Tuesday, June 08, 2010

Choose: Choice is good or bad

Boston Globe columnist Steven Syre offers a thoughtful political view of health care issues in Massachusetts today. An excerpt:

The latest edition of an annual health care poll conducted by Mass Insight suggests most people don’t find the price they pay for health coverage to be a serious problem. The poll, which will be officially released next week, also shows a large majority of people don’t want to give up anything when it comes to health coverage or the freedom to choose whom they see for medical help.

... A majority of people polled said they disapproved of limiting coverage for high-cost and experimental treatments as well as policies that limit coverage for prescription drugs. A whopping 80 percent were against limiting consumer choice of doctors and hospitals.

I found this to be interesting because it is consistent with polls I have seen over the years. It suggests a disconnect between the policymakers and the general public, particularly on the issue of choice. But, perhaps there is an understandable reason for this disconnect: People have no sense of what it costs to get medical services at different hospitals; and they have no sense of the relative efficacy and safety of treatment in those hospitals. Maybe if they knew, they would be more amenable to paying less and getting equal or better care.

Last year, when the MA Payment Reform Commission issued its report promoting a move to global payments, many people who were enthusiastic about the report skimmed over the issue of patient choice. Limiting patient choice is a sine qua non if the state is serious about changing the mode of payment to a capitated system. But we do not have to have a repeat performance of the disaster of managed care from the past. Transparency of payment rates and clinical results is a necessary condition for success.


Keith said...

Mass. is the grand experiemnt of what is to come with the new health care bill. It is curious to watch as the goverment that created this new program in your state now wrestles with the fact that inadeaquate cost restraints were put in place, and how they can reign in these costs. Health care will need to learn to get by with less or they risk killing the goose that laid the golden egg. As much as many rail against goverment interference, it is goverment that is paying a larger and larger part of the health care tab, and as such,we need to be mindful of what impact this industry has on goverment deficits.

It is also interesting to see how we have come back around to the notions of capitation, which we unfortunatly let the insurance industry use in the past to offload risk without adequate reimbursments for assumption of that risk. The result was a disaster for providers, but I bet the insurance companies did quite well with that model. Will we make the same mistakes again and let for profit insurers pick our pockets while feathering their own nests? Hopefully the federal restrictions on insurance company overhead will limit this abuse, but it seems the health insurance industry is already working feverishly on how to make their medical loss ratios look higher than they actually are.

Laura said...

I'd like to see the parameters of this poll. How was it conducted? Who was surveyed, demographics of age, etc. I'm not doubting the results, especially as you say they seem consistent with past polls, but that is always a question I have about polls/surveys when they try to generalize on such an important issue.

I agree that patient choice is key and cannot be glossed over if we want to find a good solution

Kyle said...

This is interesting, because I was just talking to my roommate about this (in practical, not theoretical terms). She has a group plan through work but they don't subsidize her premium, and so she's curious what her other options are and what she could trade for lower premiums.

Personally, I'd gladly trade less choice, some restrictions on prescription drugs, etc., for lower premiums, but I get my insurance through work and, I guess, most of the people I work with feel differently, so I have a higher-end plan than I feel I need and I can (and sometimes do) use doctors and hospitals that I know are probably overpriced.

There's still so little individual choice in health insurance. I think there would be a market for lower-premium health insurance with more restrictions on providers, but because so many of us get our insurance through our jobs, the minority who are willing to trade choice are locked in to what the majority want.

Anonymous said...

From Facebook:

Winnie: I think this all goes back to the basic question of whether or not healthcare is a right or a privilege. I don't think most people want to think of better healthcare as just another perk for the "haves" and limited services/substandard care to be a consequence of being a "have not." I believe that healthcare consumers, for the most part, want to think of healthcare as the great equalizer.

Anonymous said...

Most people would tell a pollster that protecting the environment was a high priority, but if asked if they support higher energy taxes or restrictions on SUV's, they would run the other direction and politicians live in fear of such voters. Nothing new about the public wanting it both ways, unfortunately.

Anonymous said...

I would modify your statement below somewhat:

"But, perhaps there is an understandable reason for this disconnect: People have no sense of what it costs to get medical services at different hospitals; and they have no sense of the relative efficacy and safety of treatment in those hospitals."

My view (and that of many physicians currently seeing patients): People do not CARE what it costs to get medical services, because they are, largely, not paying for it except in the small group and individual markets. The only thing they care about is the size of their copayments, because that's all they can see. They also have the idea that better care costs more. (This view was expressed in a recent survey I read,but I cannot find it. Will keep looking.)

I have heard all the arguments about making people have more "skin in the game" leading to deferral of necessary as well as unnecessary medical care, but the bottom line is, Americans fully expect to have their cake and eat it too. This expectation is perpetuated by our current insurance payment system.

