Stop rearranging deck chairs and focus on the engine room

Don Berwick is absolutely right about this:

The litany is long of similarly important problems in health care reform for which solutions have lately stalled on the shoals of angry, scientifically uninformed political combat: the proper use of evidence in clinical decision making, exploring new roles for nonphysician clinicians, enormous regional variations in care and outcome, addressing the nation’s obesity epidemic, maddeningly complex and anachronistic rules for physician and hospital payment, and much more.

What we’re observing is a battle over whether and how to insure Americans for health care. We’ve been having this fight — on and off — for a century, and particularly vigorously for the better part of the last five years. It’s sucked up most of the oxygen, leaving little for conversations about health care delivery.

This almost exclusive focus on insurance crowds out reasonable and necessary conversations about the items Berwick ticks off, among others. But these, in fact, are more important than how Americans get coverage, provided they do so. We’re applying a perverse 80/20 rule. After all, at least 80 cents of every dollar in health care ends up in the delivery system. Our bang for the buck is not to be found in policy arguments over how to insure for health care. It’s to be found in how deliver it.

In part for this reason, I’m relatively agnostic about the broad structure of a health insurance regime. There are many different examples exhibited by our peer nations and they all spend less for outcomes that are certainly not broadly worse and, arguably, are broadly better. The devil is in the details, of course, but not in every detail.

The details that matter are how the financing regime interfaces with the delivery system, what type of care it rewards and discourages. You don’t get at that by arguing over whether a tiny percentage of Americans should be able to keep their old plans or whether coverage should be private or public. System-wide, you don’t save any money by increasing the Medicare age or by shifting Medicaid beneficiaries to a managed care organization.

Not only are these ideas, and many others pertaining to coverage, rearranging the deck chairs, they’re focused on the wrong level of the ship. The deck may attract a lot of attention, but it’s got nothing on the engine room. Until we learn to live with something a little — or even a lot — less than our personal ideal in the realm of coverage, we won’t ever focus on delivery, which is the real engine of the health system. And, until we do that, we won’t make much headway on spending and quality.


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