Fred Goldstein, a health care veteran who believes in the free market, calls a spade a spade in a hard hitting call for ethical improvement in health care over at HealthLeaders. Go read his list of transgressions which we all know about individually but are hard hitting when read together. Bonus points if you can name the guilty. His point is that it’s pervasive because we’ve collectively let it happen. Here’s his conclusion.

Unethical behavior exists among healthcare organizations and professionals of all types. Organizations that try to do the right thing are often outmaneuvered by those that do not. Self-interest is often hidden behind a facade of patient concern. “We do this for the patient. If you withhold our services, you will hurt the patient.”Worse, these self serving behaviors have become so common that professional outrage has been dulled. But to save healthcare, we can’t just take these acts for granted. The prevalence of inappropriate actions in healthcare drives additional margins in the industry’s supply, delivery and financing sectors. It is at the root of our cost explosion and our healthcare crisis. And, it is based on an ingrained acceptance of unethical behaviors.The recent movement toward transparency and quality reporting will shine a bright light on some of these practices, and should tone down the environment of opportunism. But many of these behaviors have been well known for years. I have little faith that, with so much money at stake, any reforms can be substantial enough to turn around the industry. This is especially true if change does not support and engage much more participation from payers and consumers.

Paul Ginsburg from HSC doesn’t quite have Uwe’s ability to damn but stay "just this side ofthe line". On the other hand he has a solid base in very sensible research. When they start talking about price transparency someone in Congress had the good sense to drag him in. This was Ginsburg’s testimony about Consumer Price Shopping in Health Care. I’ve abridged it and commented a little:

Unfortunately, much of the recent policy discussion about price
transparency downplays the complexity of decisions about medical care
and the dependence of consumers on physicians for guidance about what
services are appropriate. It also ignores the role of managed care
plans as agents for consumers and purchasers in shopping for lower
prices. Well-intentioned but ill-conceived policies to force extensive
disclosure of contracts between managed care plans and providers may
backfire by leading to higher prices.

snip

ut we need to be realistic about the magnitudes of potential gains from
more effective shopping by consumers. For one thing, a large portion of
medical care may be beyond the reach of patient financial incentives.
Most patients who are hospitalized will not be subject to the financial
incentives of either a consumer-driven health plan or a more
traditional plan with extensive patient cost sharing. They will have
exceeded their annual deductible and often the maximum on out-of-pocket
spending. Recall that in any year, 10 percent of people account for 70
percent of health spending, and most of them will not be subject to
financial incentives to economize.

snip

In addition to those with the largest expenses not being subject to
financial incentives, much care does not lend itself to effective
shopping. Many patients’ health care needs are too urgent to price
shop. Some illnesses are so complex that significant diagnostic
resources are needed before determining treatment alternatives. By this
time, the patient is unlikely to consider shopping for a different
provider.

snip

So there is a solution — THCB readers who know that I’m an Enthoven disciple will not be too surprised as to what it is.

Some of these constraints could be addressed by consumers’ committing
themselves, either formally or informally, to providers. Many consumers
have chosen a primary care physician as their initial point of contact
for medical problems that may arise. Patients served by a
multi-specialty group practice informally commit themselves to this
group of specialists-and the hospitals that they practice in-as well.
So shopping has been done in advance and can be applied to new medical
problems that require urgent care. This is a key concept behind the
high-performance networks that are being developed by some large
insurers.

snip

Even when services are good candidates for shopping by consumers,
comparison of prices is not easy. Much treatment is customized. For
example, an elective rhinoplasty, more commonly known as a nose
reconstruction, is not a commodity, and a plastic surgeon cannot
provide an estimate without examining the patient. Often a medical
treatment involves an uncertain number of services by a number of
separate providers, but few bundled prices are available in the
marketplace today. As mentioned above, limitations in useful
comparative quality data make patients reluctant to choose a provider
based on lower price.

