The results are not pretty. Even the rosiest scenario shows decrease in employer sponsored health insurance (below 50% in the worse scenario), and all 50 states show an increase in the uninsured under all scenarios. Uncompensated care goes up, and Medicaid and SCHIP (children's health insurance) costs skyrocket.
This is the study to support Obama's contention that "When it comes to the cost of our health care, then, the status quo is unsustainable" (AMA speech, 6/15/09).
Harvard full-text link (requires HU login)
The impact is impressive! In the ten communities, rate of MI decreased by 17% (confidence interval from 8% to 25%), and the decline continued with subsequent years of observation. The impact was most pronounced for the young (which means more averted years of life lost) and nonsmokers.
This is strong evidence indeed -- and a good example of a community-wide intervention that can save lives (and costs) AND improve care.
- Integrated systems, including full electronic medical records
- Multidisciplinary teams of clinicians
- Impressive evidence from the Dartmouth Atlas of cost-effectiveness of care
- Excellent quality numbers
- Excellent reputation
I'm personally convinced that multispecialty group practice can provide excellent care and excellent value.
- Mayo charges additional fees to Medicare beneficiaries coming from outside of its area. This is important because it means the
Here's a link to a past blog on some of the potential flaws of using Medicare claims data to infer total cost-effectiveness
That $409 billion is the actual decrease in federal spending on health care – whereas all the other changes represent only shifts of costs.
The CBO estimates cuts of $182 in fee schedule payment updates, $123 billion in cuts to Medicare Advantage programs, $48 billion in cuts to hospitals that care for a disproportionate share of the poor, $23 billion in cuts based on recommendations of a future Medicare Commission, and $33 billion in other spending cuts.
The Washington Post estimated that the total cuts to hospitals are $155 billion, to nursing homes is $40 billion, and cuts to other providers are smaller.
How would this work?
The Massachusetts experience with cuts to “disproportionate share” hospitals is troubling – the government subsidies evaporated more quickly than insurance for the impoverished kicked in. The insurance industry has been vilified by the Obama administration in recent weeks, and it’s likely that pushback against Medicare Advantage cuts will continue. Hospitals, as I’ve mentioned before, are the largest employer in most communities –and these kind of cuts will really hurt. I see a lot of community nonprofit trustees making a pilgrimage to talk to their congressional representatives.
There is a lot of good in this bill - including consumer protections, a pool for those difficult to insure, and value-based Medicare purchasing for starters. There is a lot that’s mediocre in the bill too – such as support to start up health cooperatives – which is unlikely to make much difference in the insurance market. There are some real worries - like the potential that cross-state health plans could undermine meaningful consumer protections currently available in states like Massachusetts which have had activist consumer-friently Divisions of Insurance.
The Baucus plan (with 0/3 Republican cosponsors) is off to a rocky start in Washington today. Hopefully, the ultimate bill will include more provisions that are likely to actually diminish the rate of health care inflation.
Reports on another innovation in health care delivery, the Patient Centered Medical Home, show improved quality with no increase in cost (but without the decrease in costs promised by advocates of patient centered medical homes.) Group Health Cooperative designated one of its centers as a "patient centered medical home," and determined that compared to other centers, this center had
We need innovations in health care delivery. Retail clinics save money, with no significant loss of quality, and medical home improves quality without increased cost (but a lot of increased effort). The hope is to define interventions that will raise quality and lower costs simultaneously.
(2) Provide insurance to those who don't.
(3) Slow the growth of health care costs
This got a big cheer from the Republican side of the aisle. The real costs of torts include substantial defensive medicine, so tort reform is a good idea. Savings will take a long time, though.
Fuchs' eight root causes for our high health care costs compared to other 'developed' countries:
Yesterday’s Washington Post headline shouted “Study Raises Questions About Cost Savings From Preventive Care.” The article itself captured some of the nuance of this article that the headline did not.
The Post was reporting on a Health Affairs web article that simulated potential savings from improved diabetes management. The improved management would lead to an improvement in hemoglobin AIC (a long-term measure of blood sugar control) and blood pressure – both are agreed to be indicative of better diabetes control. The simulation suggested substantial savings from major complications of diabetes including blindness, kidney failure, amputations, stroke, and coronary artery disease. However, these savings were not enough to pay for the intervention to improve diabetes care.
You read that correctly – the cost of improved management of diabetics would be more – not less -- in the 10 year or the 25 year time horizon.
The authors’ argument – a bit academic – is that the ‘excess’ cost of better management of diabetics is less pronounced at 25 years than at 10 years. Therefore, it’s unfair for the Congressional Budget Office to give thumbs down to an intervention based on a projections of results over ten years. Alas, with this particular simulation, the CBO would still give a thumbs down for results of a program that would increase the federal deficit over 25 years (just not as much per year).
A few other tidbits from this journal article: The intervention model suggested that the highest payoff over 25 years was in the youngest diabetics; there was cost saving in the population of diabetics 24-30. Of course, that’s a pretty small cohort. The simulation also suggested that the cost of diabetes direct care would increase by about $600 per year based on increased testing and more use of medications. This is no surprise, but a blow to the argument that better diabetes care can save money over the short-run.
Most of what we do in the medical field doesn’t save money over a 1, 5, 10 or 20 year time horizon. The medical ‘industry’ delivers better quality (or quantity) of life – and does it in a manner which is (usually) cost effective –not cost saving. No one thinks it saves money to dialyze a patient whose kidneys have failed, or to replace a worn out hip. These interventions yield quality adjusted life years at a reasonable price. So too, more intensive, evidence based care of diabetics can mean a diabetic will have improved vision, won’t have a stroke, and won’t need kidney dialysis. Even if this effort doesn’t save money, it seems like a good idea.
The best idea is to get the benefit of better health care and not spend so much on program costs. How can we do that? We should dramatically decrease the cost of chronic disease management programs using remote monitoring technology. This might also allow for better patient selection – making expensive interventions only for those diabetics who really needed them. We need improved patient engagement, including more effective programs and better incentives that fully employ the lessons of behavioral economics. We also need to improve the care delivery system itself, as interventions to augment the delivery system are by nature expensive and duplicative.