Map of life expectancy at birth from Global Education Project.

Monday, May 14, 2012

This is apparently supposed to be a secret in the U.S.

Eminence grise Arnold Relman, former editor of the New England Journal of Medicine, has published an essay in a British journal, that you aren't allowed to read if you aren't on a university faculty, about why the U.S. health care system is heading over the cliff and how to get it back on the highway. Great move Dr. Relman! That should have a big impact on the debate here in the United States, which I believe is why you might write such an essay.

We actually see a lot of this -- leading scientists taking to the pages of The Guardian to rebut climate change denial that appears in the Wall Street Journal  comes to mind. I suppose it's just not possible to get liberal arguments published in the United States.

Anyway, Relman basically makes three points: the concept of the "free market" does not work in health care; therefore we need universal, comprehensive, single payer national health care; and we need to reorganize the system into multi-specialty group practices with physicians paid salaries and some form of capitated payment.

It's the latter point which goes a step further than single payer advocates necessarily go. I've already become something of a broken record on the first two here but let me make a couple of quick summary points. Relman points to provider induced demand as the key failure of "the market" in health care but actually there are many others. These include the unpredictability of any given individual's need for health care -- unlike your need for food, clothing and shelter which is roughly similar for everyone; the very serious negative externalities when people don't get health care that they need, such as loss of economic productivity, transmission of infectious disease, and failure to care for dependents; and the erosive effects on society and culture of mass-scale abandonment of desperate people.

Relman also points to the inefficiency of private insurance and the massive waste it entails in the form of profits, marketing and administrative costs. But he does not see moving to a single payer system as sufficient in itself to solve our problems. Provider induced demand will continue to generate waste and even harm patients as long as doctors and hospitals are paid more to do more, and as long as drug and device manufacturers continue to bribe them, and manipulate both doctors and patients into wasteful spending. Salaried physicians in so-called Accountable Care Organizations are the solution for Relman. Maybe that is a good idea, but I should point out that they have done pretty well in Canada with fee-for-service primary care, while in the UK, physicians are paid salaries but they operate independent small practices for the most part.

Anyway, Relman notes that many physicians are already moving to multi-specialty group practices because there are advantages over being in business for yourself. These include reasonable hours, having administrative staff to worry about all that nonsense, more economic security, and having colleagues with varying expertise to collaborate with. He hopes that if this trend continues, it will become politically easier to make policy changes. But he also doesn't necessarily expect it. He thinks we'll likely have a catastrophic failure of the system, after which, eventually, after Grover Norquist and Paul Ryan are sent off on an ice floe, we might be able to fix things.

We shall see.

No comments: