Enthoven: Consumer Choice Health Plan -- Again

An Op-Ed in the New York Times of December 28, 2008 by Alain Enthoven, Professor of Management at Stanford, brought back memories of his “Consumer Choice Health Plan” published in the New England Journal of Medicine in 1978[1] and brought back in 1989.[2] In this current piece, Prof. Enthoven cites a plethora of problems with the health system that are not likely to be addressed by the current Obama health plan. These include having ”…a health care system that regularly rewards waste and punishes efficiency…”, that we are weak on and do not reimburse for preventive services, and a fragmented, unintegrated system of care. He also notes the cost to the federal budget of more than $1 trillion, citing not only the direct costs (Medicare, Medicaid, federal employee benefits, military, VA) but ”…the cost of excluding employer health contributions from workers’ taxable incomes”. Woolhandler and Himmelstein have demonstrated in a number of studies (extensive references) that this amount, plus the amount spent by states and local governments, is not only nearly 60% of US healthcare spending, but exceeds the amounts spent per capita by all other countries. (Thus, they note, we are paying for a national health system, but not getting it!)[3]

Unfortunately, Enthoven’s solution is to bring back out his same plan. There is nothing wrong with having the same ideas in 2008 as in 1978 and 1989 – single payer, for example, was a good idea at those times and remains so. The problem is that the Consumer Choice Health Plan was a bad idea then and remains so. It advocates efficiency, large group practices, physicians working for salary instead of fee-for-service, preventive care and cost-conscious behavior. However, it seeks to achieve it by a complex system based, essentially, on making patients pay for a larger percent of their health insurance premiums, which will incent them to insist on cost-effective, efficient practices. This concept is heavily based on the idea that it is the doctors’ fault that the system is bad. In talking about the “85 percent of doctors [who] work in small, fee-for-service practices, he is willing to admit that “Many of these doctors are very good and hard-working.” Not even “most”. But they are also “…unable and unwilling to be held accountable for the quality and cost of the care they deliver.” Unable perhaps; the system does not encourage this, and frequently does not make it possible, but “unwilling”? Based on what? Moreover, employees have been having their health benefits cut back dramatically over the last several years, bearing larger and larger percentages of the cost and this has not resulted in increased competition, increased efficiency, or increased quality. Mostly it has resulted in fewer people being able to afford, and thus having, insurance.

I agree that we need a health system in the US that encourages and rewards quality care, that increases communication and sharing of information, that fosters the development and implementation of system-based practices. But there is no reason to think that Prof. Enthoven’s plan will result in such a system, much less is a good way to get there. It does not address the issue of the uninsured, the fastest-growing part of our population. He makes it seem that most employees have generous health plans, while the fact is that they don’t, and even those who have – notably employees of large car manufacturers such as GM and of state governments (he cites Wisconsin and California) are having great cuts to their benefits.

As noted by Schiff, et. al. in 1994[4], lack of access is the greatest quality deficit, and Enthoven’s plan does not even begin to address this. We need a comprehensive health insurance plan, preferably a single-payer plan such as an expanded Medicare-for-all as called for in HR 676, so that everyone is covered and can get access to the health care that they need. Only then do plans to increase quality, efficiency, and cost-effectiveness make sense. Otherwise such consumer directed health plans are, in Woolhandler and Himmelstein’s words “except for the healthy and wealthy, unwise”.[5] My in my Christmas Day (Dec 25) post I discussed a funding situation that makes hospitals and other health care institutions pursue some (profitable) “product lines” and not others demonstrates this insanity. Why should the diseases some people have be “profitable” and some “unprofitable” resulting in inadequate or unavailable care? Why should care for some people be profitable or unprofitable?The only solution is to develop a system where everyone is covered, where access to care is based upon health needs, where the payment system doesn’t perversely encourage treatment rather than prevention, or intervention rather than waiting, or high-cost drugs rather than low-cost, or care for some conditions rather than others of equal or greater health risk/benefit.
[1] Enthoven AC, Consumer-Choice health plan. A national-health-insurance proposal based on regulated competition in the private sector (two parts), NEJM 1978 Mar 23;298(12):650-658 and 1978 Mar 30;298(13):709-720
[2] Enthoven A, Kronick R, A consumer-choice health plan for the 1990s. Universal health insurance in a system designed to promote quality and economy (two parts), NEJM 1989 Jan 5;320(1):29-37 and 1989 Jan12;320(2):94-101
[3] Woolhandler S, Himmelstein DU, “Paying for national health insurance – and not getting it.” Health Aff (Millwood) 2002 Jul-Aug;21(4):88-98.
[4] Schiff GD, Bindman AB, Brennan TA “A better-quality alternative. Single payer national health system reform. JAMA 1994 Sep 14;272(10)803-8.
[5] Woolhandler S, Himmelstein DU, “Consumer directed healthcare: except for the healthy and wealthy it’s unwise”, J Gen Int Med 2007 Jun;22(6):879-881.