That we are experiencing a “consumer revolution” in healthcare is a durable meme in the media and in policy circles just now. When you hear the word “consumer”, it conjures images of someone with a cart and a credit card happily weaving their way through Best Buy. It is, however, a less than useful way of thinking about the patient’s experience in the health system.
A persistent critique of our country’s high cost health system is that because patients are insulated from the cost of care by health insurance, they freely “consume” it without regard to its value, and are absolved of the need to manage their own health. In effect, this view ascribes our very high health costs to moral failure on the part of patients.
Market-oriented policy advocates believe that if we “empower”patients as consumers by asking them to pay more of the bill, market forces will help us tame the ever rising cost of care. If patients have “skin in the game” when they use the health system and also “transparency” of health providers’ prices and performance, patients can deploy their own dollars more sensibly.
This concept played a major role in the otherwise “progressive” Affordable Care Act. The 13 million people who signed up for coverage this year through the Affordable Care Act’s Health Exchanges opted overwhelmingly for subsidized policies with very high deductibles and out-of-pocket cost limits. The “skin in the game” argument has also heavily influenced corporate health benefits decisions. More than 30 million workers and their families receive high deductible plans through employers.
Pundits abound when it comes to health care plans. They come from many different backgrounds: conservatives, liberals, academics, business people, doctors, politicians and more often all the time various combinations of these. But they all have one characteristic in common. They all want a different kind of health care for themselves and their families than they profess for everyone else.
I am acutely aware of this as I am in a position that demands that I find special appointments for them. A day virtually never passes when I don’t receive requests (often many in a single day) for me to either see these people myself or arrange for their special care elsewhere, including other parts of the county and the world. My own personal ethical code of conduct prevents me from mentioning their names or anything that could identify them. Suffice it to say that I have yet to see a single exception to this principle.
At the heart of this crisis is the misalignment of two very different cultures.
Academic scientists tend to focus on publishing papers, and usually assume that the results will eventually be useful. They place a high value on novelty, and relatively less value on whether the data are robust, easily reproducible by others, or truly relevant to human disease. Captivating data from putative laboratory models of disease generate publications, even if the model is not very predictive of human disease – and unfortunately, most models aren’t.
Conversely, big companies traditionally focus on generating efficiencies through scale, and on developing reproducible processes. This works very well for manufacturing, reasonably well for large late-stage clinical trials, and essentially not at all for early-stage (discovery) research.
I’ve seen a number of responses to the news that the Medicare demonstration projects were not successful. Some have claimed that they were only demonstration projects, and the fact that some succeeded means we should look into those further. Others asserted that this once again proves that the government is incapable of making the health care system better.
As to the first point, it’s hard to get excited about this. By chance alone, a couple of programs were likely to save money. Four out of 34 reducing hospitalizations (when the best of them might have had inadequate data)? Hardly something to get excited about. Remember that two out of the 34 actually saw increased hospitalizations, too. I think it’s totally reasonable to think hard before just assuming there was something special about those four programs, and throwing more money at them.
But I think the latter point, made by Peter Suderman, is a bit of an over-reach as well. It’s important to remember that these were attempts by private hospitals and private physicians to change the way they care for patients. Granted, government was paying the insurance bills through Medicare, but this would have looked awfully similar if a private company had footed the bill. And, yes, private insurance companies have tried to use care coordination and disease management to reduce costs as well.
The current economic recovery effort presents an opportunity to build stronger, healthier communities. That’s a central goal for the Create Jobs for USA Fund that Opportunity Finance Network (OFN) and Starbucks launched late last year to support job creation and retention.
Economic growth and job creation provide more than income and the ability to afford health insurance and medical care. They also enable us to live in safer homes and neighborhoods, buy healthier food, have more leisure time for physical activity, and experience less health-harming stress. The research clearly shows that health starts in our homes and communities and not in the doctor’s office.
In that way, economic policy is, in fact, health policy.
Since 1985, OFN’s national network of community development financial institutions (CDFIs) has loaned more than $23 billion to benefit low-income, low-wealth, and other disadvantaged communities. The Robert Wood Johnson Foundation (RWJF), with an endowment of around $8.5 billion, is the nation’s largest philanthropy focused solely on improving health and health care for all Americans. Marrying the business acumen of CDFIs and others to health philanthropy’s ability to supply the research, analysis, and expertise to make sure community development activities improve residents’ health is a powerful union.
A relatively obscure paper (gated) published in an academic journal the other day was completely ignored by the mainstream media. Yet if the study findings hold and if they apply to a broad array of health services, it appears that the orthodox approach to getting health services to poor people is as wrong as it can be.
At first glance, the study appears to focus on a rather narrow set of issues. Although most states try to limit Medicaid expenses by restricting patients to a one-month supply of drugs, North Carolina for a period of time allowed patients to have a three-month supply. Then the state reduced the allowable one-stop supply from 100 days of medication to 34 days and at the same raised the copayment on some drugs from $1 to $3. Think of the first change as raising the time price of care (the number of required pharmacy visits tripled) and the second as raising the money price of care (which also tripled).
The result: A tripling of the time price of care led to a much greater reduction in needed drugs obtained by chronically ill patients than a tripling of the money price, all other things remaining equal.
This study pertained to certain drugs and certain medical conditions. But suppose the findings are more general. Suppose that for most poor people and most health care, time is a bigger deterrent than money. What then?
If that idea doesn’t immediately knock your socks off, you probably haven’t been paying attention to the dominant thinking in health policy for the past 60 years.
The health care community is discovering to its shock and dismay that it’s not simply traditional Republican conservatives who have taken control of the House of Representatives, it’s a new group of cynics.
Conservatives, like liberals, have a more-or-less coherent set of ideas. They use political power to push preferred policies, whether related to health care, housing or a hundred other possible issues. William F. Buckley Jr., one of the fathers of modern American conservatism, “had a way of … making conservatism a holistic view of life not narrowed to the playing fields of ideology alone,” as one admirer put it.
Although cynics may claim conservative credentials, their view of government is really nothing more than a quarrel about its cost. It brings to mind Oscar Wilde’s immortal phrase, “The cynic knows the price of everything and the value of nothing.”
The contrast between the two viewpoints was on stark display at two recent marquée meetings, AcademyHealth’s yearly policy conference and the sprawling Health Information and Management Systems Society — HIMSS — Health IT Conference and Exhibition.
AcademyHealth’s “Running of the Wonks” (my term, not theirs) is a magnet for researchers and policy mavens who are inured by long experience to most political rhetoric. Yet at the general session featuring a bipartisan dialogue among congressional staffers, the harsh rhetoric from the GOP participants stunned the crowd. The new federal health law, it seemed, was evil incarnate, and the rhetoric of “repeal and replace” was wielded with a fundamentalist zeal.Continue reading…
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