I’m a big believer in spending more money on the study and understanding of health care delivery in part to inform and improve the way we pay for care, but it might also reform the way we educate the next generation of care practitioners. Some variation I get, but what we find in health care today is beyond the bounds of reasonable explanation. It also represents a ton of money - and is, in large part - the answer to Paul’s previous commentary.

More on this issue in my next post - which will be about the role and mentality of Medicare.

I agree it would be easier if it were invisible in that way, i.e, already done at the time of delivery. But, so far, efforts to change practice decisions by doctors have not worked very well if imposed from the outside.

On the prescription drug marketing, let it be so! I am stunned by how much consumer demand for drugs is driven by those ads on television. They put local primary care doctors and others in a very awkward position.

I understand the need for providers to enhance quality of care and take other measures that combined will achieve operational efficiencies — and, in fact we are building our BIDMC business plan around that — but I don’t see much evidence that many places are doing this. Further, even if they do come around to this philosophy, will these changes offset the underlying demographic forces throughout the region or country?

Put another way, does anyone out there think that we can dramatically slow the growth of health care expenditures in a society that demands that all services and treatments be available to all? I have heard Charlie talk persuasively about the slow speed with which changes in direction occur in this field. This is not a question of design of insurance products or systems. I don’t see that this country will quickly adopt underlying changes in medical treatment philosophy — so whether the insurance system stays the same or moves to a more national health system approach — there will be a cost squeeze on somebody. It might be taxpayers, employers, employees, or providers, but most likely a combination of all.

In short, it seems to me that we have all decided that more medical care is better. We have greater and greater expectations for treatment of acute and chronic disease. We persist in ignoring investment in the parts of the health care system that would emphasize prevention, life style changes, and early intervention. Is there really any doubt as to why the current trends exist?

Some of this, I believe, is about ease of administration. If you take coverage through work, even if it’s expensive, it’s not a lot of administrative hassle for you. The larger question being posed by the Connector is what happens when a state entity tries to make the administrative part of the transaction less complex. Will people buy it?

We’ll have to wait and see.

Barry, I totally agree with your idea of modeling the delivery method of an Institute for Healthcare Delivery after the Federal Reserve Board. I do think, though, there is potential for controversy when comparing ‘Drug A’ to ‘Drug B’ on an effectiveness level. Even more so than in the case of other medical treatments, there is much more variation between patients as far as their responses to certain medications. What may be very effective at treating my condition could well have little to no effect on your identical condition. I do support the idea of legislation restricting the marketing of medications, as is currently being mulled over by the US House of Representatives.
As for your last point, I think you are totally correct. End of life healthcare and other similar scenarios are ethically challenging to begin with. If the government were to regulate these procedures, we could potentially enter a realm where the government would impede upon some very basic constitutional rights that they are bound to serve and protect.

The least controversial mission for such a group would be to assess the comparative effectiveness of similar drugs and treatments. Determining that Drug A is just as effective as Drug B and is half the price or less does not deny care to anyone; it just helps to identify the best value.

As I’ve said numerous times before, we need to find ways to safely reduce utilization of services which is much trickier. I would like to see universal living wills or advance directives to minimize futile and often unwanted care at or near the end of life. Sensible malpractice reform could, over time, reduce defensive medicine.

While I’m a big fan in price transparency, I think we might be better served if doctors became the focus for taking advantage of it. Doctors drive virtually all healthcare spending through hospital admissions, ordering tests, prescribing drugs, referring patients to specialists, consulting with patients and doing procedures themselves. If the doctors had robust price transparency information at their disposal in an easily accessible format, they could more easily direct their patients to the most cost effective providers. At the same time, if insurers could track utilization by doctor and adjust it for the risk of each doctor’s patient population, insurers could more clearly identify the best practicers and the high utilizers. Perhaps it could then design a system to reward the best practicers either with meaningful bonuses and/or higher reimbursement rates and, at the same time, help the high utilizers improve their practice pattern.

By far, the most controversial potential strategy would be rationing by denying care based on QALY metrics or arbitrary age cutoffs. We would need to carefully study how other countries handle this and then, through our elected representatives, determine to what extent, if any, our society and culture is prepared to move in that direction. At the very least, we would need to demonstrate that we have aggressively pursued and fully exploited all other reasonable cost reduction strategies first and should only resort to explicit rationing as a last resort.