Need a much deeper de­bate

Modern Healthcare - - OPINIONS LETTERS -

Re­gard­ing the ed­i­to­rial “At a turn­ing point” (Dec. 10, 2012, p. 22), I think you need to look at the sit­u­a­tion we are fac­ing a lit­tle more deeply than is ev­i­dent in your ed­i­to­rial.

Yes, we are ag­ing; yes, we are a more seden­tary so­ci­ety and a richer, less-dis­ci­plined one. But I would ques­tion “the health­care sys­tem’s best ef­forts to cre­ate a health­ier so­ci­ety.”

We have some qual­ity is­sues; we have some ser­vice is­sues. In the di­rec­tion we are head­ing, cor­rect­ing those is­sues will be part of what sep­a­rates the sur­vivors from the also-rans.

But the cost is­sue is most com­pelling. There is an up­per limit on the per­cent­age of gross domestic prod­uct that health­care can ab­sorb. If health­care is ef­fec­tively free (low de­ductibles and co­pay­ments) and no other re­stric­tions are put on ac­cess, con­sumers will, by and large, con­sume all that is of­fered.

Chang­ing provider pay­ment in­cen­tives to some type of per-capita ba­sis rather than a feefor-ser­vice ba­sis will prob­a­bly re­duce the amount of health­care of­fered, which is one form of ra­tioning. Up­ping the de­ductibles and co­pay­ments will also act as a form of ra­tioning in that the pub­lic will not con­sume cer­tain ser­vices if the per­ceived out-of-pocket price is too high.

Re­duc­ing the cost of health­care (per­cent­age of GDP used) will not be sig­nif­i­cantly changed by in­cre­men­tal ef­fi­ciency im­prove­ments among providers. While a health­ier pop­u­la­tion will re­quire less health­care, this is only true up to the end-of-life stage, where we spend an aw­ful lot of money. If we don’t do some­thing about end-of-life costs, all a health­ier pop­u­la­tion will do is de­lay the end-of-life ex­pen­di­ture some­what. It would be a one-time sav­ings.

Given the above as­sump­tions, there are two routes to con­tain­ing health­care costs.

The first is at­tack­ing the life­style is­sues that con­trib­ute to the cur­rent level of gen­eral health. Smok­ing, drink­ing, poor eat­ing habits, lack of ex­er­cise are the low-hang­ing fruit. That should re­duce health­care de­mand in the gen­eral pop­u­la­tion up to end of life.

The sec­ond route is ra­tioning of health­care. This can be done in a lot of ways. But what­ever name you put on it, it is ra­tioning.

There are three play­ers here, and any or all of them can be the ra­tioners: government pay­ers, non­govern­ment pay­ers (em­ploy­ers or in­sur­ers) and pa­tients. All have a large stake in the out­come. None of th­ese op­tions is very pleas­ant, but one of the un­der­ly­ing is­sues that needs to be ex­plored is how does so­ci­ety at large want to go about this. Af­ter we work through that thorny ques­tion, then we can start to work on how we will ac­tu­ally cre­ate the in­cen­tives and le­gal struc­tures to make it so.

John D. Starr Board chair­man Lit­tle­ton (N.H.) Re­gional Health­care

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