What a breathtakingly honest assessment from David Leonhardt of the NYT. Of course now we all need to discuss how to recoup the enormous waste. The problem is that policy folks must find the right level of policy intervention: blanket policies with major but imprecise effect or targeted policy that should address a specific problem?
Blanket policy is sweeping in effect and simple but often fails to address the underlying issues well and thus fails in intended effect.
Take for example the Sustainable Growth Rate (SGR) policy that ramps back Medicare spending through automated across-the-board cuts to Medicare payments to the health care delivery system. You'd think that this would lead to savings, but in the real world the health care delivery system responds by ramping up the volume of services and the total cost of Medicare continues its seemingly inexorable march to consume the nation's GDP.
The targeted policy approach holds much appeal as legislators can pick their pet peeve or help their corporate sponsors but unintended consequences can swamp the intended effect. Even if well intended the targeted approach can fail if it is not aimed at a root cause of the problem and/or if it has unintended side effects.
Take the example of Prior Authorization (real example from my practice days in Rochester NY):
- Head MRI costs a lot and is often done without appropriate indication (waste)
- Managed care plan new policy mandates prior authorization for head MRI
- Staff in MD offices spend more time on calls @ prior auth, the docs and nurses spend more time figuring out how to get the MRI anyway, the MRI center hires more staff to make sure the prior auth
- To make up for the added costs (estimated @ $65-85K per doc per year) the practices crank up the volume of services and add more cost to the health care system
- And the MRI is done most of the time anyway
The good news is that we're not stuck. There is blanket policy that can improve outcomes, improve the experience of care and 'bend the cost curve.' Multiple studies document these as the result of effective primary care.
Blanket policy that fully funds the work of effective primary care will improve population health, improve the experience of care and reduce per capita health care costs.
This policy can and should be linked to primary care delivered effectively. Patient experience defines the level of achievement of effective primary care:
- I can get care when and how I need it
- My PCP/nurse know me as a person
- My PCP/primary care office cares for the bulk of my health care needs
- My PCP/office coordinates all care I need in the larger health system
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