Snip

But the Cato guys tell us that LASIK surgery is cheap and got cheaper because of consumer facing price competition. So what about those self-pay markets that we’ve herd so much about? Turns out that’s not quite so clean either.…

LASIK has the greatest potential for effective price shopping because
it is elective, non-urgent, and consumers can get somewhat useful price
information over the telephone. Prices have indeed fallen over time.
But consumer protection problems have tarnished this market, with both
the Federal Trade Commission and some state attorneys general
intervening to curb deceptive advertising and poorly communicated
bundling practices. Many of us have seen LASIK advertisements for
prices of $299 per eye, but in fact only a tiny proportion of consumers
seeking the LASIK procedure meet the clinical qualifications for those
prices. Indeed, only 3 percent of LASIK procedures cost less than
$1,000 per eye, and the average price is about $2,000. I can only
wonder about the extent to which policy advocates have themselves been
deceived by these advertisements and inadvertently perceived a sharper
decline in prices than has been the case.

For the other procedures that we studied, we found little evidence
of consumer price shopping. For dental crowns and IVF services, many
consumers are unwilling to shop because they perceive an urgent need
for the procedure, and other consumers are discouraged from shopping by
the time and expense of visiting multiple providers to get estimates.
In cosmetic surgery, a limited amount of shopping does occur,
facilitated by free screening exams offered by some surgeons. However,
quality rather than price is the key concern to most consumers in this
market; in the absence of reliable quality information, most consumers
rely on word-of-mouth recommendation as a proxy for quality, instead of
shopping on price.

snip

So it turns out you need a sponsor

Much of the policy discussion about price transparency has neglected
the important role that insurers play as agents for consumers and
purchasers of health insurance in obtaining favorable prices from
providers. Even though managed care plans have lost some clout in
negotiating with providers in recent years, they still obtain sharply
discounted prices from contracted providers. Indeed, in my experience
as a consumer, I often find that the discounts obtained for the PPO
network for routine physician, laboratory and imaging services are
worth more to me than the payments by the insurer.

Insurers are in a strong position to further support their enrollees
who have significant financial incentives, especially those in
consumer-driven products. Insurers have the ability to analyze complex
data and present it to consumers as simple choices. For example, they
can analyze data on costs and quality of care in a specialty and then
offer their enrollees an incentive to choose providers in the
high-performance network. Insurers also have the potential to innovate
in benefit design to further support effective shopping by consumers,
such as increasing cost sharing for services that are more
discretionary and reducing cost sharing for services that research
shows are highly effective.

Snip

Conclusion:  The need for consumers to compare prices of providers and treatment alternatives
  is increasing and has the potential to improve the value equation in health
  care. But we need to be realistic about the magnitude of the potential for improvement from making consumers more effective shoppers for health care. Whatever the  gains from increased shopping activity, rising health care costs will, nevertheless, price more consumers out of the market for health insurance and burden governments 
struggling to pay for health care from a revenue base that is not growing as
  fast as their financing commitment. For those who have health insurance, their health plan will be a key agent in facilitating their obtaining better value. Government needs to take care not to interfere with this relationship and should
  focus instead on the needs of those without insurance

And what he doesn’t say but we all know is that if you regulate the way the plans behave effectively (and heaven knows there’s enough written about this that I don’t have to tell you how) they’ll start competing amongst consumers about the right things…

Whe I was first figuring out the private sector in health care about 10-12 years ago while Hillary was trying and failing to get reform done, I heard a gazillion people, usually in the strategy or policy dividions of big plans and drug companies tell me that we didn’t need government reform because the market was going to sort it all out itself. And ten years after we got the market reform that meant we didn’t need governmnet reform. What happened?

"In a decade that saw the rapid rise and hard fall of tightly managed care, there was plenty of change but little progress in solving the cost, access and quality problems in the health care system," says Paul Ginsburg in the release about HSC’s 10 year retrospective.

You can read the full report here. It’s taken me ten years to figure out what went wrong. Let’s not have that happen again next time, eh.