Monday, August 25, 2008

Healthcare Reform

From DeLong on Waldmann's Healthcare Reform a most informative comment:

Wow. Where to begin.
1.) The assertion that high tech/high cost intervention is responsible for improvement in coronary disease mortality is at least questionable and probably wrong. The US actually trails most other developed nations in the effectiveness of care for coronary disease, and almost all of them use much more conservative care based on medicines and rehab and much less coronary bypass (the US performs 75% of the bypasses done in the world) and angioplasty. The big changes in coronary disease mortality are better ascribed to the development of new classes of drugs (especially beta blockers) than to interventional techniques. A recent US study showed that angioplasty actually resulted in worse outcomes than medical treatment in most patients.
2.) The regional differences in health care costs people like to talk about are based on two things: lower utilization of high tech/high cost techniques and the government policy of paying providers much less for care in some parts of the country than others. The index study on this compared Minneapolis and Miami. Miami happens to be the highest reimbursement area in the country. Minneapolis is in the low range for reimbursement among large metro areas. The government (HCFA) justifies these differences – often as much as 80% -- in reimbursement based on cost of living, but in reality political considerations are very important (if you are a congressman from South Florida and wish to continue your employment, you had better be very interested in Medicare reimbursement issues regardless of what party you belong to, whereas a congressman from Minnesota may be much more interested in farm policy.)
3.) The notion that health care costs are lower for people with good health habits is true only in the short term. Investigation by the Dutch national health system showed that non-smokers, people of more ideal weight, and people with healthy exercise patterns actually cost the system more in the long run. The reason is that they live longer. All people absorb large amounts of health care expense when they go through the process of health collapse and dying, and all people – especially old people – absorb health care expense in both a regular (normal year to year care) and irregular (more acute care) basis over time. People with less healthy habits enter the crisis stage of health care at a younger age. The baby boomer population of the US is now in an age range (45-65) where there is sharply increased morbidity and mortality among people with poor health habits. The more healthy boomers will experience the same sort of spike when they reach their 70’s, 80’s, and 90’s, and in the meantime will receive cataract surgeries, hip replacements, hysterectomies, prostate surgeries, treatment for low grade skin cancers, etc. etc. In the words of Bruce Springsteen, “everyone dies, and that’s a fact.” The only health care systems that benefit financially in the long term from insuring more healthy patients are systems, like our private insurance programs and HMO’s, which can dump the cost of caring for older people on other systems – Medicare. So while better health habits benefit the patients themselves and are to be strongly encouraged, they will actually increase costs to the entire national medical system in the long run. The notion that better health habits will reduce overall health costs is not correct.
4.) Prospective payment systems – paying providers a lump sum based on numbers and possibly types of enrolled patients – do not save money and do not improve health outcomes. America’s thirty year flirtation with HMO’s has shown that beyond a reasonable doubt. Most systems throughout the world have found that fee for service payments work best. While fee for service does contain some perverse incentive to provide extra unnecessary service in order to increase profits, that tendency can be controlled by use of practice standards enforced by central payers in single payer and social insurance systems. The perverse incentives in prospective payment systems are to deny necessary service in order to increase profits and to select patients less likely to require services while rejecting patients who need them. This has proven much more difficult to control since it involves much more subtle forms of behavior. It is much easier to tell a provider that they will not be paid for lumber spine MRI in a patient who does not meet certain criteria than it is to figure out that providers are not offering MRI to people who actually need it or are avoiding covering people with history of back pain.
5.) THE MOST IMPORTANT POINT: I am always amazed at the discussions by American economists, political scientists, health care providers, health care theorists, and politicians about health care and the question of what will work. This discussion is similar to someone debating how to manage infectious diseases but pretending that they have never heard of antibiotics or that antibiotics are a strange and questionable development. The answers to how to make health care work are on the shelf. They have been discovered by everyone else in the developed world. They have been shown to work well in general and specifically to work much better than our system both economically and medically. We are at the bottom or near the bottom in terms of health care performance in the developed world and at the top in terms of health care costs by a wide margin. To deliberately pretend that there is a question as to what would work better than our system is to literally bury our heads in the sand. Conservative politicians of all stripes, and the insurance companies, pharmaceutical companies, HMO’s, medical equipment providers and others who realize huge profits from our current mess of a system (at the expense of both patients and the economy) are only too glad to encourage this behavior, but it is disappointing when people who should know better play along.

Posted by: Patrick Schoenfelder | July 27, 2008 at 07:39 AM

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