• Health reform prisms, scope, and needles

    Igor Volksy does a superb job summarizing Jaan Sidorov’s insightful post on risk transfer and health reform. In even shorter form, the cost of Medicare to the federal government is or will be too high, threatening to overtake other priorities. It’s a risk that many no longer want the government to take, motivating policymakers to find someone else to hold the hot potato. Will it be beneficiaries (a la the Ryan Roadmap) or providers (a la the ACA via ACOs, bundled payments, and the like)? Finally, one could transfer risk to insurers, as in Medicare Advantage (albeit with a reformed payment rate setting mechanism).

    In my view, this is exactly the right way to look at the problem. I like to combine this prism of risk with a consideration of who has the most information and influence relevant to spending. In principle, it could be the insurer, if we can stand much more care management (as in 1990s-style managed care). Or, it could be the consumer, if only consumers could intelligently make informed choices about care (I am deeply skeptical they can). In practice, it is and likely will be predominantly with providers.

    I infer that the architects of the ACA thought so too, at least implicitly. By shifting risk to providers they are aligning it with the seat of maximal information. I’m not just talking about medical expertise relevant to care choices, though doctors obviously have that. I’m also talking about the detailed knowledge of and control over the cost of care and its quality. Patients don’t have that knowledge and control. Insurers don’t either. Providers do. It’s their shop, their equipment, their advice, their knowledge.

    In addition to this prism of risk and prism of information, I think there is a third crucial element that determines how one views reform: scope. Is your focus the spending by government only or total spending? If your focus is on government spending only then things like raising the Medicare age, which shifts spending to others, might make some sense, though you still have to overlook quite a few problems to accept it.

    If your focus is on total spending, then you have to admit you have a lot of work to do. Even the ACA isn’t likely to succeed in dramatically reducing that total, even if it succeeds in reducing (relative to trend) the federal total.

    Thinking about risk, information, and scope goes a long way to establishing the type of comprehensive health reform you’ll find acceptable. Then the only trick is getting something like your preferred, comprehensive reform through Congress or passed into law. That’s not a prism and has nothing to do with scope. It’s an eye of a needle. And, though attempted many times, it has only been threaded once.

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    • ” I’m not just talking about medical expertise relevant to care choices, though doctors obviously have that. I’m also talking about the detailed knowledge of and control over the cost of care and its quality. Patients don’t have that knowledge and control. Insurers don’t either. Providers do. It’s their shop, their equipment, their advice, their knowledge.”

      Yes and no. While I disagree with your inference above, I get your thrust.

      My conclusion is, docs are the least best option given our choices. We are not prepared to steer the ship, although we are the most informed. On the latter however, defining “informed” is relative. There are mounds of evidence to substantiate our woeful performance, as you know. Citations, I believe, are not necessary given their attention on TIE..

      Brad

      • Too literal a read. Docs are at the sharp end. They need input from research, naturally. They need incentives from payment systems, of course. And that’s the point. Put the risk (via change in payment systems) at the sharp end, supported with research (unspoken in this post). I do not think we disagree. One post can’t say it all.

        • Still, the myth of “providers know all” is pervasive. Literal reads are in the eyes of beholder:

          Even with evidence for doc support, its rough sailing:

          • I get you. But don’t tell me docs/providers (hospitals) don’t know their costs! They have to. Also, don’t tell me they aren’t the most important player in controlling and implementing quality. This must be their jobs. It is their jobs. Maybe they’re lousy at it. Maybe they need the right incentives, support, etc. But I cannot see how it cannot be their jobs. It is certainly going to be their problem, so they better get used to it.

            Don’t make me get all Uwe on you. If docs can’t play a huge role in cost and quality, how are they to sit at the table as we figure our way out of this mess? Maybe they should just be told what to do. Good luck with that.

            I should add that am being sloppy, using “docs” and “providers” (by which I mean provider orgs) interchangeably. You can slap my wrist on that. I’ll be better about it.

    • Its not their (“providers”) costs I am worried about. Its cost to the system.

      I know we agree, but I want to be clear on it. We may not like the responsibility thrust upon us, however, it is akin to asking the obese to “take control and lose the weight.”

      Problem is multifaceted, and like we live in an obesogenic environment, we live in a cost-ogenic one as well. Docs that dont know, and dont know that they dont know, are not dangerous, just in the dark. Flipping on the light switch will take years of education and support change. Expectations and cost growth expectations have to adjust accordingly.

      I don’t promote my link above for self-gratification. Its for real. My concluding anecdote drives this home. I pay attention to these issues, like a hawk, but when I put my doc cap on, its a dfft world and a lot more complicated.

      I know you know these things, but again, it gets back to expectations and realistic timeline implementation.

    • PS–sorry about the parry and lengthy thread, but is a conversation worth having. Its how we bridge the policy and clinical world–and leads to more understanding. I hope.

      Please have the last word if you choose.
      Brad