One man's ceiling is another man's floor

And that's also true when we're talking about health care costs -- any money we save is money somebody isn't getting. And that's the real reason we don't get real reform in this country.

Atul Gawande, as usual, is pretty good. In this piece his McGuffin is the small percentage of patients who account for a bit percentage of medical costs. He isn't talking about people who are near death, either. These are folks who are out in the community and if they appear not to have long to live, it's not because they're medically hopeless. Many of them have major psychosocial problems that make it difficult for them to follow medical advice, take medications, and keep appointments. A few of them are just victims of very bad coordination among providers.

Gawande discusses various reasons why some people have very high health care costs, or costs that are much higher than they need to be, from poor parenting to cognitive limitations to copayments that prevent them from filling prescriptions.

But I just want to focus on one point. A payment system in which teams of providers are compensated by capitation to take care of high costs patients, and get to pocket a portion of savings, completely realigns incentives. It makes sense to hire patient navigators -- lay people trained to help people take care of themselves better. It makes sense for the various providers, including specialists, to talk to each other and coordinate services. It makes sense to do home visits, offer walk-in visits, hire a social worker, for those people who are going to avoid hospitalization and ER visits as a result. It makes sense not to provide unnecessary services while making sure the necessary ones are delivered no matter what.

But, that means somebody else is losing money. Gawande tells of one model clinic -- he doesn't really use the labels but you could call it an Accountable Care Organization and a Patient Centered Medical Home -- that found that one group of hospital based physicians that saw it's hospitalized patients wouldn't work with them - meaning longer stays, and higher costs. These doctors hung out in the ER and tried to poach their patients.

And oh yeah -- why would hospitals participate? They just lose income. (Remember my post a few days ago about retiring RI Health Director David Gifford suggesting that in a world where saving money was the objective, hospitals would be sanding sidewalks to prevent people from falling.) But Emergency Department orthopedics is a profitable business. Why would they want to lose it?

And that's why wealthy specialists, drug companies, and for-profit hospitals are paying untold millions of dollars, in secret, to convince you that Democrats want to kill your grandmother by cutting Medicare spending and destroy freedom by putting bureaucrats between you and your doctor. Spending less money on health care is the only way to get better care. And no, there's no plan to install bureaucrats in doctors' offices but there is a plan to pay doctors to keep you healthy instead of rewarding them when you get sick. What they're afraid of is losing money. What ought to be your money.