Austin has a post up this morning discussing a Victor Fuchs and Arnold Milstein NEJM Commentary from last week. As he notes, it’s a long critique, with blame for everyone, getting at why cost-effectiveness research is slow to diffuse. I think Austin is also correct that Drs. Fuchs and Milstein eventually get around to pushing the idea that physicians should be at the forefront of this endeavor, since they have the clout and trust to accomplish it.
That may be, but it’s not going to happen.
I don’t disagree that they could; I disagree that they will. With few exceptions, physicians are not trained to think in these terms. In my seven years of medical training, I can count on one hand the number of hours I spent learning about the costs of care, how the health care system works, or how economics comes into play at all. That’s not hyperbole. Moreover, physicians are inherently trained how to do things. And doing things costs money. We want to make people better, we want to do it fast, and we never, ever want to miss something. So all of a sudden, asking physicians who have been practicing this way for a long time, to change everything they do is not going to work.
As I’ve noted before, it’s hard to get doctors to change their behavior even when money is not involved. Asking them to practice like this is also asking them to change their behavior in a way that will potentially cause them to make less money. Doctors are human beings, and there’s a reason that ten cent coupons work. Small monetary incentives can influence behavior, even if only subconsciously.
I don’t think this is hopeless, though. I think that, instead, we should be focusing on insurers. If we want someone to fight for cost-effectiveness, it should be the stakeholder that has the most to gain from it.
If I were head of AHIP, one of my top priorities would be to push for a large and powerful Institute of Cost-Effectiveness Research. Insurers absolutely, positively do not want to pay for things that don’t work or that work too poorly for what they cost. Insurance companies say, though, that they fear making coverage decisions of this nature because of the potential backlash. So let cost-effectiveness research give them the cover. Let them agree to make decisions based on how cost-effective therapy is.
In other words, they should be pushing for this type of research so they can create value-based insurance around it.
Even if insurance companies were jittery, why aren’t large employers who self-insure fighting for this? Create plans based on cost-effectiveness research and then offer it to employees at reduced rates.
Insurance companies win, because they will hopefully wind up saving money. Patients win because they will hopefully get more cost-effective care. The country wins because we can hopefully bend the curve on health care expenses.
Please note, before you scream “death panels” or “rationing”, that I haven’t included government in this post at all.
