The Unschism on Health Care
Via Ezra Klein, the Kaiser Family Foundation’s Drew Altman calls attention to a potential “new schism in the debate about health reform.” This would be between “Delivery System Reformers” who are primarily interested in making health care more effective when it’s delivered to people on the one hand, and “Financing Reformers” who are primarily interested in securing affordable access to health care for as many people as possible.
It’s an excellent observation that these are different things and that the difference ought to be kept in mind. But it seems a bit odd to me to call this a “schism.” After all, there’s no contradiction between these two aspirations. As Ezra and, indeed, Altman says reform of the delivery system is integral to making universality affordable over the long run, and universality sets the context for delivery reform in many ways. At the margin, I’d definitely put myself in the “Delivery System” camp but it’s not really a choice.
Meanwhile, Ezra recommends that you download CAP’s book Reforming the Health Care Delivery System to learn more on this subject. It’s free! Enjoy.
15 Responses to “The Unschism on Health Care”
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November 17th, 2008 at 6:31 pm
Matt,
No, No, No!!!
You were a philosophy major, you should know about different relationships things may have. You’re right that these ideas aren’t competing or mutually exclusive, like Ezra seems to claim, but where you’re wrong is that while they may be symbiotic in the long term, in terms of short term priorities, the two notions seem to me to be competing.
The best analogy I can think of is a cognitive mechanism that has to allocate resources between the competing but not mutually exclusive concerns of function and efficiency. For example, putatively epistemological mechanisms need to compromise between truth-seeking and efficiency, and language generating and comprehending mechanisms need to compromise between relevance and efficiency (per Dan Sperber and Deidre Wilson’s excellent book “Relevance”).
Likewise, with healthcare, we need to compromise between improving the system and making it more affordable.
November 17th, 2008 at 7:10 pm
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November 17th, 2008 at 9:27 pm
I appreciate the post a lot. Matt, who is in no way a free market ideologue, has nonetheless fallen for libertarian arguments more than a few times. But this is different: there’s a contradiction only if you seriously believe that markets are keeping health care costs down rather than creating a cost problem that only exacerbates the risk to those without insurance.
November 17th, 2008 at 9:58 pm
This is one of those “do both” things, in my opinion. Access to care must be increased, as well as effectiveness and quality increased as well. I suppose it still does some good to give people access to crappy care if they didn’t have ANY access in the past, but as a nurse, we must always strive to increase efficiency, quality and access. You just can’t strive to do one or the other. Of course, once efficiency is addressed, care costs less and more people can afford it. But you can’t come at it from one point of view, it’s and/both.
November 18th, 2008 at 9:30 am
I agree with Ms. Anne, and I think, further, that the most pressing reform need (other than ensuring access) is physician payment reform, that “values” primary care intervention significantly more than it does now. The current system of Medicare reimbursement (on which private payers piggyback) has led not only to reduced relative income to pcp’s, but it has incentivized the whole medical system towards a much more interventionist mindset — because that’s where the money is. The so-called RBRVS payment system wasn’t designed to do this, exactly, but by rewarding “intensity” of input (e.g., using “resources” as a proxy for value) it completely overlooked the public health “value” of having more primary focused health care delivery.
This isn’t guaranteed to cut costs, especially since so many resources have been parked in specialty care, including the number of doctors who have entered specialties, but I have come to believe that it, plus some similar changes in GME and ancillary provider licensing (nurse practitioners, physician’s assistants) are probably essential to making true health care reform work.
November 18th, 2008 at 10:15 am
Ezra’s post raised a question in my mind (see, you don’t have to say “begs the question”). That is, why are health care costs so much less in other countries that have national health care? Is it something in the way the national system is structured? Or have they introduced cost-limiting programs? Or what?
November 18th, 2008 at 11:06 am
The main answer to that question is that we use more of everything and are far less likely to evaluate the efficacy of doing so. If you read my prior post, you will see why — physician payment rewards physicians who do a lot of stuff, whether it’s needed or not. I really don’t think we can stomach a constant overseer system of every physician decision, so we need the next best thing, which is more of a primary care gateway approach to medicine that simply reduces the amount of specialists and specialty device inputs in the system at large by making it less rewarding.
But the second consideration is, there is so much distortion within the system due to its fragmentation at every level that we really don’t know how much could be saved by making it more efficient and covering all people.
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