The new voodoo economics is the claim that because we can (will?) make cuts in Medicare spending, we can afford to spend lots of money elsewhere. I explain this in my latest column. Excerpt:
Drawing upon the ideas of the Harvard economist David Cutler, the
Obama administration talks of empowering an independent board of
experts to judge the comparative effectiveness of health care
expenditures; the goal is to limit or withdraw Medicare support for
ineffective ones. This idea is long overdue, and the critics who
contend that it amounts to “rationing” or “the government telling you
which medical treatments you can have” are missing the point. The
motivating idea is the old conservative chestnut that not every
private-sector expenditure deserves a government subsidy.
Nonetheless,
this principle is radical in its implications and has met with
resistance. In particular, Congress has not been willing to give up its
power over what is perhaps the government’s single most important
program, nor should we expect such a surrender of power in the future.
There is already a Medicare Advisory Payment Commission, but it isn’t
allowed to actually cut costs.
Obama, to his credit, has very recently proposed to change this. But will the fiscal story have a happy ending? Probably not:
If we are willing to take comparative-effectiveness studies
seriously, we could make significant cuts in Medicare costs right now.
We could cut some reimbursement rates, limit coverage for some of the
more speculative treatments, like some forms of knee and back surgery,
and place more limits on end-of-life-care.
Those cuts alone will
not solve the fiscal problem, but if we aren’t willing to take even
limited steps to conserve resources, we shouldn’t be spending any more
money elsewhere.
Of course, we have not made such Medicare spending cuts yet, and there are few signs that we will. A Kaiser Family Foundation poll
found that 67 percent of Americans believe that they do not receive
enough treatment and that only 16 percent believe that they have
received unnecessary care. If the Obama administration covers more
people with government-supplied or government-subsidized insurance, the
political support will broaden for generous benefits, their
continuation and, indeed, expansion of current expenditures.
Read the whole thing.
“end-of-life-care,” is heretofore guaranteed to be.
Mick,
The question is whether the 65% who are insured or overinsured are receiving too much “care.” The uninsured or underinsured are partly the young who need no care whatsoever. Doctors don’t do prevention. They barely do cures. That being said, I don’t want the politicians making the decision. If the government wants to limit its outlays for its own selfish reasons, fine, but it won’t work that way, they will make a virtue out of necessity and screw it up for everyone. In this fight between doctors, insurers and the government, the patients are a rabbit being fought over by dogs and the voters are being asked to bet on one of the dogs.
I am largely in agreement with you here. We can make significant cuts in costs if we do it the right way. We ned to cut down on the places that are dong twice as many procedures with no better or worse outcomes. My fear is that this will be approached by just cutting reimbursements across the board. This will hurt places, like the Mayo Clinic, cited in the Dartmouth study without necessarily doing much to the over-utilizers.
The end of life issues will provoke the evangelicals/Catholics. This will be a political hot potato. Total joint surgery and back surgery will probably require taking on the AARP. These will not be easy. We already know that any attempts to control costs will provoke the dreaded rationing word.
I would disagree with you on the electronic records. While we do not know for sure when we would se savings, I can tell you as a practicing physician, that I routinely order redundant tests because I cannot get access to prior studies. Much of my work is time sensitive and it is easier to get something repeated than spend hours trying to get something sent to me. It is often most difficult to get information on studies performed recently and nearby. As those places are economic competitors, they are not motivated to share. It would also help immensely with the number of people we have who speak poor English or have other mental/emotional issues making communication difficult.
Steve
Why don’t we start by looking at the industries that are known for cutting costs and improving their product at the same time. They have a common feature. They employ people in the roll of engineer. What they do not do is get large political committees together to find cost savings.
How many medical, (or educational) engineers are there? What percent of the budgets are spend on R&D? Quality and Process control etc.
Yes we spend money on drug and device R&D, but I am talking about of the medical practice, hospital process etc.
There was a series of articles on the impact of using very basic checklists in medical practice, and the cost and medical outcome improvements that they achieved. Yet there was despair by the people advocating them, that they met with such high resistance to change.
I don’t think you’re allowed to say “read the whole thing” about your own articles. “read the whole thing” is generally used to say you think the article is good.
This is going to get worse before it gets worser.
From Andrew:
Sentence of the month.
Consider the financial situation in which we find ourselves. The finance industry does not lack for availability of data or information, nor did it lack for high powered intellectual horsepower, still some firms like AIG and others blew things badly. How, then, do we think we can apply yet defined metrics around incomplete data and be able to measure the comparative effectiveness of a clinical product when we so badly missed comparative effectiveness of financial products?
I wonder where the notion came from that if you take smart people out of the private sector and place them in the public sector, they become infinitely smarter. I’m just an RN, so perhaps you can help me, why the optimism?
rjh- Not necessarily. Much of the increase in utilization simply results in larger salaries for those who over utilize. I am a physician and I see this a lot. One of my local Orthopedists follows shoulder pain with an MRI every six months(this is just one example). Guess who owns the MRI? Anyway, this doc makes a lot of money. If we cut down on not needed procedures, he will still make a very good but not outrageous living. I suppose it is possible that his personal chef or his high priced girl fiend may need to go. His wife will probably be sad at the loss of one of those.
Steve
The contrary position is what the f&#k does it matter. Does anyone serious think we won’t end up in the same position sooner or later? ‘This will make it worse’? No, it’s as worse as it gets. The sooner the current system meets its end, the better for everyone. Attempting to drag it out only delays the inevitable. If it takes a complete collapse to move forward, we are far better off bringing it about than pretending in some fantasy. Bring it on.
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