Arnold Kling  

No Perfect Health Care System

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Robert J. Samuelson writes,

Americans generally want their health care system to do three things: (1) provide needed care to all people, regardless of income; (2) maintain our freedom to pick doctors and their freedom to recommend the best care for us; and (3) control costs. The trouble is that these laudable goals aren't compatible. We can have any two of them, but not all three. Everyone can get care with complete choice -- but costs will explode, because patients and doctors have no reason to control them. We can control costs but only by denying care or limiting choices.

In my forthcoming book on health care policy, I say almost exactly the same thing. Only it takes me a whole chapter to say it. The chapter is called "No perfect health care system."

However, I think that the objective of making care available to people regardless of income is not an impossible challenge--getting people to take responsibility for obtaining preventive care is more of a battle. What I think is the objective that really makes health care difficult is the objective of keeping people insulated from health care costs by offering "insurance" that is really a pre-paid health plan.

I call the three incompatible objectives Affordability (meaning overall health care costs--Samuelson's number 3), Accessibility (the same as Samuelson's number 2), and Insulation.

UPDATE: Trent McBride has a different perspective.

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COMMENTS (6 to date)
Robert Schwartz writes:

Isn't insulation a snare and a delusion? We all can't push off our costs on somebody else. Even the most socialist system gets paid for.

Cyberike writes:

You are sorta right. There is insulation because few people pay for their costs directly. The federal government pays for individuals health care costs (Medicare and its share of Medicaid) by issuing debt, and the states cover their share (medicaid) by reducing education expenditures, among other things. Looks like in both cases our children are being shortchanged. I doubt they have any idea what is happening to them.

Charles Beauchamp MD, PhD writes:

There are some huge public expenditures that are elective for health care and, all in all, useless that should be redirected into paying for "Boutique Preventive Medicine" for the uninsured:
1) Expenditures for unproven OTC's, nutraceuticals, sundry lotions/potions/snake oil remedies.
(Don't get me wrong, I do believe there are some reasonable purchases of "nutraceuticals" but the great majority of what my patients purchase are snake oil.)

2) Expenditures for "Botox oriented plastic surgery", tummy tucks, face lifts....
(Don't get me wrong about plastic surgery. I have a double clef lip and palate but decided at age 19 to not have any more plastic surgery even though my current appearance is not so good)

3) Expenditures for medical record personnel, coders, office primary care. Take a look at the Electronic Medical Record called tkfp. It is programmed by a family practitioner and integrates all these functions on one screen controlled by the FP her/himself as well as an EMR integrated with decision support that is state of the art - literature and rule based algorithms. Cost to the FP: 0 $ It even runs in a free OS: Linux. And please don't assume you get what you pay for here. You get what you train yourself to use in terms of this technology. And, every medical student should have this technology on their laptop and EVERY DAY have to go through a case that integrates their basic sciences and core clinical rotations with the good stuff that is in tkfp. Go to sourceforge and learn more.
(I am a general internist, not an FP but general internal medicine is dying as is family practice to a certain extent. We must especially support and increasing make family practice with "specializations" in adult general practice, pediatric practice....etc a financially desirable way to practice with an emphasis on preventive medicine. If radiology residents can demand a STARTING salary 3-4 times what a family practitioner makes after 30 years of practice, watch out America, you will get what you are paying for, so to speak.)

4) Develop and Foster NATIONAL procurement programs for drugs, nutraceuticals/otc's, office equipment, even computers/software....etc
(When VA drug costs, on average, are MUCH lower than Canadian drug costs and MUCH, MUCH lower than Medicare Part D drug costs AND National Procurement efforts are banned in the Medicare Part D program. Check out the cost of Travoprost, a glaucoma med at Walmart - ~$71, and the cost of that 2.5 cc vial of medicine to the VA - about $7. SO, procure nationally and if there is any profit to be made give it to the primary care physician, not the bad, corrupt, stupid guys.)

