Tuesday, October 27, 2009

Public option or no public option: that is not the question

I'm interrupting a series of posts on conflicts of interest in medicine in order to say something about health care reform, which is approaching a critical point as Senate and House negotiators try to combine the various bills that have emerged from different committees. One widely reported point of contention is whether or not the final bill should include a so-called "public option," a government-sponsored insurance product that its supporters feel would provide needed competition with private insurers and make the cost of insurance more affordable. Opponents believe that the public option would end up driving private insurers out of business and end up being the only option. While I think that this idea is hardly revolutionary - Medicare, after all, is a "public option" for senior citizens that's been around for 45 years - I also believe that it's a distracting side issue to what our health care system really needs: comprehensive cost control.

Public option or no public option, health care premiums are on a course to consume the entire average income of an American household by 2025 - a mere 16 years from now, when my oldest child will be entering college. While you might think it's okay in an abstract sense to spend a million or more dollars to save one life (especially if it's your life or that of someone you love), even the wealthiest nation on the planet can't afford to pay for every possible intervention that promises a tiny bit of improved health or longer life for somebody. We need to make choices, as a society, about our collective health priorities.

Other measures that have the potential to address skyrocketing costs (but are being underemphasized or completely ignored in the focus on the "public option") include:

1) Flat-fee primary care combined with insurance for catastrophic medical events. Your car insurance doesn't pay for oil changes, your home or rental insurance doesn't pay for furniture, and your health insurance shouldn't pay for basic primary care visits.

2) No-fault compensation programs for all but the most egregious medical errors (e.g., if your surgeon cuts off the wrong leg, or your internist prescribes toxic drugs for conditions you don't have, you would still have the right to sue).

3) Reforming medical education and continuing medical education to provide safeguards against conflicting interests (e.g. pharmaceutical and medical device companies) that lead to inappropriate or potentially unsafe prescribing practices. More on this in future posts, but I think we have a long way to go.

4) Let the insurance "bureaucrats" make informed decisions based on cost-effectiveness of medical interventions. I know that this is an unpopular position. I'm not talking about setting up death panels, or even dialysis panels, which actually existed in the past. And I'm not saying that insurance shouldn't cover every medication or surgery with a high price tag. What I'm advocating is that we take a hard look at what we're getting for the billions we spend on health care, the way you make decisions about how to spend your own limited budget. After all, drug companies still do business with the United Kingdom, even though their National Institute for Health and Clinical Excellence (NICE) applies strict cost-effectiveness criteria to determine whether drugs are worth paying for. If a drug doesn't meet NICE's standard, the company will often lower the cost of the drug so that it does. Not so in the U.S. - which is why we generally pay the highest prices.

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