• Washington State Health Technology Assessment Committee

    Interesting article in yesterday’s New York Times on the Washington State Health Technology Assessment Committee. This committee makes decisions about what is (and is not) covered for state employees, the Medicaid program and worker’s compensation in Washington state.  The primary goals of the committee according to its website are to make:

    • Health care safer by relying on scientific evidence and a committee of practicing clinicians
    • Coverage decisions of state agencies more consistent
    • State purchased health care more cost effective by paying for medical tools and procedures that are proven to work
    • Coverage decision process more open and inclusive by sharing information, holding public meetings, and publishing decision criteria and outcomes

    Who could be against safety, consistency, effectiveness, no longer paying for things that don’t work and doing all this in a more inclusive and public manner than is now done?  In short, everybody!  Patients, providers, critics of the Affordable Care Act who say it is a harbinger of things to come, etc. I have given numerous talks around North Carolina and the country about health care costs and health care reform to groups of providers and the public.  The talks tend to go something like this.

    • I describe how our health care system is unsustainable
    • The audience nods vigorously and  says things like ‘we must stop this out of control health spending!’
    • I describe several possibilities for how we might address costs (a board like the one noted above; reform the tax preference of employer paid insurance; change methods of reimbursement, etc.)
    • Lo and behold, the audiences hate all of the possibilities!

    If we ever slow per capita health care costs as compared to what they will be with no change it will mean that less care is provided, and/or providers are paid less for that care.  Even if a ‘market based’ solution were achieved, cost savings would mean less care and/or less payment per unit of care.  Any savings achieved by any means will be a reduction in someone’s income compared to what it would have been with no change, and our culture strongly assumes more care is better.  The hardest part of slowing health care costs is cultural, not technical.

    • The rest of the developed world has figured this out and it is not rocket science. All other developed countries provide near universal access at less than half of what we spend on health care and their health indicators are better than the US.
      How do they do this? Patients do not need to accept less. Patients in these other developed countries have good access to high quality care for all necessary care. (Please let’s don’t rehash the myth of “Canada waiting times”)
      Here is where you are correct. The problem is a “cultural” one. The medical industry would earn less money (half) and they have a strong cultural disposition to continue their high profits and they are willing to do anything to continue this system. They have effectively purchased the congress to ensure their profits. Patients have no control over prices and services and are just pawns in the process.
      All other developed countries have strong controls on prices and this keeps their costs down. They also don’t pay for ineffective medical services and procedures. However, they don’t “ration” necessary health services.

    • I describe several possibilities for how we might address costs (a board like the one noted above; reform the tax preference of employer paid insurance; change methods of reimbursement, etc.)
      Lo and behold, the audiences hate all of the possibilities!

      You describe why it is very difficult for politicians to control the growth of health care spending without using monopsony. They lose votes as soon as they propose sensible cost controls.

      On the other hand the market is currently slowly separating employment (employers are dropping insurance) and health insurance and raising deductibles (employers are raising deductibles) both good things but they are painful and so Democrats have stepped in to try to prevent these measures in order to gain votes. Not good IMO. In the long run if new norms are built up in response to fewer employers offering coverage and higher deductibles this will be a good thing.

      The Government alternative is monoposony which is what Canada uses. Monoposony effectively reduces the huge excessive licensing hurdle without politicians getting blamed. It does this by lowering the income of people in health related fields thus lower the quality of candidates to medical and nursing schools. It will also reduce the engineering going into medical equipment design.

      In democracies it very difficult for politicians to give tough medicine to the median voter.

      I think government can go for Monoposony or stand aside.

    • @Mark Spohr
      re waiting lists, a few semesters back I assigned students to investigate waiting times for specialty visits for a series of conditions (I gave them a street address in Canada, UK and here in Durham, NC). They easily found the info in UK, and some got better info than others for Canada. When checking locally, they called Duke specialty clinics asking about waiting lists and several reported being told ‘we don’t have waiting lists.’ OK, when is the next appointment? ‘7 weeks.’


    • Reading comments above, and somewhat related to your post Don, sparks the notion of what US citizens experience/undergo via our HC system vs. citizens in other countries. In this case it is CER and resource scarcity.

      For some reason, and sometimes we cant explain the trigger, I was reminded of this post on HA blog from sometime back (3 years + ago, go figure). The title may not jazz you, but read it. It is insightful, and the lessons that these overseas fellows took away from “immersing” in US healthcare system could teach us all a lesson.

      The whole issue of CER, American exceptionalism (“we do it better”), gets spun on its head given the observations of these young investigators. It is not a hard leap to go from NICE, primary care access to the morass we have here.

      Its a short and interesting read: http://healthaffairs.org/blog/2007/10/16/us-health-care-international-scholars-experience-our-system-what-they-found/