• Addendum to “memo to the super committee”

    As I anticipated, the comments on my memo are good. Here are three points inspired by them. I’m putting these cryptically for brevity. Believe me, they do a lot of work. Unpacking them would take several long posts.

    Would-be Medicare reformers should:

    1. Beware the cost shift!  “Cost shift” here is in two senses: shifting to beneficiaries and shifting to other payers. The former relates to ideas such as increasing the age of Medicare eligibility. The latter pertains to the consequences of reduced Medicare payments in a climate of increasing provider market power. Only here I am also deliberately confusing it with price discrimination, which is a chief barrier to reduced Medicare payments hidden in plain sight. This circles back to all-payer rate setting.
    2. Focus on managing chronic disease.
    3. Related, pay attention to the small proportion of beneficiaries that incur the majority of cost.
    I assert focusing on these would go a long way to more sensible Medicare policy. But it isn’t exactly easy to see how to get from here to there.
    • 2*. Focus on PREVENTING chronic disease.

    • First, define just what ‘health care’ consists of. Are sanitary sewers, clean drinking water and sewerage treatment part of health care? I would say yes. And they only work if provided to everyone regardless of ability to pay. It is probably the same for most of the rest of health care.

      Second, remember that diseases are infectious. At least two cancers are now shown to be caused by viruses. And the role infection plays in the etiology of heart disease is beginning to be understood.

      Third, there needs to be a firm understanding of the scientific mechanics of illness and disease before going into the financial aspects. Some of the proposals being put forth are on a par with saving money by letting everyone treat their own sewerage. Pit latrines are a health hazard in urban areas.

    • Invest in doctors. Offer to pay the med school tuition of some number of doctors (all GPs-to-be, perhaps, so that there are more of them in the system). These doctors will be salaried at some reasonable amount for X years, and must work entirely on Medicare/Medicaid patients for those years (probably at a government practice). Perhaps they will have to continue doing so for some percentage of their work for some additional time afterwards.

      Good for doctors (they get their MD without additional debt), good for patients (cost-controlled environment), good for the general populace (more GPs in circulation), and nobody gets forced into anything.

      And, what do you know? You’ve created the basis of a single-payer system without knocking over the apple cart of the existing system.

    • I forgot to mention; another low-hanging fruit is to get drug companies to stop advertising directly to consumers.