Those on the left will pretty much sacrifice everything to attain their goal of universal coverage.
But, in this well-reasoned piece by conservative economist Tyler Cowen, expanding coverage won’t necessarily control costs, which is a more imperative issue. The bandied about means of cost control, such as electronic medical records, cutting provider payments, and preventive care, all will have little nor no impact in controlling costs.
Take physician reimbursements, for instance, a favorite target of health reforms. According to Princeton economist Uwe Reinhardt, a favorite son among policy wonks, cutting physician pay by 20% would only reduce spending by 2%.
Furthermore, under the current payment system, simply cutting provider reimbursements will only give more of an incentive to do more procedures to make up for lost revenue.
The hard truth is that care will be rationed, and that’s something the Obama administration is unwilling to admit. Indeed, as Mr. Cohen writes, “if we aren’t willing to take even limited steps to conserve resources, we shouldn’t be spending any more money elsewhere.”
Cost control first before universal coverage, and therein lies the central contention of the debate.
And the worst case scenario, as progressive blogger Ezra Klein correctly surmises is, “that the final bill will include a pricey expansion of coverage paired with a speculative and uncertain set of cost controls.”
Related posts:
- Medicare and cutting health care costs
- ER visits and health care costs rise in Massachusetts due to lack of primary care access
- Rationing health care by waiting times, or by cost
- AMA: Curbing the rise in health care costs is key to health-system reform
- Health care costs 101
- Op-ed: Doctors’ pay cuts save little in health costs
- How the widespread adoption of electronic medical records can raise health care costs
{ 17 comments }
We have got to do something about the money wasted on futile end of life care. The culture of medicare encourages hospital admission, multiple consultations and multiple tests. Money is wasted. Elderly patients suffer and are still dead in 4-6 weeks.
I am not in favor of some tribunal deciding who lives and dies.
However, I am in favor of a massive public education campiagn, much like that advising people not to smoke, to educate patients and their loved ones to let go when the time comes.
Pope John Paul did it, so it is not a religious issue.
Rationing of care has to be coupled with medical liability reforms. I am sure even with rationing, the doctors will have the power to overide such rationing in special circumstances. And to avoid liability, they might just do that.
It is well-known that a LOT of healthcare costs are totally preventable or unnecessary (see http://www.nationalprioritiespartnership.org). I think that if we could more efficiently implement/follow clinical guidelines (based on good cost-effectiveness research), we could significantly reduce the overuse/misuse of care that leads to increasing costs??
Richard Fernandez-
…Ultimately health care reform is as much about politics as it is about medicine. The discussion in Dr. Emmanuel’s paper is incomplete if limited to pure public health considerations. Politics is central to the whole issue. Whatever “guidelines” are chosen, however rational, however humane, can never implement themselves. Human beings in positions of power are required to do that. And while it is important to note that even under the current system these decisions are being made by someone or by some consensus, it is also vital to realize that in any “health care reform” effort, one of the principal outcomes is to shift the power to make those decisions to someone else. That may not be a fit subject for the Lancet, but it is the elephant in the operating room in the national health care debate.
http://pajamasmedia.com/richardfernandez/2009/07/06/electing-god/
Kevin,
Your comment, “The hard truth is that care will be rationed”, may not be correct and is a bit of scare tactic that has been around for years. If the system fails, we will then definity have rationing. Our system today has rationing, it is based on your ability to pay. We as American also have to realized that 80% of our total health care costs is incurred in the last 2 yrs of your life. Yes, some countries do make decisions on care based on age, illness, and probabilities of outcome. We also do that in the US but it is not talked about.
As for reimbursements, the name alone is ambiguous and I agree this system also needs reform and quickly.
I don’t have the answers but I am glad that we are all talking about it. I commend the Obama administration for taking on this sacred cow.
Jeff Brandt motionPRH for the iPhone
MyMobileMedBox for Android
Yeah, um, isn’t that what they did in Cuba?? *Everyone* has FREE healthcare, yet there is nothing for anyone. It’s rationing to the extreme. Look, people, socialism has never worked, and it never will. Cuba is an extreme of this – why would we want to steer our country to anything even resembling it? When you try to equalize people in a county, all you do is bring everyone DOWN. Also, socialized medicine in other, less extreme, countries results in just mediocre drs. They’re good, but have no incentive to be great. That is why so many forgeiners come here for specialized care.
Obama and the democrat party regime currently in power will under absolutely no circumstances be honest or open in its true intentions.
On the other hand:
Bill
Comparative effectiveness is a rationing system that weighs the costs of treatment against the relative value of the person getting treated. The people most likely to be affected by “comparative effectiveness” rationing in a single-payer system are the elderly. Stuart Altman explained that all too well to Congress earlier this year:
Remember, our population is aging. And with the very, very elderly, the costs go down, so that percentage should be falling, and it’s not. Second, the cost of care is growing by so much, so at the same percentage, it’s worth a lot more. So let’s go back to the issue of comparative effectiveness, which we’re supporting. That’s where that can have a big impact. It’s not only there, but that’s where the waste is. That’s where people are using technologies that really either don’t work at all or keep people alive for for very limited [time] and [at] very high cost.
