Monday, December 6, 2010

Consumer-Driven Health Care

One of the many problems facing health care delivery in the United States is the performance of unnecessary procedures. This contributes greatly to a health care economic model driven by the supply of a particular provider, as opposed to patient need or demand, and which in turn ratchets up cost. The underlying logic is complicated, but for now it's enough to now that fraud is rarely a factor.

A -- not "the" but "a" -- recognized driver of this  is a tendency on the part of employer-insured patients to request (and get) care and procedures that they don't need simply because the cost is invisible to them: They show their insurance card, make a co-pay, and leave the rest to their employer and the insurance company. Consumer-Driven Health Care is a conservative response to this problem aimed at righting the supply-demand relationship, making the patient more prominent and responsible for health care decision making, and reducing the role of the employer so that insurance becomes portable.

Generally, this involves an individual or family establishing a Medical Savings Account (there are a number of different types) paired with catastrophic health insurance. The individual contributes pre-tax dollars to the account (some plans permit an employer match) that incur tax penalties if spent only on anything but health care. Unspent dollars roll over to the next year and the account belongs to the individual: Even if an employer matches it or sets it up as part of a health coverage plan, an individual changing jobs take the account with him or her.

Criticisms of the plan take aim at its lack of utility for the chronically ill, unsuitableness for low income people who might quickly use up their medical savings and repeatedly hit the gap between the account and the insurance policy, the issue of health literacy, and the real possibility that the pendulum will swing too far and create a situation where people don't get care that they do need. In my mind, though, none of these objections are necessarily insurmountable. (Health literacy is a complex issue that I don't deal with here.)

But I believe that the real Achilles Heel of CDHC lies elsewhere, and that if it becomes the dominant health care financing paradigm -- a real possibility -- it will if anything exacerbate the problem it is designed to solve.

It's a curious thing that when experts on left and right debate health policy, they conduct the debate from an Olympian perch that ignores one of the most important commercial forces in American life, and that has certainly happened here. When the aggregate dollars in the various accounts reach a certain level, they will attract the attention of a marketing and advertising apparatus. This apparatus will labor mightily to separate that money from the accounts and transfer it to the interests they represent. And the apparatus is very good at what it does. People will be told that they "need" certain procedures and that they should not "forget" to get a regular this or that, none of which they will actually need, at least at the pace recommended by the various advertisements.

The campaigns will work well enough that the health care system will wind up performing just as many or more unnecessary procedures. We'll be right back where we started from, except that the health care system will have deprived people of their savings and turned hospitals, clinics, and group practices into racketeers. I don't think that that is the kind of doctor-patient relationship that Hippocrates or Galen had in mind...

One of the most important ongoing health care projects is the Dartmouth Atlas of Health Care. Dr. John Wennenberg, the genius behind the atlas, discovered and first documented the phenomenon of unnecessary care driven by provider supply in a particular area. Unnecessary procedures do not affect health outcomes in a given area. For example, it's possible for heart surgeons in one area to install twice as many stents as heart surgeons in a different area but resulting in no discernible difference in overall cardiac health. In this case, we would say that the difference in the number of procedures may have been unnecessary. Use the atlas to find out which procedures in your area may be performed at an unnecessary rate...


pammi said...

Stent has proved to be a life saving tube for cardiac patient which is used in angioplasty surgery. The tube is a tiny, expandable, mesh-like tube made of a metal such as stainless steel or cobalt alloy. A cardiac stent is a small tube that is used to widen arteries supplying the heart that have narrowed. Stent for heart is sold by different companies in the world.Stent for heart

Steven said...

Medical savings accounts are criminal. I have seen friends and relatives put off care because they weren't fully funded. Without prompt care, their health problems escalate. This is where the widespread problem of health 'illiteracy' shows up to exacerbate those health issues. They simply don't know when to seek medical care and they won't even consider it till their savings plan has enough money in it. My son-in-law is having surgery today, in December, because he finally saved enough for the deductible this year. He's solidly middle class...I can't imagine what would happen to him if he were poor. And unemployed.

paula said...

Comparative effectiveness research (an expansion of the Dartmouth Atlas on a grand scale) will help, but it might take at least a decade to ramp up to a meaningful level of findings. Once we have a base, many patients aren't going to like the results, and will demand expensive treatment whether they need it or not. Or the docs will. WHo's the final arbiter? Presumably, CER. You better believe the insurers will want to play a hand in that, too. They'll be funding research into minimum treatment for whatever they cover. I think CER will have a big impact on research dollars, don't you? Why bother, if it's going to take even longer to move findings from bench to bed? It's bad enough now, even when quick dollars are out there for promising (not proven) therapies.

Foxessa said...

Nothing good anytime in the foreseeable future, particularly, as, as a caption in the NY Times today put it: "Obama willing to alienate his base in favor of compromise."

If he'd really studied Lincoln's administrations and the run-up to the Civil War, he'd know that compromise with them goes one way and one way only: Their way, and it's all or nothing.

I'm getting the sense that Obama's extraordinarily ignorant of American history. Or any other history, for that matter. His rivals on the other side, however, know history very very very well, and have learned very very very much from it.

Love, C.

K. said...

Pammi, no one disputes that cardiac stents save lives. The question is how many stent installations are unnecessary, and there's a growing body of evidence that many are.

Steven, I'm afraid that this is where we're headed. CDHC is either overly simplistic -- to put a good face on it -- or just another scam to force the sick out of the system.

Paula, CER certainly has promise. But just to illustrate the kind of stuff patients can run into, I stumbled across one very slick website that claimed to promote CER. It had former congressman as spokesman. Then I started reading their "studies." Essentially, they cherry-picked other studies that supported the use of generic drugs and "proved" that those studies were wrong, that the newer and more expensive drugs worked better. Now, who do you think funds this web site? As my grandmother used to put it, three guesses and the first two don't count.

Foxessa, I hear what you're saying, and I much prefer a bill that repeals the tax cuts for the wealthy, extends them for the middle class, and extends unemployment insurance. Now, how do you get from here to there? I don't know, and I have yet to read a plausible suggestion. And I've been following this closely.

Bernie Sanders says he'll filibuster. If he doesn't, does that make him a sell-out and a liar?

Sherrod Brown wants to play chicken, saying that -- and this is an actual U. S. Senator talking -- the Republicans will bail at the last minute because they will have this sudden realization that they are on the "wrong side of history." When did being on the wrong side of history ever motivate a reactionary to do the right thing? I don't know whether to laugh or cry when I hear something like that.

Is this really and truly the best that the liberal base can come with?

What I'm hearing is that repealing the tax cuts is more important than extending unemployment for decent people who can't find work in a recession. If we leave those people out in the cold over an ideological matter, what have we become?

Foxessa said...

I'm reading things written by slaveholding southerners from 1820: the language is exactly that of sp's -- and these are men who are professors at William & Mary.

Their fantasies are never checked by so-called reality, because in their world it is all fantasy and nobody deals with reality. It's myth. It's anti-rational. They are happy. They think this time they will get it all their way. Brasil and Canada, watch out! Cuba in particular, so perfect for private slave estates as it is.

Manuafacturing has all been moved out of the U.S. so they have nothign whatsoever to worry about.

Love, C.