Wednesday, April 22, 2009
Health care reform graphic of the day
Courtesy of McKinsey, behold a useful graphic that describes many of the various ways in which we might reform the provision of and payment for health care in the United States in order to dampen demand and alter the arc of treatment for many patients. We would not implement all of these reforms and there are others that might make sense, but the table is nevertheless a reasonably useful tool to put particular reform proposals into some context.
6 Comments:
By 
JPMcT, at
Thu Apr 23, 07:10:00 AM:
Substitute "Health Care REform" with Congressional Reform" and we might actually have something!
Reading thru this makes me smile. Lots of nobe intention, but the bottom line will be....RATIONING!
By TigerHawk, at
Thu Apr 23, 07:29:00 AM:
Well, JPMcT, all systems, including the one we have, use "rationing" of some sort.
Look at it this way: There are only three ways to allocate health care (or any other good): By auction (abiliity to pay), queuing (standing in line literally or figuratively), or bureaucratic fiat (whether HMO or governmental). The U.S. uses all three such approaches: Auctioning for breast augmentation, queuing in the emergency room, and bureaucratic fiat in certain managed care or public health contexts (for an extreme case, think about the public health response to a shortage of flu vaccine). The question, which is a legitimate one, is whether our approach is as effective, cost-effective, and just as it might be. That is a worthy debate, and it will always involve "rationing" just as our current system does.
By Elise, at
Thu Apr 23, 01:27:00 PM:
"Dampen demand". Are there really that many people out there who demand medical care when they don't need it? I know there are people who look forward to seeing yet another new doctor so they can fill out reams of paperwork and then check out who has the best flimsy paper gowns; love lying on cold steel tables so machines can make strange noises that exacerbate their claustrophobia; and adore being stabbed with gigantic needles that siphon half their blood supply into tubes with pretty tops. I just don't think there are enough of them to save significant money if we somehow discourage them from pursuing their strange hobby.
And I have lots of questions about the slides:
Slide 3: What's in the "Other" category that accounts for so much of our spending? Does the spending for heart disease count, say, statins while the incidence of heart disease does not?
Slide 4: Who's the "Other" in the US that lives very nearly as long as the Japanese?
Slide 9: I know that Republicans are excited by the idea of allowing health insurance to be bought across state lines since they believe that will bring down costs. It will also gut state-specific insurance requirements which will simply mean that fights to re-instate those requirements will now occur at the Federal level. Trust me, with the current Administration and Congress the whole country will end up with New Jersey's insurance requirements.
Slide 14: Bad comparison. Total Public is 49%; total private is 52%; the use of the 13% out-of-pocket for comparison purposes is specious.
Slide 15: What the heck happened in the mid-90s and can we do it again?
Slide 16: So private insurance represents a subsidy for Medicare and Medicaid. This seems kind of insane. Almost as insane as charging people with health insurance a discounted rate for procedures while charging people without health insurance the full rate.
I'd love to see some research that looks at what exactly is killing people in the United States. Is our life expectancy rate lower because we lose too many young people to automobile accidents, suicides, and violence? Or is it because we lose too many middle-aged people to heart disease and diabetes? Also what happens to the incidence of various diseases if you control for financial condition? Do poor people die from different causes than rich people?
Finally, why can't we adopt Bill Bradley's old idea and let anyone who wants to buy into the Federal employees' health insurance program? Charge a small overage if necessary for administrative costs and have the government subsidize those who can't afford it. Why set up a whole new mechanism instead of just using one that already exists? See how it goes and adjust as necessary.
By JPMcT, at
Fri Apr 24, 10:48:00 PM:
@ TH
I think you miscue "rationing". What we really have in the US is "Triage".
In other words, we ALL have access to care (insured or not)but those who have the most need move to the front of the line.
By law, everybody who goes to an ER in the USA HAS to be seen BEFORE his insurance credentials are assessed. By and large, the sickest get treated first, but everybody who can wait long enough will be treated. The uninsured receive the same care as the insured (you may disagree...but I can attest to this on a daily basis). The difference is that the uninsured generally don't pay for their treatment...and generally never do.
That's why a lot of professional organizations favor nationalized health care. It "thins the herd" thru rationing, pays for those who historically get a free ride and reduces administrative costs.
What you lose in the equation is the TRIAGE. The most needy get bogged down in the administrative quicksand and the medical staff, bureauocrats all by this time, cease to be patient advocates.
Those who want plastic surgery and "concierge care" may or may not be able to get it.
Those who wait in line for care become the majority.
Those who get their care by bureauocratic fiat join the others in line.
"Cost Effective" is relative. If you make health care a minimally expensive utility, everybody will want their share...the lines will grow long...the triage element disappears...and VIOLA....we have CANADA!
CANADA...massive expense, long waits and day-job doctors. The healthy love the system. The ill tend to die off or go elsewhere.
The only thing that keeps the Canadian healthcare system from being a public health menace is the availability of triage based care in the United States.
If we adopt their system...well...Que lastima, amigos!
By Elise, at
Sat Apr 25, 10:22:00 PM:
JPMcT, your statement that everyone gets help at the ER doesn't account for people who need, for example, ongoing treatment of a chronic illness. If someone cannot afford a prescription drug he needs and does not qualify for Medicaid, he is not going to show up at the ER every day or twice a day to get his meds. We are thus rationing that person's medical care by ability to pay.
By JPMcT, at
Sun Apr 26, 07:27:00 PM:
Elsie, ER's have become the "doctor's office" for lots of people who need to see a doctor, but who don't want to a. wait and/or b. pay.
Chronic illness is covered in a variety of ways: less expensive medications can provide good care to a huge majority of people...not everybody has to be on the latest ACE Inhibitor or Statin. Most, if not all, docs give care away on a routine basis to those in this predicament, usually the "working" poor. I do a fair amount of free surgery both within and outside of programs set up for just these kind of people.
Very few people "want" for care...VERY FEW....and they almost have to want it to be that way.
