THE FOUR RULES

There have been recent reassessments of the insolvency date for Medicare. Yes, it’s even sooner than the experts thought. I can’t believe it [yawn]. Last year the predicted date moved five years forward to 2024. This year it’s 2022. So I’ve decided to present Heartheaded’s Four Inviolable Rules:

  1. Don’t believe the experts. They either don’t know or have an agenda. This should have been apparent to us in 2008 when all we heard from them was a collective gasp when the bottom fell out of the economy.
  2. There must and will be rationing of health care. Period. Except for prisoners and the ruling class.
  3. The “right” amount of health care is an ideal and a moving target, sort of like a galloping unicorn. In camouflage.
  4. In the aggregate, physician practice patterns, even among the stout of character, inevitably drift to follow the incentives, with a capital $. The moth-and-flame analogy is apropos here.

Managed care got its start in the 1980s because of concerns of out-of-control health care spending and, despite the many criticisms, did contribute to an awareness of the need for cost-conscious and cost-effective medicine, something almost totally lacking at the time. Why then do I resist its siren call and the single payer drumbeat?

Managed care is like socialism. It inevitably rewards for doing less, and encourages stagnation. It is contrary to human nature, which thrives on innovation and reward. Traditional fee-for-service is in line with these natural inclinations, and might have succeeded if allowed to function within the marketplace, but interposing third-party payers (read: insurance companies and the government) isolated the customer (i.e., patient) from costs and contributed to the mayhem. Health care, being a unique and often critical need, has been deemed too fragile to expose to the short- and intermediate-term vagaries of the marketplace, and this is not an unreasonable premise. Still, in my lifetime, insurance has morphed from a backstop to provide in times of medical catastrophe to a pay-for-all for stubbed toes and runny noses. It’s hard to say at this point to what extent the evolution of the third party payer system is responsible for encouraging the spiraling costs or exists because of them.

This brings me to the nagging question of what we can do about it. The current exploration of ACOs or accountable care organizations is an experiment in progress that is attempting to meld the current system with a managed care shell. My initial exposure to it tells me that it will be a long, tortuous process with a very uncertain outcome. So, if we must control costs but can’t do it through managed care, what are our options?

When I started this blog over two years ago I laid out the many problems in all areas of the system and suggested changes that would need to be made concurrently for any hope of success. One of those was a program to be administered by the professional societies that would provide the physician and other health care providers with personal statistics of their ordering and prescribing patterns, and their place relative to their peers. The idea behind this is that we’re the engine pulling the train—ultimately our management decisions drive the costs. Granted, there are many factors influencing these decisions, but there is still 20-30 percent waste in the system that must be excised. When presented with personal statistics, I believe well-meaning doctors (and that is the vast majority) will voluntarily change their practice patterns more in the direction of best-practice guidelines, without costly and inefficient government meddling. Physicians that aren’t “up to snuff” will also get a wake up call. Those few that are malevolent will likely change behaviors as well, fearing that the statistics will be used in a way that will ultimately have professional or criminal consequences. This approach is a way of using the medical marketplace constructively without the downside of exposing patients to potential short term financial ruin.

We can’t escape the Four Rules. But we can do a lot better job of living under them.

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2 Responses to “THE FOUR RULES”

  1. Sue Says:

    What do you mean, there will be rationing? We certainly have it now–by the insurance companies, as I see it.

    • heartheaded Says:

      As I’ve stated past rants, and as you’ve perceptively noted, rationing has always been with us and will continue. It’s only a question of how it’s done and who’s doing it. I can only tell you with a high degree of certainty that it will get worse. Without appropriate changes,don’t expect the rationing to be done rationally. I wouldn’t hang my hopes on Obamacare as the solution.

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