Tuesday, June 30, 2009

Medicare Open to All (3)

President Obama's lobbying efforts with governors may be smart politics, but they show the sad state of ethical discourse with regard to health care reform. Here's what I read in this morning's New York Times:
In a meeting last week with five governors — including Republicans who may be more sympathetic to health legislation than those on Capitol Hill — Mr. Obama privately urged them to serve as his emissaries to Congress. He even coached them on the language they should use with lawmakers, two of the governors said, advising them to avoid terms like “rationing” and “managed care,” which evoke bitter memories of the Clintons’ ill-fated health initiative....Instead, he spoke of “evidence-based care,” the practice of using research to guide medical decisions.
Unfortunately, thoughtful rationing and wisely managed care are exactly what our health system needs!

As I've written about before, the public option proposed by the administration has a crucial advantage with regard to the all important goal of cost containment (see here and here for previous posts). At least 30% of the care we currently pay for is useless at best, and potentially harmful through side effects and errors. We can't have an affordable health system without managing our utilization. This won't happen by publishing studies. We have to manage care!

Good insurance companies like Harvard Pilgrim Health Care, the not-for-profit health plan at which I direct the ethics program, know how to do this and can do it in a clinically guided, ethically justifiable manner. But the public rebelled against the idea of insurance company driven managed care, largely because of distrust of for profit insurers, who were seen as withholding necessary care to maximize profit and provide huge executive bonuses. Insurers have largely backed off from managing care, which contributes to the runaway cost trend.

A public program would have a significant advantage for managing care - it is ultimately governed by the public! If it chose not to cover marginally useful care it could be criticized for its decisions, but could not be accused of serving private profit or executive salaries. That potential legitimacy matters a lot for setting limits.

As I've said before, a public program could act as a "down field blocker," taking the lead over time in helping the public understand what it means to set limits fairly. If a public program made managed care more understandable and acceptable, private insurers could follow its lead.

But if a public program simply acted like today's Medicare it would have a significant disadvantage. Medicare is currently not allowed to use cost-effectiveness calculations of the kind every human being uses every day. As a result, its main weapon for cost control is the fees it pays. This is a blunt weapon, and has had the effect of discouraging the service we need most - time spent with patients planning rational treatment and explaining why some things patients may want are not needed.

It's fine for political leaders to avoid using the terms "managed care" and "rationing" as long as they are not deluded by their own rhetoric. "Evidence-based care" and "using research to guide medical decisions" may be more acceptable wording. But evidence doesn't make decisions - doctors do. We know from the Dartmouth Atlas studies that doctors vary enormously in how they respond to evidence. We will have to "guide medical decisions" actively to make health care more affordable!

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