This is the fourth and final part of the 23rd Charles Odegaard Lecture, "Good enough for government work:Quality, cost and gaming the system. I will put the entire talk up as an attachment soon.
Is this
really true? Aren’t some of our costs “our fault”, or at least “their fault”,
that is other people? What about those folks who are “gaming the system”, by
holding out on buying insurance until they get sick? Aren’t they driving up
costs? Insurers like Aetna and Anthem make the accusation that people are
misusing Special Enrollment Periods (SEPs) for this purpose. This is debunked
by the evidence, cited by Michael Hiltzik of the Los Angeles Times, but even if they were, they’re poor people trying to get by! Wondering if they can put off
buying health insurance so that they can pay the rent! Who is really in a
position to develop and implement strategies to “game the system”?
Unsurprisingly,
as Hiltzik also reports, it is the insurance
companies (as well as big health system providers) who are masters of these
strategies. Besides, if we have concern about “buying to use” behavior, the
best answer is to get rid of the jumble of insurance companies and enrollment
periods and have one national health insurance plan that has, in the words of
the recently deceased Quentin Young, “everybody in, nobody out”.
The most
amazing thing about all of this, the way in which the system is gamed, is the
way it transfers public money intended to provide healthcare for people into
private pockets far in excess of the cost of providing that care. Himmelstein
and Woolhandler provide us with data that shows that we already pay for a
national health system, with over 50% of “health” costs being borne by
government, far over 60% if we count the loss of revenue from employer
contributions to insurance being tax deductible, but we still don’t come close to
covering everyone, because our system is so inefficient, and so much boodle is
being raked off.
Nowadays,
when we hear the phrase “good enough for government work”, we tend to
think of something that is poor quality, or only just meets the minimum
standards set by government. The Urban
Dictionary defines the phrase as “Probably not the best, but what the hell,
at least we got the job done to minimally acceptable standards.” And, yet, when
this phrase first came about it was a compliment; it meant that the government
set minimum standards of quality that had to be met, and if you had someone
(say a contractor) doing work that was “good enough for the government” it
meant that it met those standards of quality, that they weren’t ripping you off
by doing shoddy work. What we have now is our publicly-funded health system being
cannibalized by profiteers, and enabled by a government that often seems to
care more about cost than quality.
Charles Odegaard, the medieval
historian and former University of Washington president after whom this
lectureship is named was, and I quote from the Coastal Research website, “an impassioned proponent of the idea that
every school within a university should be engaged in the advancement of
society in the communities and regions that surrounded it. As a result of Dr
Odegaard’s leadership, UW became a leader in the decentralization of medical
education, including the unprecedented commitment to training physicians from
and in the surrounding states of Alaska, Montana, Idaho and Wyoming.” [1]
There are great positives to
decentralization, whether for education of doctors or for administration of
social programs. It can decrease the cost of large, unresponsive central
bureaucracies, and put control in local areas that are more knowledgeable about
and responsive to the needs of their populations. There are, also, risks.
Sometimes control at the local level is more about maintaining the power of one
sector of the community at the expense of others; one just has to look at localities
and states in the South in the Civil Rights era defying integration (or,
perhaps, many states and localities more recently). More to the point of this
talk, there is the risk that smaller, more decentralized activities can be more
easily underfunded. Think about the deinstitutionalization of people with
severe and persistent mental illness toward the end of the 20th
century. When I was in medical school, I was taught that 1 in 3 hospital beds
was occupied by someone with schizophrenia. That is certainly not true today,
because of deinstitutionalization. And so we do not have the horror of people
with mental illness warehoused in enormous facilities, but we also do not have
anywhere near the degree of community-based mental health services that would
allow them to live successfully in the community. We have people with mental
illness living on heating grates and under bridges and, according to a June
2015 article by Matt Ford in The
Atlantic, our nation’s largest mental hospital is a jail (absolutely
believable to anyone who has ever worked in one).[2]. It is
only ok to decentralize when we can assure that necessary programs will be
maintained and will be well funded. We have long since privatized the health
care in most prisons, and there is a (to me) disturbing movement to privatizing
prisons altogether. Cost, again, trumps quality. Especially, of course, if the
prisoners are mostly “not us”. Seeing a trend?
So…is it possible to have quality
and still reduce costs? Of course. Our system is not only financially
inefficient, and the victim of massive skimming by the private companies, but
it is one which is geared to care for individual patients rather than
populations; where there is not rational allocation of resources to the areas
where they will do the most good, but rather decisions made for each
individual, often where the provider has a financial incentive to do more.
Oregon’s CCOs, a kind of state-sponsored but decentralized (there are 15 in the
state) ACO designed only for Medicaid patients, have provided some movement in
this direction, but they are limited because they are, in fact, only for
Medicaid patients. This permits skimming, as we see in recent data that shows
that the places long touted for their efficiency and low cost for Medicare,
like Grand Junction CO and Rochester MN, are among the most expensive for
private insurance. The same characteristics, integrated health systems which control
most of the care in a community, that allow them to be efficient with fixed
Medicare funds, also allow them to raise the rates for private insurance.
Gaming the system.
We could have a good health care
system. It needs to be built upon quality, and quality has to be based on
consensus, and has to apply to everyone, rich and poor, young or old. It cannot
be segmented into different versions of quality for privately insured,
Medicare, Medicaid, and uninsured people. The “how-to” is not hard; other countries
have shown us how. The money is not hard, we are already spending excessive
amounts. What we need is the will.
3 comments:
i like this blog, since 2008 good
This is a great article as it addresses a lot of the "issues" with the current health care system. I've recently read How To Get What You Pay For by Joe Flower. He addresses the ways that we can bring the costs down. He's got a lot of good info, he has the right idea. We could use some of his ideas and run with them.
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