Andrew S. Brem
Dr. Andrew S. Brem is an emeritus professor of pediatrics (nephrology) at Brown University’s Warren Alpert Medical School. He lives in East Greenwich.
Conservative health care economists Lanhee Chen and James Capretta wrote an op-ed for The New York Times, which appeared on Jan. 26 (“We Can Improve Health Care. It Just Takes Compromise”). Conservatives last proposed health care policies in the early 2000s with the Heritage Foundation white paper outlining what would eventually become the Affordable Care Act (ACA).
Now the Biden administration is hoping to further modify the ACA. Clearly, political compromise is needed, but we should understand and consider all of the variables in planning policy. Models used by economists and political groups often don’t include factors unique to medicine. Some examples appear below.
Competition has always been promoted as a way to lower costs. In medicine, that assumption doesn’t always work. For example, if two hospitals each operate a cardiac surgery program in a given city, they need to be on call 24/7 with a full team of physicians, surgeons, nursing staff and other professionals. Those costs are fixed. Moreover, each team has to perform a minimum number of cases per year to remain proficient and accredited.
Using epidemiological methods, we can track the frequency of cardiac disease in a population, and from that data, we can predict the number of patients who will require surgery in any given year. If the need for cardiac surgery in that community isn’t high enough to support both programs, both are in danger of failing, and failure drives up health care costs. Cardiac surgery programs aren’t like car companies where you can “lay off” workers when business is slow.
Cost-cutting in health care is an easy target, but remember, one person’s waste is another’s livelihood. Medicine is moving toward “evidence-based” care where there is a scientific foundation behind treatment decisions, and treatment should be cost-effective. Eliminating unnecessary, repetitive and unproven procedures is difficult but doable. It takes time to “re-educate” medical providers.
However, cost-cutting by giving patients final clinical decision-making on the basis of cost, deductibles and co-pays is problematic. Not all hospitals and physicians are identical in their proficiency and ability, and a consumer/patient may have little idea whether they are getting the same quality of care for the dollar at competing places.
Moreover, I have no doubt about the outcome of a patient having to choose between paying an “out-of-pocket” deductible on a screening colonoscopy or using that money on a new flat-screen TV. The elderly woman who falls and breaks her hip isn’t about to price-shop hospitals while waiting for the ambulance to come.
If one really has an interest in attacking medical costs, administrative costs are a place to start. Every dollar spent on excessive medical advertising is a dollar not directed toward providing medical care (for example: the costs of Medicare Advantage ads shown per hour on CNN or Super Bowl ads promoting a treatment of a rare form of lung cancer the average consumer would have little knowledge about).
Real policy should focus on real-life situations, not just economic models, which may have limited relevance to the practice of medicine. Decisions to allocate resources should be made on need, and not just on margin.