I'm going to defer any comment on the raging insanity around us and discuss a matter of direct importance to me. As Austin Frakt discusses in the (highly successful) New York Times government -- at all levels really -- has an allergy to any rigorous investigation of whether policies actually work as intended. (Sorry if you've spent your free NYT chits for the month, I'll summarize a bit of it.) Health policy is part of my portfolio, and it's undergoing massive experimentation and innovation. Policy makers are struggling to address the rising cost of health care, the fragmentation of services, and the gaps in coverage, financial burdens and complexity faced by most of us.
Many ideas to improve health care organization and finance seem intuitively compelling, you never know what's really going to happen till it happens; and drawing causal inferences can still be difficult. If a change in payment policy is followed by reduced billings, is that because we're reducing unnecessary services, or people aren't getting care from which they would actually benefit? Or does it really have nothing to do with the policy change at all, but something else that just coincidentally happened at the same time?
So the best way to really study the effects of policies is with some form of randomized controlled trial. There are difficulties in doing these cost effectively and ethically, but cluster randomized trials -- i.e. policies that are implemented with some institutions or communities and not others, allowing for comparison at the cluster level -- or quasi-experiments -- taking advantage of natural differences in policies or circumstances -- are usually possible. They present their own difficulties as Frakt discusses -- communities or institutions that choose to participate may not be similar to the ones that don't, they may drop out, it can be hard to sort out which components of an intervention really matter. But good research design including thorough process evaluation and measurement of as many relevant variables as you can makes for more credible results.
Frakt notes that the Oregon medicaid experiment improved beneficiaries' financial stability and reduced rates of depression, but hasn't shown significant impact on other health indicators. I think that follow-up is too short to really be able to say that. The benefits of access to primary care for people who aren't already sick enough to be eligible for disability take a long time to become evident. That's another problem with policy experiments, follow-up is usually too short.
But it makes sense for government to invest in high quality, long-term evaluation of public policy. It doesn't make sense to try to save a few percent of the cost of a policy that would go into evaluation if you're actually wasting 100% of the cost, or even doing harm. But the real obstacle is politics. Many policies have political constituencies that don't want honest answers. Firearm safety is a really good example, but we see the same thing with health care policies. Physicians, drug manufacturers, device manufacturers, hospital and health system owners and administrators, politicians with constituents who don't want to pay taxes or do want something they think will be good for them even if they're wrong -- all of these stand in the way of objective assessment of policies.
And the public in general is drawn to simplistic solutions and doesn't want to listen to complicated arguments about why they don't work. "Tough on crime" policies are a great example. Unfortunately most voters don't have the attention span for complicated policy discussions and are too committed to their preconceptions anyway. I'll keep trying to raise the discourse level.
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6 comments:
How do you feel about increasing competition and allowing health insurance purchases across state lines? Do you believe that would create meaningful downward pressure on prices and force more efficiency?
Most healthcare expenditures are not emergencies. Could market competition encourage more efficiency in the services delivery by maybe posting costs for common procedures as well as success (or survival) rates?
Would making it easier to accredit medical and osteopathy schools help?
Is any of this politically possible?
Well okay.
Conservatives used to argue for allowing health insurance to be sold across state lines. That was an issue when insurance regulations varied widely from state to state. The idea seemed to be that people could buy crappy insurance that their own state didn't approve of, which would presumably be cheaper, but ipso facto correspondingly crappier. With ACA establishing minimum requirements nationally, this isn't as much of an issue. But in any case it isn't a solution to health care cost or quality.
Price transparency certainly makes sense in principle. However in the current real world it's complicated. Payers negotiate prices with providers, so the sticker price is essentially fictitious. Of course people mostly care about their own out of pocket costs anyway, which they already know, or at least should if they're paying attention -- the deductibles and co-pays are disclosed to consumers.
Outcome rates are tricky because it depends on what is called case mix. If providers are worried about getting a low quality rating they will refuse to take the more difficult cases. Paradoxically, the most highly skilled and qualified providers in tertiary care centers may tend to get the most difficult cases so they're outcomes won't look as good. For less complex procedures, people who are generally older or sicker won't do as well, so providers who serve those populations will look worse simply because of their case mix. There are attempts to adjust for these problems mathematically but they aren't very compelling.
I don't think making it easier to accredit medical schools is any sort of an answer. We don't want poorly trained physicians, and in any case it's still going to be very expensive to make a new doctor. I think expanding the work force of advance practice nurses and physician assistants, who can take routine care off of physicians' workloads, will indeed help. But we should maintain the quality of the physician workforce at the same time.
No, state regulations were not to prevent you from buying "crappy" coverage. It was to establish financial solvency standards so policy holders are not left high and dry.
And there's nothing wrong with transparency of prices, even negotiated prices. No negative here. I think this would be a popular idea with everyone except the providers. Not doing so allows health providers to avoid questions about why one group is paying more than the other.
It wouldn't be much of a task to set some standard of reporting of outcomes.
Shoving more hands-on care to non-physicians would seem to lower quality of care more than expanding medical schools.
I am glad to see someone discussing the actual delivery instead of just focusing on the insurers.
Well sure, states enforce solvency standards. But state insurance regulations are much broader than that. There's no particular reason why a policy sold in one state would be cheaper than a policy sold in another, other than the quality standards. Most insurers are in fact multi-state entities.
I agree that there's nothing wrong with price transparency in principle, but given the current state of affairs it tends to confuse consumers rather than enlighten them. Right now people in fact get statements that show some ridiculous price for services, then show a negotiated rate with the insurer, then show what you actually have to pay. Most people find these baffling and throw them away without bothering to try to understand them.
It is indeed much of a task to set some standard reporting of outcomes. Smart people have been working on this for many years and they have yet to find a satisfactory way to do it. The problem consumes the time of innumerable researchers. If you enter the phrase "outcome measure" in PubMed it will return nearly 3,000 publications.
There is a boatload of research finding that care by NPs and PAs is not inferior to physician care. In this situation the comparisons are easier to make because the providers are practicing in the same setting. Most medical visits are for routine problems like minor infectious diseases, monitoring of chronic conditions, earwax removal, stuff like that. MDs are expensive and in short supply and they don't have to do that stuff. They can step in when more complex problems arise.
Oh, I agree about the expanded role of the PA. I was asking why expanding their role results in no degradation of quality, but producing more doctors would.
Also, I like the idea of expanding the role of Osteopaths. Osteopaths take the same physician's exams as do medical doctors and have the exact same privileges...prescribing drugs...surgery, specialties, etc. They are in every sense of the word...DOCTORS! Any argument that Osteopaths are somehow less qualified is simply not true.
Focusing on osteopaths might be part of the solution to the high cost of medical services since the AMA tries to control the number of medical doctors in this country.
Not an issue. In the U.S., D.O.s already are considered equivalent to M.D.s, and have all the same licensing and privileges. There really isn't any way to expand their role. And since their training is fully equivalent to M.D.s, they don't produce any shortcut or cost saving to increasing the physician workforce.
(Not so in Europe BTW, where osteopathy is still a heterodox school similar to chiropractic.)
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