Tuesday, March 30, 2010

The Healthcare Hangover, Part 2

"Law May Do Little to Help Curb Unnecessary Care"--that's the headline atop Gina Kolata's story in The New York Times today. As Kolata notes, people still want to be treated. (We can leave aside, just this once, the question of who decides what is unnecessary.)

As the Times explains: "It is no surprise that Congress shied away from a serious effort to hold down overuse. The public has made it clear that it does not want to be told what medical care it can and cannot have." And she adds a colorful quote from a well-known expert:

“The minute you attack overutilization you will be called a Nazi before the day is out,” said Uwe E. Reinhardt, a health economist at Princeton.

Ouch! Of course, "Nazi" might be too strong, but "death panelist" will certainly be heard. Continuing, Kolata adds these skeptical grafs on a major article of healthcare reform faith--comparative effectiveness:

Some hold out hope for the comparative effectiveness studies.

But “there is no direct link between the development of that evidence and the use of that evidence,” said Bryan R. Luce, senior vice president for science policy at United Biosource Corp., a Washington consulting firm.

The idea of the comparative effectiveness guidelines is a sort of an “if you build it, they will come” notion, said Dr. J. Sanford Schwartz, a health economist and internist at the University of Pennsylvania. But that is not going to be sufficient, he said. There needs to be a way to effectively link what the guidelines say and how they are put into effect, how they are interpreted, what insurers pay for and what doctors do.

One way to make those links is to do what some other countries do — say that there will be no payments for care that is not deemed the most cost-effective. But politicians shy away from such measures, Dr. Luce said. “That is not likely to happen soon, particularly at a national level,” he said.

It would mean rationing, said Dr. Robert D. Truog a professor of medical ethics, anesthesia, and pediatrics at Harvard Medical School. “That’s the word nobody wants to use. It’s just a firecracker. Nobody wants to touch it.”

So what, exactly did get cut? We know that we will add 31 million people to the insurance rolls, but if the thrust of Kolata's story is accurate, then it sure seems as if the cost-curve was bent upward, not downward. Yes, Peter Orszag made great arguments about controlling costs and all that, but those arguments don't seem to have gone very far beyond the marbled palaces of Washington. It doesn't appear that either doctors or patients have paid much heed. The bogies of demanding patients, defensive-medicine-ing docs, and overall inefficiency still seem to be with us. So we'll be waiting to see if Orszag & Co. now wade into the details of cutting costs, and how Congress, and the American people, react to such wading-into-ing.

But for now, we might ask: Is this why we passed this bill? To spend more? Interesting.

Here at Serious Medicine Strategy, we have long argued that spending is not the problem. Instead, the problem is what we get for the money we spend. The "get" can be improved, of course, but not by talking about cutting costs. The get can only be improved by improving the quality of care, and the quantity of cures. That's how to save money. Nothing else works.

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