OP-ED

Pay (Only) for Health Care that Works

By DAVID HYMAN

Health care is expensive partly because governmental payers and insurers foot the bill for large quantities of medical services that are ineffective, unnecessary, or unproven. According to a RAND report, studies of clinical efficiency “indicate that one-third or more of all procedures performed in the United States are of questionable benefit.”

When state and federal governments set the minimum terms for insurance coverage, this problem is likely to worsen. Governmental decisions reflect the political power of providers (who want to sell more services), the sympathy felt for patients (who want to consume more services and have other people pay for them), and the desires of bureaucrats (who generally want to maximize their budgets and their importance). These interests coalesce, causing governments to aggressively mandate coverage of services that may or may not be necessary.

The health reform proposals pending in Congress require all Americans to have insurance coverage. The problem with this “individual mandate” is that Congress (or some other regulator) will have to decide the minimum amount of insurance Americans can carry. The need to set this requirement is an open invitation to aggressive lobbying by health care providers. Wanting to ensure that the minimum benefit package covers their services, providers will spend millions on advertisements and campaign contributions to persuade legislators and regulators that more coverage is better. Lobbying from providers and supportive patients explains why many states already mandate coverage of elective services like in-vitro fertilization, massage therapy, and visits to athletic trainers. Concerns about the efficacy and cost-effectiveness of treatments are washed away by a stream of campaign contributions, and sad stories about patients who can only obtain the “necessary” services if the insurer will pay for them. The result is a one-way ratchet toward richer (and more expensive) benefit packages.

A similar political dynamic explains why Medicare, Medicaid, Tricare (the health insurance system for people connected to the military), the federal employees’ health benefit system, and private insurers have spent tens of millions of dollars on non-medical services, such as prayers, for Christian Scientist patients “who choose to rely solely upon a religious method of healing.” There is no persuasive evidence that prayer treatments work. A recent large study found that prayers had no effect on the rate of complications among heart surgery patients. In fact, patients who knew others were praying for them had slightly more post-operative complications than patients who did not.

Even though prayers are obviously not medical treatments, Christian Science Practitioners charge for their services at rates comparable to those of real health care providers. In Minnesota, a Christian Science Practitioner reportedly charged the parents of Ian Lundman, an 11-year-old with diabetes, $446 for two days of prayer-treatments. (Ian died.) In Michigan, a Christian Science Practitioner demanded $1,775 after praying for someone in a coma. State Farm initially refused to pay but capitulated after they were sued.

One of the major health care bills currently pending in Congress would continue and almost certainly expand this indefensible stream of payments. It uses the language of discrimination to hide what’s going on. The problem isn’t discrimination against members of a particular religion. It is that public officials should not spend our tax and insurance dollars on services of no proven medical value.

Christian Scientist Practitioners account for an infinitesimal fraction of the cost of health care. Indeed, it is almost always cheaper to pay for prayer-based treatment than to pay for medical treatment for patients with the same illness. But, our willingness to waste tax and insurance dollars on prayer treatments is symptomatic of a larger failing. Wasteful spending abounds in health care because providers have defeated all efforts to control costs – and routinely lobby for laws requiring that they be paid for the services they render, regardless of whether their efforts actually improve patients’ health. A business that charged through the nose for repairing cars or computers would quickly find itself out of business if “one third or more [of its work] was of questionable benefit.” Why shouldn’t we subject health care to the same discipline?

Congress seems bent on imposing an individual mandate. If so, it should impose a strict efficacy requirement as well. Congress’ rule should be: No governmental payments or insurance mandates for any goods or services not proven to work. Christian Scientists and others who want ineffective, unnecessary, or unproven services will still be able to get them. They will just have to pay for them.

Professor Charles Silver holds the Roy W. and Eugenia C. McDonald Endowed Chair at the University of Texas School of Law, where he writes and teaches about civil procedure, professional responsibility and, increasingly, health care law and policy. Professor Silver is currently an Associate Reporter on the American Law Institute’s Project on Aggregate Litigation and a member of the ABA/TIPS Task Force on the Contingent Fee. He has been Visiting Professor at the University of Michigan Law School and the Vanderbilt University Law School.

Professor David Hyman is considered to be one of the country’s top health law scholars, and is the Richard W. and Marie L. Corman Professor of Law, teaches civil procedure and health care regulation. His principal research interests are the regulation of health care financing and delivery and empirical law and economics. Professor Hyman has published articles on a wide range of subjects, including medical malpractice, managed care, consumer protection, narrative, professional responsibility, tax exemption, and civil procedure.

