I enjoyed the discussion at the HPM workshop this afternoon, but I think one point that was glossed over was the idea of "meaningful" reform. For the sake of argument, let's suppose that Professor Robinson's predictions come true: Obama signs a bill in the next few months that includes an individual mandate, no public option, some malpractice reform, etc. But none of these components - and really none of the discussion that I've seen of health reform so far - have given any real evidence of containing costs.
I certainly think it would be an accomplishment to pass a plan that makes a dent in the huge number of uninsured, but covering more people isn't necessarily going to contain costs. I understand the argument that with more people, particularly young healthy people, in the insurance pool paying premiums the costs per patient may go down slightly, but I don't see how this could cap any skyrocketing costs due to technological advances and expensive pharmaceuticals, for one. So my question is: can we call a plan without any real cost-containing measures "meaningful" health reform?
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I see your point, but one must also consider that there is little we can do to lower the overall cost trend if our population is getting older and fatter, and thus sicker. Due to our country’s lack of focus on preventive care, we have to deal with the consequences and treat these people with chronic conditions. What we can do is take as much waste out of the system as possible, like discouraging defensive medicine, discouraging unnecessary overuse by the public, and regulating insurance behavior. I can see this spending problem being similar to global warming: even if we were to stop all carbon emission today, the earth’s temperature would still continue to rise before equilibrating and then decreasing. As much as it pains our society’s need instant gratification, we will have to look at things in the long term and accept that perhaps cost containment will take a while to equilibrate and become apparent. Let’s hope that people’s post-economic meltdown spending habits becomes a permanent fixture and makes them more cognizant of their own healthcare spending, too.
To stay with prevention for a moment...
There's also the chance that a preventive-care-based medical home model will receive more attention. Obama noted one of the hallmarks of the Healthy San Francisco plan in his speech - the piece that requires employers to either provide coverage or pay into a system that covers all uninsured employees. If he's willing to talk about that, maybe he'll be willing to talk about the need for prevention-based models like the medical home - another hallmark of the Healthy SF plan - and the aggregate cost savings of a healthier populace. Even if the medical home model specifically gets debunked in the long run, the floor would be open to talk about preventive care.
Alana - I believe that we can, although I do not know exactly how much 'cost' would be saved.
I think it is worth thinking about 'cost' for the moment, and what that means in this situation.. Direct financial burden for service? QALY's lost? Workforce lost? Mental distress/anguish? I would say all of the above, and having health insurance coverage for primary care/acute care/support services/home services when you need them can address many of 'alternate' costs.
Returning to the traditional 'cost' definition, ie. 16.5% of our GNP, I would say that we also must remember the hidden costs, and how coverage would effect those. Yes, having the young pay premiums decreases premiums for the rest of the population, but for those who have chronic illness and cannot get coverage, or those with acute illness who are young/old/unemployed without coverage, being able to have them under a health plan will directly decrease their cost of care. If they are uncovered, the cost of their visit is either paid by them out of pocket at max price, or is distributed to other patients through increased fees, which then either perpetuates itself within this cycle for the next uninsured patient or in increased premiums for the insured (and their employer).
If they are covered, the insurance company will pay, but has the negotiating power to pay, say, 60% of the total bill. Also, those chronically ill patients and older patients will now theoretically have some sort of access to primary care so that they don't need to use the ED or other expensive urgent care clinics to receive their regular care.
While there are many problems with this argument, I think that it actually is feasible to say that by covering the uninsured, costs will be reduced. Not the most convincing of arguments for your everyday consumer though..
On another note, depending on what type of malpractice reform is included, it could considerably reduce costs. It has the definite potential slowly change U.S. physician's value systems and practice habits (ie. order less). Malpractice reform is always mentioned on the periphery, but there is truly a great amount of excess cost caught up in defensive medicine. Unnecessary tests to 'CYA' often lead to more tests as they are equivocal, and often to procedures that were never needed in the first place. If some 'meaningful' malpractice reform (ie. alternative medical courts, alternative dispute resolution, enterprise liability) were put in place, this could potentially be a very effective cost saving measure.
Finally, to allude to what Eddie and Marco are saying about preventative care, the beginnings of any reform plan will get us that much closer to more of a focus on prevention, no matter what the model. It may be more slow and incremental than we would like, but it would at least spark more preventative medicine conversation, ultimately leading to overall better health and cost-saving.
I agree with Evan in that malpractice reform could make a very significant impact on changes in the cost of care. Based on what I've learned, the medical malpractice infrastructure in this country is broken, requires physicians to protect themselves with expensive malpractice insurance plans, and indirectly leads to skyrocketing costs for patients. In an “ideal” world, shouldn’t malpractice law protect the patient from undue injury by providing appropriate, effective, and need-based compensation in a timely manner, while educating health professionals and making sure they continue to “do no harm?” In reality, the cost to a patient of bringing a claim to court can nearly match their ultimate compensation, which may not be determined for years. In fact, the average time it takes for a claim to come to trial in medical malpractice cases in this country is 4 years! I hope that when/if medical malpractice reform takes place, more than just liability caps are included and that a more efficient, fair, logical, and cost-saving system comes out on the other side.
Danielle
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