countries and that partly accounts for the difference in overall life expectancy. Certainly the number is an average of all the deaths.

  • msmilack

    I have a friend whose husband has been in the hospital for ten weeks. He has had emergencies that involved not only ambulances but medical helicopters because he was on an island and had to be taken to a city hopsital where he underwent over several weeks two major operations (life saving), many weeks in intensive care and is now having rehabilitation. I wouldn’t know how to begin to guess at the total cost of his medical bills with or without insurance — the cost is the same, just a question of who pays for it. In his case, he is a retired coach and teacher and with his retirement came medical insurance plus medicare.

    I think of Dick Cheney and his multiple heart attacks and stints and life saving operations and his recent implant of a heart pump. I can’t imagine the cost of all his medical care (I’ve read the pump could be a couple hundred thousand dollars) but I have no doubt his is also paid for by his medical insurance from the government.

    The difference between the two men is income. My friend lives on a small pension; if he had to pay out of pocket for his care, he would be long dead. In Cheney’s case, he has made millions of dollars over the years and could easily pay for his treatment.

    Question: should Cheney (as a symbol) pay for his treatment? Should people of vast wealth pay the same amount of health insurance as the average Joe?

    It seems fundamentally wrong to me that people who can afford to pay don’t have to pay.

    I’m sure no one agrees with me and I’m not suggesting it would work as legislation. I’m just telling you how it makes me feel: like it is intrinsically wrong.

  • SFTor1

    I recently worked with a medical devices company. The VP of Regulatory Services could tell me that the company at all times had about 75–100 lawsuits going against other companies, and that they had about the same number of lawsuits facing them from other companies. Eye-opening numbers if you ask me.

    And let’s face it, health care will always be rationed. We need to take care away from patients in their last months of life and replace it with hospice care and palliative care. Yes, doctors are competent to make the determination whether you are on your last legs.

    And then, more social medicine. More initiatives against obesity, diabetes, and heart disease. More initiatives to increase the health status of the general population. That’s how we provide meaningful care and strengthen our economy to boot.

  • Bebe99

    it is mind boggling that there are no limits on the kind of care given to those nearing the end of life. Extrordinary measures are taken routinely to simply extend the lives of the terminally ill. In some cases these measures are only extending the suffering of the patient. Just because we CAN extend a life doesn’t mean we always should. This might be called rationing, but it is the issue most needed to be resolved in order to save our medical system.

  • forgetn

    Bebe99:

    It is very rare for hospital to undertake extraordinary measure on terminally ill patients. Not only is there a cost element, but within the medical community there is a realization that extraordinary measures (and I don’t mean keeping the patient comfortable) are cruel as most medical procedures are intrusive, painful and dangerous. The exception historically has been for ground breaking work — think heart transplants etc. But then the patient has decided to “donate” their body to science.

    Other countries (than the U.S.) have a very well established “hospice” system, that provides end of life counselling for both patient and family (Ms Palin’s infamous Death Panels). This in not something that is common in North America because of the country’s litigious nature (again no criticism — just an observation). The reality is also that doctors are today much better trained to understand when end of life treatment is appropriate. These are complex ethical and moral problems with which doctors have to deal with.

    As an example of the change in attitude, 15 years ago a treating physician would usually give to the patient and the family a positive statement as to the nature and progression of the illness. It was though that hope by the family and the patient would “improve” the healing, and increase the likelihood of recovery. Believe it not when this “view” was tested it proved to be false, because as soon as the patient faced a setback (which happens all the time), he became discouraged. Today, “failure is not an option attitude” is no longer part of the vocabulary of the treating physician, they will provide a forthright analysis of the outcome, providing the patient (and his family) with a clear outlook (the internet has also helped): This has proven to be the best outcome for patients since they can “trusts” their physicians — counterintuitive, yes but that’s the result of empirical analysis

  • busboy33

    So the plan is to achieve all the good things about reforming our Healthcare, without actually reforming it? What we’re going to do is, doctors will be super-good and patients will be super-honest and fair.

    I got this plan right? Because if that’s the case . . . yes. That would totally work. If things got better, then things would be better. Yes.

    . . . and a personal tip of the hat to throwing “British system” in the 1st paragraph. Totally irrevelant to your point, but really emotional trigger — saying “European Socialist” would have been too obvious, agreed.

    Besides, you’ve got the commenters to pick up the ball and run with it. So well done in terms of professionally manipulating people. A skillful job, Mr. Goldfarb. If you want to make it less obvious next time, bury the British reference until about the 35%+ mark. Get at least one random objective point going, then call the trigger. Right in the opening is a tad gouche.

  • oldgal

    Rather than worrying about who gets what when, we would be much better off developing health care delivery systems and tuning them – we have very few in this country and for-profit insurance companies, for various reasons, have little incentive to develop them. Kaiser Permanente and Cleveland Clinic are good examples of health care delivery systems that could be adapted. Anyone who has not studied these delivery systems should stay mute on the topic.

  • Stan

    It’s shocking but not surprising that Goldfarb omits mentioning the Independent Payment Advisory Board in his post. It’s discussed briefly in this article:

    http://www.nytimes.com/2010/07/29/us/politics/29bai.html?hp

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  • buddyglass

    One way to make consumers “feel” the cost of health care would be to regulate the insurance industry and stipulate (generally) what sort of plans it can offer. For instance, require that all plans have a deductible of at least X and establish an acceptable range for the percentages at which they cover visits, procedures and drugs.

    The goal of the plan’s structure should be to maintain the customer’s cost incentive not to utilize services unless they really need them, while at the same time preserving the reason we buy insurance in the first place: risk sharing.

    Consider a plan for a single person with a deductible equal to the median per capita health care spending in the United States (say $3000) that covers all visits, procedures and drugs at 50% until the deductible is reached, then at 95% after that. Maybe add a max-out-of-pocket clause of $10,000 per year.

    I know I would think twice about certain health care “purchases” if I were going to pay 50% of the cost. The deductible should be high enough that most people won’t reach it, otherwise everyone banks on hitting it and bases their decisions on the 95% post-deductible coverage.