There is a growing consensus in health policy circles that overtreatment is the source of all problems in our health care system. Like most common beliefs, there is some truth to it. For example, clinical research is clear that stents inserted into the arteries of people not having a heart attack do nothing to prevent heart attacks or extend life, even a little bit. But hundreds of thousands of Americans get stents inserted every year anyway.
Talking to people about overtreatment, I find two opposite reactions. Many people have a story about themselves or someone they know who received treatments that weren’t needed and ended up causing more harm. A large number of this group also believes that providers overtreat people for financial reasons.
However a large number of people are surprised that overtreatment happens to others and only have stories for themselves or people they love who didn’t get critical care they needed, and it caused them harm. Many of them also believe it was because of financial reasons. US physicians are 23 percent less likely to accept a new Medicaid patient than one with private insurance.
Two very different sets of experiences, but they are both right. You would think they were from different countries or different health systems, and in a way they are.
In my experience, people who know only health care overservice are generally very well-insured. They have generous benefits, with generous payment rates, and consequently, large panels of providers competing for their business. As economists point out, if you make money on a service, you are going to do more of it. Unlike other service providers, health care providers can generate more demand for their services. Most patients didn’t go to medical school, so if your doctor says you need something, then you do.
Also in my experience, people who only know underservice tend to be uninsured, on Medicaid or have bare bones, high cost insurance plans. Those same economists will tell you that when a provider is paid less for a service, they will provide less of it. Providers can regulate that demand as well, telling us we don’t really need all that extra care or not even telling us about all our options.
This is all deeply insulting to doctors and other providers. Many conscientious providers fight hard to get their patients the care they need, risking anger from colleagues, insurers, and bureaucrats. While no individual provider would consciously discriminate based on coverage, the larger health system does. Doctors didn’t go to medical school to deny people care, or to give them harmful care they don’t need. But it happens anyway. A study of victims of serious car accidents found that uninsured patients received 20 percent less care than people with private insurance and were substantially more likely to die.
This is why nothing is simple in health care, as our President is learning. What is true for one population can be exactly the opposite for another. But wonks speak in universal terms, and policymakers like simple messages – overtreatment is the problem. Overtreatment appeals because the solution – less care – also saves money, at least in the short term.
So they’ve developed a very simple answer to the problem – shared savings. The sales pitch—all we need to do is “align provider incentives”. In shared savings, providers and their health systems get paid more to deliver less care. This payment model is built on the insulting myth that providers only respond to financial incentives. To appease the advocates, they throw in a few, narrow, very low quality standards to get the bonus. Even worse, they’ve applied this simple answer to undertreated populations like Medicaid, just because they can. Lowering the level of care for people who aren’t getting enough has predictable results.
Not surprisingly, shared savings isn’t working. Nothing is that simple. Complex excuses are circulating – we have to give it more time, “culture change” is hard, the upfront costs are too high, and the current favorite—the incentives aren’t big enough. But it’s just not working and doubling down with more coercive provider incentives is only going to make things worse.
It would be nice if there were a simple answer to the problems of over and undertreatment, but health care is hard. The real solution is to figure out what each person with his or her unique health problems does and doesn’t need to get better. While that’s pretty simple, it is also hard work. Until we stop looking for one-size-fits-all payment models to solve complex problems, costs are going to continue to climb.
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