Good article in today’s
Wednesday addendum: David Leonhardt of the NY Times weighs in, noting that the "insurance lock" of the current system contributes to what he calls our "innovation deficit," where 1.5 million don't change jobs because they don't want to jeopardize their current insurance.
There is a big social benefit to being sure that 55-65 year olds can be insured. The ability to buy in to Medicare could make this group feel more comfortable changing jobs or taking a risk, and it would mean fewer medical bankruptcies going forward.
The Mass Division of Health Care Policy and Finance sponsored an impressive review by RAND researchers of potential cost-saving opportunities in Massachusetts, which was published in August. I blogged about this late this summer, and have always felt that this extensive analysis didn't get nearly enough attention.
The NEJM last week published an article by same RAND researchers extending this analysis to the rest of the country.
This remains an important study - and I'm glad to see an extrapolation getting new press.
I'm also intrigued by the differences in findings.
Hospital rate setting: Maximum savings in MA 4%; US 2%
Healthcare IT: Maximum savings in MA 1.8%; US 1.5%; Maximum increase in costs in MA 0.6%; in US 0.8%
Expand scope of practice for NPs and PAs: MA range savings 0.6%-1.3%; US 0.3%-0.5%
Medical home: MA maximum savings 0.9%; US 1.2%
Disease management: MA maximum savings 0.1%; US maximum savings 1.3%
It makes sense that rate setting might be more effective in Massachusetts to the extent that prices are higher. In fairness, this might not be a 1:1 comparison since the NEJM lumps a few different options together. Scope of practice savings might be different based on supply of physician and non-physician providers. I'm surprised to see higher projections of savings for medical home, since our specialist:primary care ratio is high in Massachusetts. I also can't explain why disease management would have so much higher projected maximum savings in the US overall compared to Massachusetts.
This analytic work is especially important as we consider what cost-control mechanisms should be included in health care reform.
Robert Steinbrook of the NEJM has posted the amounts spent on lobbying Congress and federal agencies so far this year. The health and health insurance industry have spent over a half billion dollars (through September). This is about 1/5 of all lobbying expenses.
With the dollars at stake in health care reform, this is probably a very small investment indeed.
All told - this is a solid double for the health care reform plan. However, we'll see how this gets interpreted by the talking heads.
Preliminary data also shows lower rates of heart attacks among those who used the program.
There are reasons to be a bit skeptical of this data. Those who used the smoking cessation program were probably different than those who didn't, and the percent drop seems quite high. Also, Medicaid is a combination of "Temporary Assistance to Needy Families" (largely pregnant women and their kids -where smoking rates do not lead to a lot of heart attacks in the short run), and those with serious disabilities, who are older and where smoking cessation could lead to prevented heart attacks over the short run.
Still - this is just great news. Smoking is a very major cause of preventable illness and death, and smoking rates remain highest among those with lower socioeconomic status. It's unfortunate that even in light of the proven effectiveness of antismoking programs states have cut funding for such programs in light of their current budget shortfalls.
One of the speakers tonight, guitarist and composer Jason Crigler, had a devastating stroke from a burst brain blood vessel in his early 20s when his his wife was pregnant with their first child. He awoke 1 ½ years later a gaunt shadow of himself, unable to move one side of his body, the fingers of his left hand contracted in a flexed position. He spoke passionately about the care he received at the
The challenge is with the blue slice of these pie --medical services that increase quality (a little) and increase price (a lot). That's true of a majority of novel interventions tested in the literature - they displace less expensive standbys, but offer some new advantage. It's tough to say no for higher quality.
Another challenge, that is ill-studied, is an intervention that is less expensive, and not QUITE as good -but really "good enough," at least for most people (yellow in this diagram). These decisions are clinically (and politically) difficult.
The early November Annals of Internal Medicine has a literature review on “decremental cost effectiveness” entitled “Much Cheaper, Almost as Good.” Authors Nelson et al from Tufts Medical Center point out that in other industries we value products and services that are “good enough,” but cost much less. Examples include personal computers (not as good as mainframes), IKEA furniture (painful to assemble, but much less expensive), and the Nano automobile from Tata Motors (sacrificing comfort and safety but costing only about $2,000). However, in health care, we only value the highest quality - regardless of the price. A good example of this was an NPR report this evening about MRIs. They often cost $2000 in the US - and we have the best machines in the world. In Japan, the government-enforced price of an MRI is $120. Is the best image worth this price differential?
The authors in the Annals article found 2128 cost effectiveness ratios in the medical literature between 2002-2007 – and only 33 involved sacrificing any quality for price. In general, these studies involved the sacrifice of between 8 hours and 1 week of quality adjusted life (0.001 – 0.021 QALYs), and the savings were beween $122 and almost $12,000 per patient. (Of the studies they reviewed, only 9 were of high enough quality to fully evaluate).
This is relevant to the firestorm over the US Preventive Services Task Force finding that evidence doesn't support recommending annual mammography for women under 50 (and only supports biannual mammography from 50-69). This recommendation was NOT made to save money - but much of the vehement disagreement is focused on whether lives would be sacrificed to save dollars. What if the number of "quality adjusted life minutes" saved by mammograms is less than the number of minutes women would spend getting additional mammography and having followup biopsies? Listening to some of the vitriol about this finding on the radio reminded me that we don't like to make tradeoffs, especially in decisions around our health.
When we’re thinking of how to lower health care costs, we’ll need to address the issue of cost per unit if we want to achieve affordable health care.
What does a public option mean for health care costs?
- Higher costs for delivering care
- A platoon of network contracting specialists across the country negotiating contracts
- Difficulty convincing hospitals and physicians in rural areas to accept its preferred fee schedule
- A much less complete network
- A much larger challenge in marketing itself, which would lead to higher advertising and customer relations costs
Background: A post in June about public option http://managinghealthcarecosts.blogspot.com/2009/06/public-plan-some-perspectives.html
Addendum: Nancy Pelosi has announced that the public option in the House bill will include a requirement to negotiate rates with providers.