Cost Control Challenges
Submitted by Dr. JG Kaplan on Thu, 2009-06-11 10:39
Dr. Atul Gawande's "Cost Conundrum" (New Yorker, June 1, 2009), is arguably, "one of the most influential health care stories in recent memory"; it helps us better see a already palpable problem and gives us pause, if not agita... .
"Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. 'The greatest threat to America’s fiscal health is not Social Security,' President Barack Obama said in a March speech at the White House. 'It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.'"
Dr. Gawande discusses "the various proposals being touted in Washington to fix the cost problem"—expansion of public-insurance programs like Medicare? Lessening the role of insurance companies? The opposite—increasing the role of big insurance companies? No help! Health or medical savings accounts and high-deductible insurance policies where patients bargain with their own dollars? "Any plan that relies on the sheep to negotiate with the wolves is doomed to failure."
See also Kaplan JG, Sneider JS. "Managed Care Plans: Sheep in Wolves' Clothing." Med Interface (Medicom Int'l, Pub.) Feb. 1994;7(2):61-66, 84.
Dr. Gawande suggests our cities "have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations."
He augurs for comparative effectiveness research, but also research that "compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions.
Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world."
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