5. Foster the entrepreneurship of the primary care physician and give her/him the "middleman's fee". For instance a customizable, Italian designed, light weight knee brace costs about $175 from the Mediven factory. If a prosthetics shop + orthopedics shop is part of the dispensing and they add a ROM (Range of Motion) related code to the bill, they can charge Medicare over $500 for that brace. Give the primary care physician the opportunity to evaluate the patient, fit the patient, educate the patient using state of the art tools and give the PCP $150 for her/his effort.
(This means going back to the basics and teaching the PCP the complete orthopedic exam using 11 count video education series for the American Orthopoedic (no sic) Society by, who else, McGill School of Medicine in Montreal. Pay the PCP to learn the exam and how to fit the brace, graduated support hose, orthopedic shoes, orthotics.....etc)

6. Play off the ingenuity and observation of the PCP to be constantly improving the cost and effectiveness of care such as:
a) using pentoxifylline to prevent shunt clotting and subsequent needed shunt revisions in dialysis patients.
b) torsemide versus furosemide for dialysis of patients with end stage chf, hep c ascites and even malignant ascites. (and pay the PCP to do a potassium and creatinine for good clinical followup of massive diuresis in her/his office using a sanctioned way to do those tests in office settings - the iStat machine)
c) nitroglycerin SR caps BID to stabilize and, for sum, fully treat certain cohorts of patients with decompensated angina where the well defined cohorts will not get better outcomes through restenting or having a CABG
d) chlorhexidine applications prn any portal of entry in the foot of a patient with diabetes to prevent osteomyelitis progressing to higher and higher amputations.
e) Risolubles from for HDL elevation, LDL decrease and insulin sensitivity increase. Add Rice bran oil:safflower oil (7:3 by weight) to your oil and vinegar salad dressing recipes and see a big addtional change in cholesterol in the positive directions.
f) policosanal 20 mg at the end of the evening meal from Darma Pharmaceutical Co of Cuba - manufactered for Darma by Canadian companies but as banned in this country as a Cuban cigar but responsible for postive cardiovascular outcomes "too good to be true". You can try American knockoffs to this Cuban patented nutraceutical but that will probably only foster the outcome of thinning your wallet.
g) give ACE inhibitors QHS for hypertension therapy, especially for African American and Hispanic males, if not everyone, to foster marked improvement in cardiovascular outcomes simply by moving the time of day of ACE inhibitor therapy from am to qhs.
h)add liquid metoclopropamide to ranitidine/cimetidine/omeprazole treatments of acid reflux before going to the "purple pill" and spending $125 dollars or more a month on unneeded PPI's. But, if a stepwise approach to treating GERD does not work (ranitidine --> ranitidine + low dose liquid metoclopropamide --> omprazole), then go with Newt's pronouncements and allow "an open formulary" and then give the patient "the purple pill")
i) try treating some cohorts of patients with hypertension with hctz 50 / triamterene 75 tablets cut in half with a dose of one half table po in the am. Generic hctz 50 / triamterene 75 mg tabs with scored centers for easy cutting cost about ~$14-18 per 90 tabs at varous drugstores - and $0.008 per tab through the VA. This is a SIX MONTH supply of a reasonable anti-hypertensive for some patients for less than a dollar from the VA and 14 to 18 dollars from your local pharmacy.)
i) etc...etc...etc

Tie ALL interventions with monitored outcomes and paid incentives for improving outcomes to the PCP DIRECTLY. Tie into a nationally credible EMR/EHR such as VA's VistA and CMS' Vista-Office while fostering the use of "little guy/gal" EMR's such as tkfp.

Save billions of dollars a year while greatly improving clinical outcomes via these and other easily identifible routes. Shunt that money into Boutique Preventive Care for the uninsured and into the pockets of the PCP - Primary Care Physician.

One disclaimer: check out all the above with your personal doctor who may disagree with any or all of the above. Don't try it on your own.

The views expressed are only my own and do not represent the views of the University who owns me and the federal government who pays me.

Matt writes:

I guess that about sums up... everything in the history of the universe.

Cyberike writes:

This may sound crazy, but I have an alternative to all the probably worthwhile but complicated advice given above by CB: Let dying people die.

Randy writes:

Dr. Beauchamp,

Great post. I didn't understand most of it of course, but I get the gist. Which is that a whole lot of money could be saved if we listened to the folks who really know what the hell is going on.


I'm with you. I think many in this country are starting to see a real moral dilemma in spending hundreds of thousands of dollars on people on their death beds, while low income families go without basic care. Not that I think there should be any kind of law passed, but I do expect the number of DNR orders to dramatically increase in the near future.

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