The New Yorker isn't allowing Atul Gawande's
latest article out from behind the paywall, but you
can read the abstract here. The basic point is well
worth keeping in mind amid all the arguments
over the Affordable Care Act: Health-care costs --
and thus our paychecks, and the federal budget
-- won't be decided by how we deliver and
structure health-care insurance. They'll be decided
by how we deliver and structure health care. And
though national policy has a role in that, it's not
always a huge role, and it's not usually a
controversial one.
Gawande relates a series of stories showing
innovation in the toughest corners of the care-
delivery system. The most inspiring is about
Jeffrey Brenner, a Camden-based physician who
began playing with his city's hospital claims data
and making maps of where the money was
being spent. It turned out that there were two city
blocks, containing two particular buildings, where
900 people were responsible for "more than four
thousand hospital visits and about two hundred
million dollars in health-care bills" over the past
seven years. So that's where he focused.
Insurers try to run from the costliest patients.
They try to kick them out for having preexisting
conditions, or they rescind their coverage, or
they price coverage beyond their reach. That just
makes them costlier, of course. Inconsistent
access to medical care means more medical
emergencies, and more medical emergencies
mean higher medical costs. Brenner, by contrast,
is lavishing them with attention. He's calling them
daily. He's checking up on their medications, their
lifestyles, their habits. He wants to open a
doctor's office in their building. His patients
averaged "sixty-two hospital and E.R. visits per
month before joining the program and thirty-
seven visits after — a forty-per-cent reduction.
Their hospital bills averaged $1.2 million per
month before and just over half a million after —
a fifty-six-percent reduction."
We don't really know if his success can be
replicated. But somebody's can be. And that'll be
where policy -- in particular, where Medicare --
comes in. The administration's vision sees things
running something like this: A promising
experiment or pilot program will come to the
attention of the newly established Center for
Medicare and Medicaid Innovation. The center will
fund it on a larger scale and study it more
intensely if. If it proves promising, the
Independent Payment Advisory Board will force
Medicare to implement it fairly quickly. And
history shows that if something works in
Medicare -- and, quite often, even if it doesn't --
it's soon adopted by private insurers.
That's if all goes well, of course. And all may not
go well. But it's important to keep in mind that we
know who costs the system money: Sick people.
And we know what costs the system money:
Their health care, particularly when it involves
catastrophic or chronic conditions. So from a
cost and quality perspective, this is where health-
care reform will live and die: In doctor's offices, in
community health centers, in operating rooms
and in people's homes.
Insurers can play a role here, as can Medicare.
But for the next few years, cost control is going
to be less about setting national policy than about
setting up the experiments that allow us to test
what national policy should be. The Affordable
Care Act's contribution to this is money, a center
dedicated to bringing these experiments up to
scale and a reform process that makes it easier to
seed them in Medicare. But for all that to work,
the component pieces need to remain in place,
and some of the experiments actually need to pan
out.
Source: Http://voices.washingtonpost.com/ezra-klein/2011/01/the_health-care_side_of_health.html
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