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    Thursday, June 03, 2004

    Questions for the Sages: A reader and frequent contributor to post ideas asks:

    What is your plan for our fractured and soon to collapse health care system?

    Well, if I had an easy answer I'd be running for office. But, my correspondent answer his own question:

    I think Brad DeLong's is correct that Kerry's proposal to effectively offload catastrophic health care coverage onto the government is a good one. I'm more skeptical about its workability in practice - the stakeholders with their snouts in the health care trough are rather powerful. I worry frankly that any non-nuclear health care reform (which would likely fail unless the people had taken to the streets or the rest of big bizness had finally gotten smart) will just get loaded up with more and more pork for the lovers of the free market as it sails through congress.

    A rather smart person recently clarified the whole health insurance issue to me -- what we call health insurance in this country has little resemblance to actual insurance, and thinking about it as an insurance problem largely muddies the issue. What we have is a health care delivery industry, with little divide between the providers of health care and the providers of health insurance. It's all one tangled mess, and the incentives are completely skewed across the board.

    An exception is catastrophic insurance, which could be more like traditional insurance if it were chiseled off. Perhaps if a clean bill could get through congress Kerry's plan is a good first step. Still, I suspect that it'll just provide another way for the health care industry, one way or another, to suck some more taxpayer dollars.

    He's exactly right about the skewed nature of our system. I would add, however, that the one thing that skews it the most is the complete disconnect between the consumer and the payer. When insurance companies pay for every screening test regardless of its usefulness, when they pay for every risk-reducing drug, no matter how high the price or how low the risk reduction, then there's no incentive for either the provider or the consumer to choose responsibly. And when the insurers don't pay, there's sure to be some activist group lobbying for a law somewhere to make them pay for it. It's too easy to cast the payer as withholding coverage for greed's sake. The result is that insurance companies (and government programs like Medicare) end up paying for things of dubious benefit.

    For example, Medicare now covers routine colonoscopies to screen for colon cancer (that is, colonoscopies on asymptomatic people), which around here go for $2,000 each. Now, there's no doubt that colonoscopies find small polyps before they become cancer, and therefore save lives, but are they worth the cost? Especially when you consider that the vast majority of them will be normal? That kind of cost/benefit analysis is best left up to the individual, and that kind of cost/benefit analysis only works when the individual has to pay the $2,000 himself. If doctors had to explain to their patients why they needed to pay $2,000 to have a telescope snaked through their colon, then we'd have a better incentive to make sure our evidence for recommending it is solid.

    Colonoscopies are just one example. The medical profession has been on a reckless recommendation spree these past ten to fifteen years (ever since preventive medicine has been covered by insurance companies), making all kinds of recommendations to minimize small risks at astronomical costs - from cholesterol-lowering medication to prevent heart disease in the healthy and cholesterol unchallenged, to stricter diabetic control with more and more medication, to screening for prostate cancer with a badly flawed blood test, to encouraging mammograms in young, low-risk women. And that's just in preventive measures. If you consider the reckless abandon with which some of us prescribe expensive routine medications such as antibiotics and blood pressure medication when cheaper equally effective alternatives exist, the problem is even worse. If we had to answer to our patients for the costs and benefits of the screening procedures and treatments we recommend, we'd make more responsible, and cost-effective recommendations. And in the process, we'd be serving our patients better.

    In the end, I agree with DB. We need a system in which the patient bears some financial responsibility for the routine medical costs. It's the only way we'll ever rein them in.

    posted by Sydney on 6/03/2004 10:12:00 AM 0 comments


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