Monday, November 26, 2007

Government Reform - 365 Blogs, 365 Days; Still No Reform in Sight

A year ago, I struck out to write a blog a day over the course of a year. Today ends that trek. Here are the changes of import I am witnessing.

Fading hopes for single-payer (even in Massachusetts, it’s clear that will not happen).

Moves towards “convenience care, “ retail, worksite clinics, ambulatory and urgent care centers, as employers search for answers to cost problems (These developments collectively may be the innovation of the year)

Embrace by the public, doctors, CMS, and health plans of generics to take edge off brand name expense ( An example of this is the rush of seniors to fill the Medicare “donut hole” with generic equivalents).

Wary gains of consumer –driven care as more and more small and mid-sized employers replace HMOs and PPOs with high-deductible/HSA fueled plans and Medicare makes HSAs universally available for the first time).

Growing empowerment among physicians as they sense that they’re central to any reform and that 70% of health costs sluice through hospitals, other health institutions, health plans, and administration structures (doctors are expressing this empowerment through, the AMA, and the Physicians Foundation for Health Systems Excellence, an organization of state medical societies representing 500,000 physicians)

I see no prospects for sweeping reforms. I’m no fan of the New York Times editorial page, but it’s lead editorial in today’s Sunday Times gets it about right on many counts ( “ The High Cost of Health Care, November 25)

Here’s what the editorial had to say.

The Problems

High health costs causes vary and are rooted deep – our wealth and willingness to spend more, our reliance on specialists and technologies, our fragmented array of providers and insurers (one man's fragmentation is another man's personal doctor). The fundamental question is: what can be done to lower costs and rate of increases, and does it matter?

The Solutions

Cut 30% cost variance by regions (to me this is wishful thinking. Every region expense priorities and beliefs in what constitutes "quality care" differs and will never be the same). Identify what care works, inform consumers what works, reward doctors that make it work (what works, unfotunately, often falls into “gray” areas, and comparative effectiveness studies are in their infancy). Managed care is creeping back into health plans in the form of protocols and P4P (but there are signs a backlash is growing ). Implement information technologies on a grand scale ( I differ with the Times assessment that “There is little doubt” widespread computerization could greatly reduce the paperwork burden, head off drug errors, and reduce replication of diagnostic tests). Preventive measures – controlling weight, exercising, stopping smoking, checkups and screening and judicious use certain drugs – will slash costs (fat chance in individualist and misbehaving America). Carefully coordinating care and managing chronic disease ( I believe this is sound approach). Have the government negotiate Medicare drug prices and import drugs from abroad (I’m not optimistic beat the pharmaceutical and device manufacturer lobbies).

Who Picks Up the Tab?

Pay doctors less ( The Times doesn’t favor this, and neither do I). Stress Primary Care ( The Times says this will be a long term-project, requiring changes in reimbursement formulas and medical education reform. I agree). Give consumers skin in the game ( The Times cites 1972-1982 Rand studies showing consumers spending own money spent 30% less, but doubts consumers have competence to second guess doctors, and says consumer-driven care will apply to the poor and the sick. Single payer whereby government pays for all care and dictate prices (The Times says such a system might cut costs but has limited political support.

The Times conclusions? No silver bullet exists to slash costs; there is not enough information to cut costs without impairing quality, and maybe, just maybe, some hope for cost lwoering lies in “cascading knowledge’ flowing from human genome project, nanotechnologies, tailor-made personal treatments. I’m dubious about the latter, but hope springs eternal, and I may be wrong.

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