Advice
It’s fun to give advice, particularly when you will never have to implement any of your suggestions. The Commonwealth Fund recently assembled the usual suspects and wrote their “Advice to the Candidates.” A lot of the paper is apple pie and motherhood or so vague that it means anything or nothing. But some of the points are familiar soap boxes for academia. Efficiency is mentioned occasionally, but the only meaningful reference is on the last page of the appendix.
Health insurance coverage for everyone is probably a done deal, at least politically. All candidates have more or less endorsed this, tho some are more tenuous about how to pay for it. As noted here before, we’re already paying for healthcare for all, but not health insurance for all. At least not entirely and not openly. A complex issue. The points in the CMWF document on this issue are generally good ideas, tho all would increase costs. They mention efficiency here, but only in “reducing transaction and administrative costs.” Admin costs are a small fraction of the cost of healthcare, so the returns would be tiny. Besides, don’t you think all those HMOs that have been doing this for years have been looking for ways to reduce their costs?
Align Incentives and cost. Many have lamented the link between volume and revenue, tho this seems a well established principle in every other industry--the more you do, the more you earn. In healthcare, the more practitioners “do” the more the country spends on healthcare. At times, we have sought to cut that link by reducing capability. HMOs originally tried to reduce access to care. At one time one state limited the number of MDs they would allow to practice there. (Restraint of trade. Didn’t work.) Some states still have certificate of need laws, but these are circumvented by bribes and favors from large players. About 1960, some wise men decided if we increased the number of doctors, the unit cost of healthcare would go down. Supply and demand. When the demand approaches infinity, the law of supply and demand just doesn’t work. All those new doctors found things to do. So now, we want incentives for them to do less and make less money. Good luck.
Management of high-cost and chronic conditions. Yes. Chronic conditions are a big ticket item for Medicare, and proper management can reduce the need for healthcare. For an individual practice, however, doing a good job means less need for your services and reduced revenue, unless you can fill the time with other patients. Of course, this would mean agreement and endorsement of practice guidelines. Maybe a role for incentives.
Prevention. This is a motherhood issue. It seems intuitive that primary prevention--reducing smoking, for example--would reduce healthcare costs. And it does. In some cases. But it takes a long time to see any financial benefit. And the most beneficial prevention measures fall into the realm of personal habits (smoking, drinking, exercise, etc.), rather than healthcare. If we closed all the coal fired power plants in the US, we could probably reduce the incidence of respiratory diseases, at least along the East coast. Prevention is a many splendored thing.
Eliminate waste. One sentence on page 28 of the last appendix. And this has the potential to reduce costs by 20 to 30% all by itself. Actually, they wrote, “Establishing incentives for elimination of waste” and this is key. The tools are there. Have been for years. But there are no incentives to use them. Price competition at the service level would do that, and the savings could pay for health insurance for all.
