In late 2007, the Commonwealth Fund published a paper entitled “Bending the Curve“. The point of the paper was that given the current trajectory, health care expenses will exceed our country’s ability to pay, leading to insolvency. Although this has been the worry of policy makers forever (what’s a good amount of money to spend onhealth care? 5% of GDP like England? 12% of GDP like Canada? 16% of GDP like the US?) and previous policy was that health care jobs were to take the place of manufacturing jobs, increasing our GDP. It turns out that there is an optimum amount to spend if the objective is to achieve optimum health with the least cost possible. That amount seems to be less than what we spend.
The report does not mention rationing at all. Many of the concepts in the report were included in HR 3200, which does not mention rationing either. What is mentioned is “medical effectiveness”, improved health information technology, and shared patient decision making. Using these three concepts, physicians can help to bend the curve down, eliminating the need for hard rationing.
Improving information regarding medical effectiveness should lead to a reduction in use of expensive, unproven technology. We Americans have a fascination with technology. In fact, part of the utilization of the emergency room by patients is because of a belief that technology is necessary for effective diagnosis and treatment. Hospitals in rural Alabama hired physicians away from their practice and had them move into the Emergency Department, subsidizing thier salaries, because they knew that would help attract patients into the hospitals who would then be referred into the technology areas (CT scans, MRIs, etc). Unfortunately, the use of this technology has not translated into people doing better (they may feel better having seen their insides but it is an awfully expensive placebo). Most insurances will pay for technology because there is limited evidence to indicate when technology is good (avoiding an unnecessary surgery) or when it is bad (finding something that is likely normal but “might be something bad” causing excessive worry and unnecessary procedures). In fact, some procedures (placement of stents in certain patients) are found to be harmful after years of having been done. Evaluation of all procedures ought to be more rigorous and establishing money with which to do this will ultimately reduce costs.
Improved information technology (already funding through the stimulus package) should help to reduce costs as well. Transferring information by snail mail and fax is the rule in health care rather than the exception now. Electronic transfer of information, with appropriate safeguards, has revolutionized the banking industry (so much so that the regulators unfortunately got lost in the shuffle). Making information easier to transfer will reduce waste and duplication.
Lastly, encouraging shared decision making is probably the most important of the three. As a physician, I get paid for time in a piecework fashion. If I need to have an hour conversation with a patient about prognosis, different treatment options, or longterm care decisions, I have to schedule it outside of my normal patient care hours and do not get paid at the same rate I would for seeing “regular” patients. Yet, this is probably the most important conversation I will ever have with a given patient. It has been my experience that when faced with a disease that is terminal or that there are several different treatment options, what people want most is someone who knows a little about them to help guide them to a decision they will be comfortable with. All too often, we in medicine assume that the patient always want more and wish to cling to every last second of life but often it is the physicians who impart their worldview instead of listening to the patients and their families. Additionally, the primary care physician, the doctor who knows the patient the best, is often not involved in these conversations at all for a number of reasons. Changing the payment structure will go a long way towards inclusion of the primary care doctor in these discussions.
It is the belief of the Commonwealth Fund as well as myself that these measures will “bend the curve” down without hard rationing. We may have a chance to find out.