When Doctors Are Called to the Rescue in Midflight
Vermont Health Plan Advances
Vermont Health Plan Advances
Vermont is moving one step closer to a goal of its Democratic governor: a state-run health plan that would insure most of its 625,000 residents.Sharing Costs Is No Way to Fix Medicare
The bill Gov. Peter Shumlin plans to sign on Thursday would create a panel whose goal would be to figure out how to pay for a new system intended to reduce the rate of overall health-cost increases.
The challenge is to figure out how to finance such a system and convince the federal government to allow the experiment to proceed as soon as 2017. It's far from clear Vermont can make it all work.
In an interview, Gov. Shumlin said Vermont needs the change because its health costs have doubled over the last decade. Between 2004 and 2008, health-care spending in Vermont grew at an annual rate of 8%, three percentage points higher than the national rate. Among the cost drivers is that Vermont requires insurers to offer coverage to all applicants regardless of their health status.
Perhaps the most famous research on consumer cost-sharing is the RAND Health Insurance Experiment, which was conducted with 2,750 families from 1971 to 1982. Each family was randomly assigned to one of five formulas determining how much of their medical expenses they would pay themselves.ER docs order tests to avoid lawsuits first, help patients second
The RAND results showed that the introduction of cost- sharing can reduce medical spending without causing harm to health -– that holy grail of health policy. The biggest reductions in the RAND study, though, came in moving from zero expense for families to at least some cost-sharing. As we already have some cost-sharing in our current system (co-pays and deductibles), that finding doesn’t suggest a new path to savings. And, unfortunately, the results from raising cost- sharing above current levels were generally more modest.
Much has been said about the growing gap between the program’s spending and revenues — a gap that will widen as baby boomers retire — but little attention has been focused on a problem staring us in the face: Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:
...Vermont Becomes First State to Pass Single-Payer Health Care
Why does Medicare spend so much for procedures and devices on patients who get no benefit and incur risks from them?
One reason is that Medicare’s reimbursement procedures are not sophisticated enough to track the appropriateness of the care provided. Medicare delegates its claims administration to private local contractors based on how quickly and cheaply they can process claims.
These contractors have few incentives to audit the taxpayer dollars they are paying out, and even if they wanted to, they would need information often not available on the claim form. For example, a claims administrator, processing a claim for a screening colonoscopy, does not know when the patient’s last colonoscopy was, or whether there was a new clinical reason for repeating it. While this information is available, finding it would require extra steps, and there are no incentives to do so.
Moreover, denying payment after a procedure is performed invites the wrath of both patient and physician. Medicare and private insurers are also keen to avoid situations that could be viewed as telling doctors how to practice medicine — even if such advice is in the patient’s best interest. The political sensitivity of limiting services based on age, for example, was illustrated by the uproar over the Preventive Services Task Force’s findingtwo years ago that women in their 40s do not benefit from routine mammography.
Another factor is the shocking chasm between Medicare coverage and clinical evidence. Our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test. So while Medicare is obligated to follow the task force’s recommendations to cover new preventive services, it has no similar mandate to deny coverage for services for which the task force has found no benefit.
Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view.
Of course, doctors, with the consent of their patients, should be free to provide whatever care they agree is appropriate. But when the procedure arising from that judgment, however well intentioned, is not supported by evidence, the nation’s taxpayers should have no obligation to pay for it.
From a substantive perspective this was perhaps the biggest gap along [the encouraging best-practices] dimension: If we had a medical malpractice system that reinforced that emphasis on best practices we would be in a much better position; so if that pop up screen for my doctor in five years also meant that the doctor knew that if he or she followed those best practice protocols I couldn't sue him or her that would help to drive a lot more medical practice.To Fix Health Care, First Reward Failure
The debate over tort reform and medical malpractice is, I think, significantly off. The whole debate is over whether we impose caps or not or whether we dial down liability when you are found to be negligent. The core problem in the medical malpractice system, however, is the entire basis upon which it is operational. That basis, so called customary practice, means that it is a nebulous standard and doctors inevitably line up sort of following the social norms among doctors in their area in part because that customary practice protocol means that they have to in order to avoid liability. We should have a best practice emphasis whenever possible.
Tort reform was, in fact, addressed during the course of the health care debate, offered by the president late in the process as a concession to demonstrate the extent of his reach for bipartisan support. But the final agreement, sending grants to states for projects to study how to decrease medical liability and increase patient safety, fell far short of what Republicans wanted. Their vote for the overall bill was never contingent on strong tort reform measures in the first place.
Tim Harford has an unusual fear about government failure. He’s not worried that the government fails too often. He’s worried that it doesn’t fail often enough. The British economist is the author of the compelling new book,"Adapt: Why Success Always Starts With Failure."
In it, he warns that "we face a difficult challenge.The more complex and elusive our problems are,the more effective trial and error" -- which is to say, failing and learning from those failures -- "becomes, relative to the alternatives. Yet it is an approach that runs counter to our instincts, and to the way in which traditional organizations work."
Health-care costs prove his point perfectly. Few policy problems are more confounding than the inexorable rise in health-care spending. It threatens the economy even as the health-care system fails at its basic task of making us healthier. But the only way to fix it runs counter to both our instincts and our political system: we need to allow ourselves to fail -- often, enthusiastically and, above all, constructively.
When you hear the words "health-care costs," it’s good to apply a quick mental auto-correct. What people really mean are "sick-person costs." When five percent of patients account for 50 percent of spending, you’re not talking about the costs that most Americans with health-care insurance rack up over the course of a year. You’re talking about the costs racked up by a tiny fraction who suffer from serious health conditions.
...
But we have not been failing in the right way. Encouragingly, the Affordable Care Act might change that. There’s the Center for Medicare and Medicaid Innovation, whose job is to generate pilot and demonstration projects that might help us learn to do things differently, and better. There’s the clunkily named Patient-Centered Outcomes Research Institute, which is tasked with compiling evidence on the effectiveness of various treatments, and when and how they’re best used. And there’s the Independent Payment Advisory Board, a group of experts empowered to take the best of these experiments and replicate them through the Medicare system.Taken together, those agencies could do a lot of constructive failing and a bit of real succeeding, too.
The only question is whether we’ll let them. In a two-party political system, one party is often better off if the customers are very, very unhappy. In fact, the minority party’s route to majority status is to keep the customers unhappy, which means contributing to failures and then obstructing the governing party’s efforts to fix them.
Failure’s Cost
Identifying, preserving and highlighting policy failures is a great way to win an election. But from a policy perspective, it’s a bad way for the government to fail. It makes the governing party overly averse to policy risks and leaves the political system incapable of learning from mistakes.
"Any politician knows he can have 50 policies going well and one failure," Harford tells me from his hotel room in Seattle, "and that failure will dominate the next campaign. So the politician is just desperate to avoid provable failure." That means politicians won’t discover the kinds of successes that emerge from constructive failures.
So when it comes to health care costs, politicians who fear failure -- or exploit it for political gain -- should ask themselves what, exactly, they think the alternative is. If we can’t learn to fail well, then we’re going to -- well, fail.
No comments:
Post a Comment