Steven Spear writes in response to an op-ed article in the New York Times. Simple and clear and clearly correct. Excerpts:
Jonathan Gruber (Medicine for the Job Market Dec. 4 08) may be right that healthcare reform will be economically good, but his assertion that we need to spend more to get more is based on the assumption that the care we currently receive is limited by the investments we make. This premise is wrong. The problem is not too few resources available to meet overwhelming needs. Rather, it is that those resources are managed in such an antiquated fashion that 1/3 to 1/2 are regularly squandered at great human and financial cost.
We do not need to spend more. Rather, we need to reward those who are getting better and provide incentive to others to do the same so what we invest is better spent. First, the federal government is uniquely able insist that performance be measured: both of treatments for various conditions and also on how well those treatments are carried out. This will be a huge benefit to payers and patients who, right now, are severely compromised in determining where they should look for care and if they are being treated as well as possible. Second, the federal government should make choices of where to access care based on those measurements, setting a powerful example for states and the private sector to do the same. The resultant shift in resources from those who use them badly to those who use them well will mean far better care for many more people–meaning poor access and poor care won’t be drains on society, and care will be provided at less cost—meaning that wealth will be available for other important uses.
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Throwing tons and tons of money at the healthcare system could end up being the same as throwing tons and tons of money at infrastructure. In the process of building bridges and roads (which will be beneficial), tennis courts and fishing ponds will also be built. I can see a ton of waste.
Receiving funds for healthcare needs to be much more of a meritocracy. The federal government can insist on these standards that you mentioned but who are the best people to establish them. Is it the private sector? Public sector? A mix? And, what lobbying interests will have to be fought to enact these measures? Are these measures anywhere in Obama's current policy or spending plans?
Here is a factoid that may help put the spending issue in a particular context. Medicare drug spending is forecast to grow from $2 billion in 2000 to $153 billion in 2016--a 7,550% increase. How will this enormous growth in Medicare’s share of total U.S. drug expenditures affect private insurers? Will it encourage employers to reduce or eliminate retiree and other "optional" benefits? How does this spending squeeze out the potential for other proactive efforts including prevention, EMR's, and quality and safety efforts?
Does the Obama team have the political backbone to go up against Pharma and other powerful lobbies whose agenda will be to preserve the status quo, in light of massive layoffs across the pharmaceutical and biotech industries?
Pay for performance sounds great on paper, but what happens when it's put into practice? Patient outcomes largely depend on comorbidities, risk factors, and the patients' compliance with the treatment program. Different physicians and different hospital systems often treat different patient populations with different risk stratifications. Therefore, if one physician's outcomes are worse than another's, it doesn't mean that one physician is worse than the other.
The practical result of pay for performance will, unfortunately, be physician unwillingness to treat the sickest, highest risk patients, and the downfall of academic teaching programs where the highest risk problems are often treated.
So care won't be better, it can be expected to worsen for the population of patients that need it most.
Health care needs reform, but pay for performance doesn't need to be part of it.
"meaning poor access and poor care won’t be drains on society"
I never understand how we keep considering human beings as expenses to be offset, instead of assets to be maintained.
Calling poor people a drain on society is to imply a net loss in their very existence, just because they're not rich. I know plenty of people - some working in healthcare - who contribute a lot to society. Their contributions happen not to be easily saleable, but they're just as vital.
This kind of cynical accounting makes me worry for everyone's future. Especially my own. I happen to live and work in in a state that's historically poor. I am part of the IT "revolution." But I make half what others in other areas - like Boston - make. I drive a 16-year-old car with 253,000 miles. I shop at the Salvation Army. I look for meat sales.
My customers love the work I do, and I keep computers helping them, not hindering. I am committed to excellence in myself and others, and have been for the 25 years I've been in the technology business. I am infectious with my smile and my attitude.
But according to this metric, I'm a "drain on society" and I guess I haven't earned the need of living. Isn't that what you're saying?
No? Then listen to yourself. Please. I beg you as an asset, not a liability
When has a new government program not promised to do more with less? The "argument to efficiency" is very popular.
The rallying cry of failure is always "we didn't try big enough." But how much extra efficiency can you wring out of a national level system instead of a state one? The big HMOs have tens of millions of members - how much fat could you trim if they had hundreds of millions?
Government isn't pixie dust. The HMOs care very much about efficiency and there is no reason to think politicians could do a better job and many reasons to think they couldn't (MRI machines in Canada aren't distributed by need but by bring-home-the-bacon politics).
Getting better is not always -as many people assume- a result of putting in more effort.
The effort has to be at the right place in the system (leverage point).
John Sterman, Head of the System Dynamics Group at MIT Sloan, gives a great example of the healthcare plans from a systemic perspective (check it out and you will see remarkable underlying reasons of the cost rising you see nowadays):
http://videocast.nih.gov/ram/ss032207.ram
Cheers,
Ralf
Back here in primary care, we struggle with arranging for P4P preventative services on an every 12 - 24 mo cycle. Yet, we know that the biology of disease does not really correlate with the orbit of the earth around the sun. It seems like we spend a lot of money on effort on P4P for many whose risk factors for disease do not justify the massive expenditure. We need HELP it selectively target preventive services to those as most risk. Have you notice that the "10 year screening colonoscopy gets repeated in 5 years....then 2-3 years because there was a slight uncertaintly about the findings. We need better research to put the resources where there is the greatest risk for particular diseases.
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