Saturday, April 16, 2016

Healthcare Buyer’s Choice – Top-Down or Bottom-Up
You pays your money – and you takes your choice.
English proverb meaning you must resign yourself to taking risks.  Everything costs money but paying something does not mean you will get it.
This morning   I read 2 articles relating to health care choices.
The first  was in the Wall Street Journal. It was by Yuval Levin, editor of National Affairs, “The Next Conservative Movement.” Levin opined that the best thing conservatives could offer to the health care world was bottom-up decentralized solutions to match today’s diverse culture.  In his words, “The new conservative approach would liberate insurers and providers to offer many different models of coverage and care and empower consumers to choose (including financial assistance to those unable to afford insurance)  and let their choices matter – making the system more efficient from the bottom up.”  Examples of this approach would be retail clinics, walk-in urgent care centers,   facilities offering focused care for specific diseases or symptoms, work-site practices, and direct-pay primary care or common, ambulatory surgeries
The second  was in the New England Journal of Medicine. Its author was Jonathon Oberlander,  PhD,  a health care policy expert at the University of North Carolina and a frequent commentator on ObamaCare.  (“The Virtues and Vices of Single-Payer Health Care. ” April 14, 2016. His take was “Preserving and strengthening the ACA, as well as Medicare, and addressing underinsurance and affordability of private coverage  is a less utopian cause than single payers.   I believe it’s the best way forward now for U.S. health care.”
These 2 points of view got me to thinking  about my own point of  view.   The old rule of writing is “ Write about what you know.   This is what I know after 40 years of writing about health reform.
·         I know health care reform is fiendishly complicated, and  no single answer exists in a pluralistic , diverse, multicultural society , and vast continental  nation like the USA. 

·         I know health care reform  gets more complicated and contentious and expensive the more medical technology advances and the older  the population grows seeking solutions to aging and chronic disease.

·         I know there are no easy solutions on either the liberal or conservative  sides of the social justice or ethical sides of the reform equation.

·         I  know that the Internet and social media are not the answers  and do not and cannot capture the humanistic nuances of patient-doctor-health system interactions or transactions.

·         I know patients and doctors will continues to seek the best technologies, online and offline, that medicine has to offer for life-style and life-saving purposes. 

·         I know people  want high-tech, high-tech care in equal doses.  

·         I know Americans are  impatient people who want action  not talk from doctors  - a prescription, a laboratory test, a CT or MRI scan, a procedure; anything, something concrete, something  they can touch, feel, take, ingest, inject, point to, biopsy ,  grasp, identify, undergo.

·         I know people will always seek  alternative or supplemental  solutions to medical care – vitamins, supplements, herbs, something outside the realm  of “scientific medicine“ and given a choice ,  will choose  prefer, private, personal , home,  and decentralized care.

·         I know more centralized care,  as administered  and managed by CMS and government,  health care corporations,  hospitals,  and other organized third  parties  will become dominant and control most physician practices, subject to the good of the organization. 
  • I \know consolidation often leads to monopolies and to higher prices.
·         I know that  there is no “free lunch,” that government policies covering the general population always have a 10% fraud and abuse price tag, and that once instituted government programs  never go away and always have constituencies.

·         I know that America’s tort system,  which promises huge casino-like rewards  for successful cases,  drive up overall health costs, especially for physicians who must pay exorbitant malpractice premiums. 

·         I know that the present  ObamaCare health exchange policies,   which raises costs for covering those being subsidized by 25% more than the general population, are unsustainable  and means insurers have 2 stark choices – jack up premiums or exit the market.
I  know not where this is all going, but my best  bet would be that a dual system will emerge – one top-down with fewer choices,  and one bottom-up with multiple choices.

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