Hospice is one option, but we do need take account of the cost — you know, I hate to say it, the cost-benefit of some of the things we do. And either we can do it directly, or we can do it by bundling the payments and let the delivery system deal with it. So it’s a combination of the delivery system dealing with it, or, and/or providing more information for people to make the right decisions, both for themselves and for the care.
Basically, the government will tell some people that they’re just not worth the effort to treat, and will send them to hospice to die instead.
http://hotair.com/archives/2009/07/08/who-says-no-in-a-government-run-health-care-system/
Whoops, I meant to say:
http://tinyurl.com/mx9xfj
Bill
And at the same time they are threatening huge cuts to hospice payments that could put a substantial number of them, especially non-profits, out of business. At the same time they are cutting eligibility and cracking down on lengths of stay even a day over 6 months.
So they will be sent “to hospice” to die…only there may not be a hospice there and they may not even meet the government’s criteria to get into hospice. So maybe just go home and die? And if you get into hospice then we euthanize you on day number 181 if you are still alive?
Saw this 70 something gentleman with advanced laryngeal cancer with PEG tube and on dialysis, losing weight rapidly despite treatment. The ENT doctor expressed that he was someone who should consider Hospice given his condition. He had no primary care and his nephrologist( private) was sort of his primary who did not pay heed to what other specialist were recommending. Unfortunately family and patient were spanish speaking and had lots of barriers and followed the nephrologist’s advice, he got dialysed until his last day and his nephrologist never discussed hospice option with family. He died in ICU. I find this very disturbing that there is a huge disparity in the way hospice services are used. Why is left to the whim of the doctor rather than being mandatory that patient should be made aware of his options. There is no excuse to put patients through agony at end of life unless the patient wants it.
Why didn’t the ent discuss it with them? I know it is best for primary care to do, but in the absence of sufficient primary care, specialty care should step up to the plate.
In my neck of the woods, we, as primary care, are frequently pleading with the patient and family to consider hospice; it is the specialists, particularly the oncologists, who push for treatment. And you know what? We are ALWAYS right, the patient is still dead in 1-3 months, albeit with more suffering and higher cost to society.
In 1973 President Nixon signed a bill which introduced HMO care into Medicare. It was championed as a solution to rising health care costs which were rising then. Nixon wanted more in the way of health care reform and national coverage, but a recession at the time prevented that. Here we are, about 36 years later, attempting to reign in costs again.
The problem is complex but there are some good examples of success in reining in costs while providing good care. Physicians do not have to suffer while achieving these successes. Some examples that are worthy are the Baldrige Award recipients in health care. The hospitals that receive the awards are in good financial shape while providing good service in their patients eyes and also keeping down the cost per patient.
The two year national project of TransforMed has demonstrated that primary care physicians can improve their income and provide good care to their chronic care patients, using principles based primarily on Wagner’s Chronic Care Model. In fact, the average physician’s income rose 14% in the program while the cost per patient dropped.
As far as prevention is concerned, promoting good lifestyle is indeed a worthy cause but it should not fall upon the health care community to drive prevention solely. There was a research project in Somerville, Massachusetts funded by a government grant whose aim was to decrease the growth in the BMI of children in grades 1 through 3 at the public schools. The program was successful because the whole community was involved. The lesson learned, prevention activities are successful based upon local community involvement. Another very successful prevention program has been tobacco cessation. In the 1950’s doctors were advertising cigarette smoking! Today, they are actively campaigning against it. They are not alone, though. Other avenues besides health care have been involved in the this campaign, including the government, schools, and media.
My point, there are demonstrable successes in reining in health care costs while improving the lot of the providers and there are excellent approaches to prevention which do not rely solely on the heath care community.
Do we dare hope that Congress and the President will follow successful models?
TexBryant,
Great response. Education and Awareness is a major part of correcting any problem weather it is smoking cessation or getting the right person to assist in correcting a problem. It has to start with the decision makers, weather that is the smoker, the hospital CEO, or congressmen. The more we talk, motivate, and execute the closer we will come to a solution that works for everyone.
We our hoping that PHRs both mobile and Web based will assist with one small portion of the problem to help people be more aware of their health.
Jeff Brandt
motionPHR for the iPhone
MyMotionMedBox for Android
Unless you are willing to abuse the emergency room, medical care is already rationed unless you are rich enough to self-insure (and therefore be able to make decisions based purely on your own cost / benefit, not what someone else thinks). Most people are limited by the limitations of what their insurance companies (government or private) are willing to pay for (and insurance companies sometimes inappropriately deny payment, apparently hoping that you don’t notice enough to point out that the policy stated that they should have paid).
While prevention is a good thing, when it comes down to controlling health care costs, there’s one chronic disease that’s tough to prevent: old age.
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