Being careful
Wednesday, October 29 2008
The last couple of days, I’ve been seeing Charlie Baker pop up here and there in the blogosphere. Charlie has a blog called Let’s Talk Health Care. I somehow thought he was a doc, but he’s not: he’s the President and CEO of Harvard Pilgrim Healthcare and former Secretary of Health and Human Services for Massachussetts.
I found Charlie’s blog through a link to his post, Be careful what you wish for. Charlie points out that Medicaid in Mass. is refusing to pay doctors, something he claims “private payors would never consider”. I pointed in comments to an LA Times article about private payers doing exactly that. Charlie’s post appeared verbatim on The Health Care Blog, as well. I commented again, and Charlie and I have had a couple of responses. None of this is criticism of Charlie; I appreciate his willingness to engage, and I respect the insight his career gives him.
In that exchange, Charlie alludes to another post of his, Health Care & the Presidential Campaign, which gives his views of potential and feasible reforms. There are four specific things he would do:
1) Encourage Medicare to pay more for primary care, and less for specialty care. [...]
2) Start doing some Medicare demonstrations in which Medicare pays for clinical outcomes and not simply for volume. [...]
3) Fix the relationship between Medicare and Medicaid for low-income seniors who qualify for both programs.[...]
4) Make living healthier lives a priority. [...]
I can support all four of these changes: they’re good ideas. That said, they’re very… administrative. They clearly reflect Charlie’s perspective as health system administrator, but as such don’t speak to the concerns of ordinary users of the system: How can I afford my bills? Why can’t I get the meds I need? Where can I get health coverage if I lose my job?
Like I said, I support Charlie’s suggestions – but even if all four were implemented tomorrow, I don’t think most patients would see much change. That’s not an argument against doing them, just an argument for not stopping there.
Duncan – Thanks for supporting these four ideas – but don’t undersell their capacity to change what the system looks and feels like to regular people. Don’t forget – Medicare makes the rules that almost everyone else in the care delivery and payor community live by. If Medicare really did pay more for time and less for technology, people would discover two things – their primary care doc would spend more time with them, and there would be more primary care doctors. Second, if Medicare paid for outcomes and not just volume, care providers would be more focused on getting it right the first time, and less focused on maximizing transactions. More than one surgeon has said to me that checklists for surgery would improve quality, but they would slow down throughput – so they’re against them. If Medicare (and other payors) was paying for quality and not volume, checklists would look a lot better to practicing clinicians.
Third, if Medicare and Medicaid worked together to finance and support care for low income seniors who qualify for both programs, I guarantee that care for this population would improve and cost less. No small feat. And finally, there are numerous studies out there that show that modest improvements in healthly behavior show big returns in health status (and happiness) and total health care spending. Yes – these are administrative suggestions – but don’t underestimate the power of the almighty dollar to re-allocate focus and priorities – which can offer enormous benefits to everyone who uses the system.
Thanks for the comments, Charlie. Again, you’re making good sense, but from the perspective of a patient outside the Medicare-Medicaid system, there is a lack of immediacy to your proposals. Even if everything you suggest happens tomorrow, how long until I see those changes reflected in my COBRA payments? A year? Eighteen months? After that, it’s irrelevant to my current problem.
Your expertise gives you a lot of insight into what can and should be fixed – but do you ever interact with your patients? It seems to me that to effect your reforms, you’ll have to tie them pretty explicitly to ordinary Americans’ experience of the health care system. I think you can do that by making your proposed reforms part of a larger package that also targets more immediate concerns – but I can also see why you might think that’s too ambitious. In any case, I think you’d benefit from trying to see these things through a patient’s eyes.