End 'All You Can Eat' Medicine

December 18, 2009|By Peter J. Pronovost and Jonathan P. Weiner

Health care reform legislation now before Congress primarily focuses on expanding health insurance. Covering the uninsured is overdue, but if health care reform is to succeed over the long haul, the nation must directly address runaway medical costs and poor quality. Unfortunately, current legislation does not go far enough in resolving the perverse financial incentives and structures that define today's U.S. health care market. Unless changes are made, the current legislation will greatly increase costs - without improving quality.

Expanding coverage to the uninsured is relatively easy. The key is providing subsidies to those with low incomes. Finding ways to control costs and enhance quality is far more difficult.

Most cost-containment efforts generally involve a massive win-lose game between stakeholders. Doctors, hospitals, drug companies and device makers battle one another to get as large a slice of the pie as possible. And these providers are pitted against those with the money: consumers, taxpayers, insurance companies, government and employers.

In the current U.S. system, this budgetary warfare is overlaid on top of an odd sort of an all-you-can-eat medical care buffet. It's akin to most of us eating all we want at a four-star buffet costing only a flat $5.99 per person. However, behind the scenes, the "chef" sends per-item bills averaging $100 a head to your employer or the government.

Most American medical-care consumers with insurance cards are welcomed into the "medical buffet line." We can "eat" as much as possible at very little extra cost at the point of service. Since providers are paid separate fees for each item we consume, they actively encourage us to "overeat." Predictably, there is much waste and inefficiency. Moreover, a huge amount of money - estimated at 30 percent of the entire budget - is spent on layers of overhead required to bill for each a la carte item of care.

To date, many if not most consumer- and doctor-targeted interventions designed to slow overconsumption have been poorly conceived. For example, indiscriminate increases in patient co-pays and deductibles reduce the use of both beneficial and nonbeneficial services. And ratcheting down the per-unit provider payment level - a favorite approach of Medicare - generally leads to a medical arms race where providers seek to increase the number of services or emphasize those with higher price tags.

Reforming this perverse framework must be a central premise of any effective health care reform legislation. Unfortunately, current legislation largely sidesteps these issues or addresses them in a very limited way.

Doctors and consumers need information about the risks and benefits of alternative therapies. And they should be given financial incentives to deliver and obtain care in accord with the best scientific evidence about what will improve health over the long term. Each of us should only be "eating" the items we really need and that our employers and our government can afford.

Piecework is hardly the preferred way to pay doctors. Alternatives include fixed salaries and flat fees for care based on the patients' medical conditions or episodes. And doctors and all other providers should be rewarded for doing a more effective job of healing you, not for doing a better job of finding things to do to you.

Prices and outcomes should be transparent to all parties. Today, few insured consumers have a clue - and surprisingly, most doctors don't really know either. Without all parties having ready access to accurate cost information, we will never achieve anything that approaches an efficient or competitive market. Yet government regulation will likely be required. For example, standardizing business practices and greater transparency are needed at all levels to help our system function more rationally. It is time to establish a health care version of the Securities and Exchange Commission, or a "Health Care Fed," to accomplish this.

Keep in mind that insurers are not evil spenders of overhead; doctors are not greedy; and patients are not unthinking, over-consuming drones. Each is playing by the rules that policymakers have set for them. And now is the time to rethink and reform how these rules are written.

Consumers and providers must learn to live within a fixed budget. Everyone must get access to care that will clearly improve, extend or enhance their lives. But we must acknowledge that, of necessity, some services will represent "extras" that will not be part of the standard prix-fixe menu. For example, a $1,000 test or treatment that is only slightly better than a $100 one cannot be fully be covered by standard insurance programs, be they public or private.

As we develop a sustainable system that ensures that all Americans can join us at the health care dinner table, it is essential we move away from the mindset of "all-you-can-eat" for some, and toward the principle of "eat-what-you-need" for all.

Peter Pronovost and Jonathan P. Weiner are professors, respectively, of Anesthesiology - Critical Care Medicine and of Health Policy and Management at the Johns Hopkins University in Baltimore.

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