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markdaniel laneUK TherapiistStephen Motew, MD, FACSpiles Recent comment authors
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mark
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mark

Socialized medicine doesn’t work, been there in the UK and it was aweful! Found a site that has Obama Aid that was great! http://www.goofballproducts.com. Worth a laugh.

daniel lane
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daniel lane

the problem is that health care in plain is just to much. 1 out of 5 americans dont have coverage. so if this new bill is passed how much ? will not enough be ?

UK Therapiist
Guest

IT is good to hear that companies are not pulling back on their investment in wellness initiatives but they are taking much more interest and finding solutions to provide cheap and useful treatment to patients.

Stephen Motew, MD, FACS
Guest

We don’t even need to start with defining or proving that all current therapies are effective, lets start with those that already have data to show they are not ‘better’ such as: cardiac interventions for non ACS pts, intervention for claudication, stenting for renal artery stenosis and htn….and the list goes on. In addition payors (including Medicare) still willingly shell-out for imaging studies performed in non-certified labs lacking quality control. It just doesn’t make sense that these examples aren’t being approached as a logical first step in cost-containment. I assure you there are billions to be saved be examining current… Read more »

piles
Guest

Despite the recession, companies are not pulling back on their investment in wellness initiatives. In fact, more companies are asking employees to fill out health risk questionnaires and are providing programs to improve and manage your health.

FarAndAway
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FarAndAway

Is the country ready for a change… ?http://www.typobounty.com/Funny/Health_Care_Reform2.htm

D'CM
Guest
D'CM

Dr. Weinstein makes a good point about the expansiveness of our ignorance in regards to proven medical effectiveness, however this should not end the conversation. The amount of downright ridiculous treatment that is carried out in many hospitals would stagger your imagination. To give you an example, right now on my 32 acute bed unit there are 4 nursing home patients who have been here for a total of 18 days waiting for a theraputic INR. There is another nsg home patient who has been here 192 days this year, gotten 185 CBCs and at least 300 doses of iv… Read more »

Peter
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Peter

It’s not what doctors get paid, it is their expectation of what they will get paid that is the problem. More docs with attitudes like MD,s breed higher expectations from would be medical students. If we pay less, and potential medical students know this, then we will get a different student with different expectations. If we promoted medical education differently and helped pay the costs we would attract students from a lower family pay grade with higher expectations of what are the rewards as opposed to what is the pay.

jd
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jd

No, I think going Galt is a punchline. I wasn’t responding to your point that primary care is hurting, since it obviously is. But unlike you, I would say the problem to address is not the payment level in primary care but the payment level in specialty care. In any case, my response was to this bit: “Compassion used to be included in the service. You cannot steal compassion at the same time you steal service. Medicaid just decreased reimbursement in North Carolina by 9%. Just what do you think that will do to the compassion? Just what do you… Read more »

MD as HELL
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MD as HELL

jd,
You clearly missed my point. And you did it with amazing skill. Funny you should mention Gault. Do you think that is what’s happening?

jd
Guest
jd

MD as HELL, it is absurd for you to whine about not getting paid as much as you think you’re worth. You probably earn in the top 3%, almost certainly the top 10% of Americans. And you’re whining. In this economy.
I hope you are planning to go Galt as soon as you find your mountain lair.

inchoate but earnest
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inchoate but earnest

Higher reimbursement for measured forms of treatment.
The “better” (the more thorough, the more transparent, the more fully shared, the more credible) the system for collecting, evaluating & reporting data on a particular treatment, the more complete the payment for it.
This doesn’t necessarily require a centralized authority to succeed.

Charlie
Guest
Charlie

There are many interesting comments on my post. Thanks to all who submitted. One theme repeated in several comments is that we don’t know which treatments work or, sometimes, how to define what it means for a treatment to work. It seems to me that the first order of business should be attending to these matters. In what other business sector (and health care is big business) do service providers get to spend enormous sums of customers’ money on services in the absence of criteria for success? Shifting to a system of paying for outcomes rather than services would certainly… Read more »

James
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James

The Seton Hospitals in Texas went to tighter standards on inducing deliveries and saw a 98 percent drop in billed charges for birth injuries. That is pretty astounding.

Hal Horvath
Guest

This post and the comments are struggling with the most difficult and important issue in health care cost. As the comments demonstrate, it is not easy to specify from the top-down what should and should not be mandated or covered. In fact, it is problematic in several ways. Paying-for-outcomes-over-time avoids these problems. It can handle real-world complexity and failures in a way that encourages treating even the most difficult patients. When a patient has a specific, narrow condition (the condition specified with several parameters), then what constitutes the best outcome, 2nd best outcome, 3rd best outcome, etc., *can be specified*… Read more »