Ultimately, I am concerned with addressing one of the major criticisms of healthcare reform: that healthcare needs to be treated like MORE of a commodity in the traditional sense. I'm still not sure how this will address the lack of universal coverage, let alone some of the quality deficits in our system, but this seems to be beside the point of this particular line of attack.
(Incidentally, I also wanted to acknowledge a subtle change in language being used by the Obama administration. They have started calling this initiative "health INSURANCE reform, not health CARE reform. Factually, I actually think this is a much more accurate description of the current proposals floating through congress. It also implicitly acknowledges that the heavier lift of healthcare reform can come at a later time--once everyone is adequately covered.)
Concering healthcare as a commodity, I think there are three main issues that require further exploration:
- Is "healthcare as a commodity" an effective paradigm for consumers?
- Are there tweaks that can be made within the current framework to improve quality?
- Are there tweaks that can be made within the current framework to lower cost?
We generally make the same assumptions about healthcare that we make about other things (TVs, cars, furniture, ect). Namely, we assume that:
- Newer is better;
- More is better;
- Brand loyalty matters (and its offshoot- brand names names are better than generics); and
- There is a direct correlation between cost and quality.
In other words, all of the rules of thumb that we might use to decide which product to purchase are completely invalid in a healthcare setting. In healthcare, there is one gold standard: evidence. After that, there is clinical consensus/expert opinion. And after that, it is all marketing. Unfortunately, we are operating in an environment that lacks good comparative data on different kinds of interventions. For example, pharmaceuticals in order to be approved by the FDA need only prove they are more effective than a placebo. At no point do these drugs have to prove they are more effective and/or have a lower side-effect profile than an existing treatment.
But, a drug company that owns a patent on a new drug is highly incented to market the hell out of the drug to make a profit. Even if it is not a "better" drug, it will be a more profitable drug. And here is where the market starts to break down. Why? Well, a more expensive drug that is less effecacious is bad for the entire healthcare system even if it is where the money is. And it is wore for you and me.
As payers, insurance companies help to stand in they way of these marketing efforts by pharmaceutical companies, in part, by using physician committees (Pharmacy and Therapeutics (P&T) Committees) to establish tiered formularies for managed care, where they may decide to place this drug in the most expensive category. Yet, even if this happens, you and I will still see the ads and request the drug from our MD.
In the US, managed care is the dominant form of healthcare coverage, which means your PCP gets a monthly payment to provide coverage for you, regardless of whether you actually come in to see her. In selecting a PCP how many of you actually found comparative quality data on your PCP? Now, maybe you went on Angie's List. Maybe you looked at where they went to medical school. Maybe you talked to other people about who they go to. In other words, you used proxies to evaluate quality. But here's what you DIDN'T do. You didn't look at any actual quality measures for your MD. You didn't, for example, look at the percentage of your MD's patients with chronic conditions that are compliant with their medications, or required tests and lab values.
And that probably means you were evaluating the service you received on your PCP's bedside manner, or the friendliness of their office staff. The bottom line is you probably evaluate your experience as you would other consumer services: how well you are treated. Let's face it, whether or not the care is any good is pretty ephemeral. Now, I'm not saying that these are unimportant considerations, but they don't really tell you whether the care you received was any good.
Bringing this back home to the issue of our pharmaceutical and cost, you come in to your PCP and request the expensive, less effecacious pharmaceutical not recommended by your cost-conscious insurance company. Your MD has two choices: she can say, "well that's reallynot the best treatment" and recommend an alternative. This assumes, of course, that she is familiar enough with the literature on this specific drug and the alternatives in this drug class. However, in doing so, she also runs the risk of providing bad customer service (the cusomter is always right, right?) and so annoying you that you choose another PCP. What is more, this probably doesn't even a address category of care quality that will be recorded or reported anywhere, let alone reviewed by someone. So from the MD's perspective, she's got a ton of downside to recommending an alternative, and no upside. If , on the other hand, she just gives you want you want so long as it does no harm, you walk away thinging that you've got a responsive PCP and you may even recommend her to your friends.
Now I amd NOT suggesting that players in this system are simply automatons that follow the dictates of the market. But this is an illustration of ways in which market forces confound each other in our system. If I was in her shoes, I know which decision I'd make.
Clearly, then, our market rule of thunb--"newer is better"--is not effective for evaluating healthcare quality.
As for the "more is better" rule of thumb, I would encourace everyone to read Atul Gawande's piece in the New Yorker from June. Not only is more NOT better, it often has deadly consequences.
Without going through and listing (and debunking) each of our rules of thumb, to me the overall conclusion is that the healthcare system is very much caveat emptor. Now, towards the end of Gawande's article he goes through the exercise of debunking the marketplace argument in the form of hospital use. (i.e. someone can't decide to wait for a better technology when they are going in for diagnostic imaging for metastatic cancer, or to question the cost-effectiveness of certain tests when they are receiving urgent/emergent care).
But I, for one, think better information comparing physician quality could help individuals to make better decisions about "purchasing" quality services from a provider. I would love to have the mandate of the Center for Comparative Effectiveness Research expanded to include MDs as well as treatment protocols.
Unfortunately, the problem with this is twofold:
- Quality reporting only covers a very narrow set of conditions--how do you ensure that your PCP can actually provide quality for the conditions you have and not just those that get reported on? And
- How do you control for differences in a patient pannel for a particular physician?
Let's assume for the sake of argument that these can two issues can be addressed. Although this would be a major step in the right direction and one I would fully support, it may not matter that much from a cost perspective.
If comparative quality information in physicians was available for PCPs, we would be "purchasing" quality at the least expensive level--outpatient ambulatory care. As Gawande notes in his article, the place where people are most likely to cost a lot is in an inpatient setting where they have the smallest capacity to be active participants in their own care. Even if we consumers HAD better information on comparative cost and quality, how exactly would we (be able to) use it?
To summarize:
1) Is "healthcare as a commodity" an effective paradigm for consumers?
No. Consumers generally lack the information to make informed decisions based on quality and cost, in part because the rules of thumb we use on our normal consumer lives are misapplied to healthcare. What is more, the countervailing forces in the healthcare marketplace in general confound attempts to make "quality purchasing" effective.
2) Are there tweaks that can be made within the current framework to improve coverage and/or quality?
Yes, but to a limited degree. Putting more comparative quality information into the hands of consumers will facilitate better decisions about whom to select as a PCP. Bu this may have limited utility in part because the state of quality reporting currently only addresses a limited number of conditions that may/may not be significant for all consumers and/or physician specialists.
3) Are there tweaks that can be made within the current framework to lower cost?
Not really. Most costs are incurred in inpatient settings where consumers have a limited ability to manage their own care (and the equippment it requires). Better preventive care in outpatient settings (a likely outcome of better quality reporting) in fact will increase costs because more people will get more of the right tests and will take more of the right medications. This may or may not lead to reduced inpatient stays, but it will improve and increase QALYs.
