Tuesday, June 16, 2009

Another vote against single payer

In the current debate on health care reform in Washington, the chance of a single payer system emerging seems to be very small. I think that's fine. Three years ago, I made this point, citing a portion of the book Redefining Health Care, by Michael Porter and Elizabeth Teisberg.

Now, Clayton Christensen and his co-authors reinforce this view in The Innovator's Prescription. They note (on pages 400-401) that "almost every government with nationalized health care has been forced to ration access to advanced care in one way or another. . . . As a result, most countries with national health systems have had to develop alternative market-based channels for coverage as well -- so people can choose for themselves whether to pay for certain services, rather than leaving that choice to bureaucrats."

They further note, "Because of governments' tight control on caregivers' salaries, in many nations the best physicians establish themselves in private practice, where they can earn higher incomes by serving the wealthy. This is another paradox of national health system: while the intent is to assure universal access, often it is the elite who see the elite, while the rest see the rest.... We ... urge America's political leaders not to view further government control as a vehicle for solving our problems."

I have made similar comments based on my trips abroad, in Iceland, the UK, and elsewhere. When we look at the complexities and flaws of the US system, it is easy to think the grass is greener elsewhere, but it really is not in many respects. But, where we can certainly learn from those countries is the importance of putting greater emphasis on primary care. Interestingly, Medicare could do that tomorrow by changing reimbursement rates for primary care evaluation, diagnosis, and disease management types of services. But, as Brian Klepper noted some time ago, this is viewed as a zero-sum game by the specialists, and so those proposals do not make progress. (Thanks to Charlie Baker for linking to Brian's post over a year ago.)


Anonymous said...


But the idea of all the stakeholders that we can reform the system and everyone still make (or not spend) as much or more $$ as they did before is fantasy, is it not? The money has to come from somewhere. As a hospital CEO, do you really think it could all come from elimination of waste, higher quality and more efficient care, without reducing someone's piece of the pie?
BTW, I am ashamed as a physician that my colleagues would actually boo the President of the United States. Our collective decline in professionalism was showing there, no matter what they thought of his proposals.

nonlocal MD

Anonymous said...

Totally agree on the last point. On the first, we have to acknowledge that greater access will require tax increases. http://runningahospital.blogspot.com/2009/06/steps-towards-universal-health-coverage.html

Anonymous said...

I don't agree that the taxpayers should bear all the burden. Easy for me to say since I am retired, but the providers are going to have to pony up too, mainly by drastically reforming the Medicare payment system - not just cutting payments.
Regarding the booing, it did occur to me that he was speaking to a selected sample of physicians - AMA members. Perhaps this says something about this particular sample. (:
(can you guess whether I am a member?!)


Sue said...

And having insurance company employees ration care, while paying millions of dollars in salaries to top executives is not "rationing"??? or is somehow a more acceptable form of rationing?

Anonymous said...

Compared to what is the question. Ask people who leave Canada to have elective procedures done in the US. Ask people in the UK who wait a month for angioplasty when they have chest pains.

Anonymous said...

There is already rationing of health care in this country when 50 million people have no health insurance. I don't care about if we have a national payer system or a full private system - what matters is an external performance measure in the system and in that way our system sucks. Every other developed system has better quality indicators then the US. We need better and strong regulation in the system so everyone has access to healthcare. Right now we have a healthcare bubble similar to the financial sector bubble. A PCP will shuffle a patient with chest pain to a cardiologist that will do a cardiac cath then will shuffle the patient to a GI doctor that will do a endoscopy and then then will send the patient back to the PCP that will conclude that the patient had chest pain from muscle strain. Everyone collects fees from the system and the risk is sent to society based on higher insurance payments. Just like the mortgage broker sold a mortgage to the bank then the bank sold it to other investors and then created derivatives - everyone made money until the bubble exploded and the tax payer got the final bill.

It is interesting that the share of the financial sector in relation to the GNP has been increasing a lot (right now is 31%) It is similar how the health care sector grew up to 17% of the GNP without any significant improvement in health care indicators. That sounds like a bubble.

Concerned MD

Anonymous said...

Of course we ration care. We do it by creating barriers that prevent working people who can't get affordable health insurance from their employer from getting basic health care.

Other systems at least ration by somewhat transparent, research-based criteria. Here ration by income and status. It's not silly or naive to prefer the former over than the latter.'

Yes, Canadians have to wait longer for some elective procedures. But no person working in the Canadian retail or service sector has to worry about the cost of basic, essential care. Millions American workers in that category -- including a lot of health care workers! -- don't have secure, affordable access.

Anonymous said...

Of course I agree on the access question, as I have noted elsewhere. Providing access is job one, and let's admit that we should raise taxes to pay for that to subsidize those who need it.

To these points:
"Other systems at least ration by somewhat transparent, research-based criteria." >>Not really.
"Here ration by income and status." >>There, too.

Anonymous said...

Excellent NYT article regarding rationing of healthcare in the US versus other countries. We have the worst kind of rationing compared to other countries because we provide lower quality of care, less people have access and we have the most expensive system

Concerned MD

Anonymous said...

Inaccurate to say "worst" because it is highly variable, both here and in those countries. I could tell you horror stories about those countries, too. That's not an excuse not to improve things here, particularly with regard to access and properly funding primary care -- but don't be too quick to assume the grass is greener over there.

Brenda RN said...

I wouldn't assume the grass is always greener over there, but rationing by insurance executives is the worst possible scenario in my opinion. We have a bit of a scewed perspective here in Massachusetts. Most of the health care plans are really good. I have had health insurance provided by a national company (the only choice provided by a previous employer). The coverage was terrible. Virtually nothing was covered (mammograms e.g.), the premiums were high, and there were high out of pocket costs. For those without employer provided coverage the choices can be much worse. We have ceded control of our medical care to the insurance companies. THAT is the true problem. A public insurance option is the next best choice if single payer is not going to happen.
There will always be horror stories, no matter what nation you are looking at. Single payer does not mean perfection. But fiscally it simply makes so much more sense. Without a public option, we will, just like with Medicare D, give insurance companies a big infusion of cash, while patients get minimal benefit.