What went wrong with U.S. health care cost control?

So if the real problem with U.S. health spending is that the U.S. diverged from its peer countries for a decade-long stretch, solving that problem isn’t quite as simple as mimicking the institutions and strategies of our peer countries, whether it’s Canada’s single-payer system or the hybrid models of France or Germany. Our peer countries are facing the same challenges we are, albeit with slightly more breathing room.

This raises the question of what exactly changed in the 1980s. Daeho Kim, a graduate student at Brown University, offers a provocative hypothesis in a new working paper. As Kim explains, a 1983 Medicare reform created the prospective payment system, or PPS, which offered fixed reimbursements for the use of a medical technology. If a physician decides to use bypass surgery as a cardiac treatment, she won’t be paid on the basis of what it cost her to perform the surgery. Instead, she’ll be paid the national average cost. This way, there is a strong incentive to beat the national average cost of performing bypass surgeries, thus lowering, in theory, systemwide costs.

But something quite different seems to have happened. A big part of the story is that providers can choose from a number of different cardiac treatments, some of which are more expensive than others. PPS encouraged them to focus on the treatments where the marginal cost — the cost of providing one more treatment, in this case — fell below the average cost, even if there are more cost-effective treatments available. Kim suggests that PPS may account for one of the most distinctive aspects of the U.S. health system — our extraordinarily overreliance on costly treatments. If Kim is right, it is the failure of bureaucratic price-setting, not the failure of market competition, that may have supercharged health inflation in the 1980s and beyond.

That is from Reiham Salam.  I will read through the Kim paper carefully and perhaps report back on it.  This is an important topic.


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