I don't know the answers, but we need to ask the right questions first.

nonlocal MD

Anonymous said...

Well, I don't even like Dr. Daniel Palestrant (CEO of Sermo), but funny he should use the exact same term I did, over at The Health Care Blog (thehealthcareblog.com) just now:

"You live in one of the greatest countries on earth, one of the richest ones, yet arguably not one of the best for medicine. You may question why that is. I think I may have some answers. Essentially, you want to have your cake and eat it too.

When you are sick or injured, you want the best healthcare money can buy. But you want someone else to pay for it. You feel should not be made to pay for things that are not your fault, as you perceive it.

When you do not feel you have gotten the best healthcare someone else's money can buy, you scream, yell, threaten and generally act like a child."


Anonymous said...

(Note to Paul: you can combine this with my previous comment if feasible)

And, the survey I mentioned above, indicating that consumers believe more care is better even if it costs more, and do not know what evidence-based medicine means:



Dr. D said...

The Alternative Quality Contract is 90% capitation/financial incentives to withold care and 10% quality metrics. Until there are quality metrics for hundreds of common conditions and transparency in quality and cost then people will not accept a repackaged capitation scheme.

Anonymous said...

I realize controlling costs is an issue but limiting choice shouldn't be the answer. As an employee(non medical)of a major teaching hospital I'd be pretty upset if my employer prohibited me from getting my care where I work and within a few miles of where I live!

Would you offer your employees a health plan that did not allow them to seek out their care at your institution?

Unknown said...

I believe the BG piece misses an important element in the poll. What happens to the answers when small and mid-size private companies can no longer support the healthcare benefit to thier employees? My company has shifted health insurance providers twice in the past five years in an attempt to manage the rate of premium inflation. We have been sucessfull at this so far, but what happens when we are not. I bet that the polls would be dramaticly different if individuals really understood the cost of insurance premiums; meaning that they had to pay both thier share and the portion paid by thier employeer. I hear how the backbone of our economy is composed predominately of small and mid-size businesses, but rarely hear discussions around the challenges these companies have providing this benefit and what happens when they can no longer afford to.

Marco Huesch said...

Hi Paul

Very interesting and important subject.

Benjamin Krohmal and Ezekiel Emanuel wrote about this in a very accessible way a few years ago (see link below).

My recollection of the piece was that a tiered system could solve the "have one's cake and eat it too" dilemma.

In such a system, we could all have choices, but only within a 'core benefits package' paid for out of pooled tax payments.

Beyond such a basic tier, ethics and justice would be satisfied by allowing further choice for higher-tier services paid for privately out of pocket.

As a health economist, this appeals to me. It's a fair middle way between the rock of a Canadian-like single tier very limited choice system, and the hard place of our current multiple tier system where poorer folks have very few choices at all.

Best of all, places such as yours that work hard at promoting transparency of clinical results would benefit under such a system, because 'core benefits' users could exercise their choice and vote with their feet.

That link: "Access and Ability to Pay
The Ethics of a Tiered Health Care System", Krohmal, B & Emanuel E, Arch Intern Med. 2007;167(5):433-437.


Anonymous said...

Well, I am writing a whole novel all by myself with my comments, but now I am obligated to correct my previous comment quoting from a post on The Health Care Blog, purportedly by Dr.Daniel Palestrant.

Now THCB has issued an apology stating this post was NOT written by Dr. Palestrant,but by an anonymous physician poster on his physicians-only site, Sermo.

As the post went straight downhill from the part I quoted, I feel obligated to correct it here. Sorry to take up the space.


Barry Carol said...

As I understand it, starting in 2011, employers will be required to include on employees’ W-2 forms the amount the employer pays for health insurance on each employee’s behalf. While some employers already include this information on the W-2 or an annual statement listing all the components of total compensation, lots of employers don’t. Moreover, employers need to do a better job of making it clear to employees that their wages would be higher if health insurance premiums, along with other benefits costs, were lower. Or, the reason wages have stagnated in recent years is because health insurance cost increases are consuming much of the budget that could have otherwise been used to boost wages and/or improve other benefits.

I think it would also be helpful if employers offered employees more insurance options. Perhaps a high deductible plan, a narrow network HMO and a high option plan would make sense. Employers might cover all or almost all of the cost of the less expensive plan and let the employee pay the entire premium difference if he or she prefers one of the more expensive options.

Providers and insurers, for their part, should agree to eliminate confidentiality agreements that preclude disclosure of contract reimbursement rates. Maybe the state could help them along with some appropriate legislation or regulatory rulings. A little sunshine could go a long way here, in my opinion.

Anonymous said...

Barry! I was starting to worry about you; hadn't seen any comments anywhere for awhile.

As usual, however, your comments are way too reasonable. The last paragraph is particularly cogent; wonder why it's being ignored.