Evidence and cost curve bends

Yesterday I posed on how total medical spending has been coming in consistently under 2010 (pre and post-ACA signing) CBO projections. That is a big deal as we have a long run healthcare cost problem on the federal fiscal level.

What is causing the shift?

Some of it is the economy. Some of it is higher deductibles leading to less care. Some of it is the Flying Spaghetti Monster and some of it may or may not be the ACA. Part of the ACA was taking any idea that a policy wonk had to reduce costs and throw them against the wall to see what worked. For that process to work, means evaluating the experiments, embracing the good things, learning from the mild failures and abandoning the colossal Buckner-esque screw-ups.

Some evidence is in on some of the ideas thrown against the wall.


From the referenced NEJM article:

During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (–$11; 95% confidence interval [CI], –$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, –$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience — discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health — both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively).

So these interventions are doing no harm. But they are doing no good either.

Back to the drawing board to figure out if there are different ways of delivering good quality care at lower prices.

10 replies
  1. 1
    gogol's wife says:

    I don’t understand any of this, but I love your posts. They really make BJ stand out from the crowd of blogs.

  2. 2
    Mary G says:

    Could a part of it be the ACA provisions that say insurance companies can’t charge more than a certain percentage for profit? I’ve been shocked because the premium for my Medicare supplemental policy didn’t go up for the second year in a row, especially since I turned 60, and those milestone birthdays used to be the trigger for a big old increase. My usage hasn’t changed much.

  3. 3
    Kylroy says:

    @Mary G: Medicare supplements for pre-65 insureds are isually handled differently. Since anyone in Medicare pre-65 (well, 64 and 11 months) has significant health issues, rates aren’t usually age-adjusted until 65 and above since age doesn’t correlate overmuch with cost of care in this (and mearly *only* this) population.

  4. 4
    MomSense says:

    I still think that patients need better ways of accessing information about options for treatment than relying on their providers (who may have an interest in “selling” you services) and webmd.

  5. 5
    The Ancient Randonneur says:

    @MomSense: Maybe a ratings service like Morningstar is for investmors?

    Richard does a ratings service exist?

  6. 6
    dr. bloor says:

    Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices

    I’d be amused if my premiums as a BC/BS customer weren’t going up double digits even while my reimbursement as a provider is being trimmed at the same time. All in the name of paying for Pfizer’s or AstraZeneca’s latest toys.

    Intellectual property reform. Rational rationing of care. The rest is just dancing in circles.

  7. 7
    amygdala says:

    @The Ancient Randonneur: There isn’t a ratings service, exactly, but Cochrane analyzes available evidence across a broad array of clinical issues. And they’re pretty good about using language appropriate for the general public.

  8. 8
    piratedan says:

    @dr. bloor: what would be nice to see is a breakdown on the costs of just who gets paid and how much. The current hospital system appears to be broken and driven by insurance reimbursement, not in providing healthcare. Does healthcare need to be profitable or is it better to consider it as a shared cost for the common good?

    How much of a hospital’s true costs go to paying its staff, maintaining its equipment, handling its liabilities, beating the bushes in marketing, acting as a data source for tracking diseases at the regional, state and national level, for providing meals for those that work for it and for whom they provide care, the inventory and dispensing of pharmaceuticals…Plus we haven’t even talked about things like Radiology, Respiratory, the staff that it takes to stay compliant with the feds and state regulators, the clerical staff to one, get the patient into the system and then to ensure that everyone who needs a report, gets one. The Pathologists, the dietary staff, the physical therapy staff, oncologists, surgeons etc….

    People rarely consider everything that goes on in a hospital and the varying degree of folks (and expertise) that resides within… all those people and all of their equipment is expensive.

  9. 9
    pseudonymous in nc says:

    Back to the drawing board to figure out if there are different ways of delivering good quality care at lower prices.

    Fixed, negotiated tariffs for common procedures, publicly disclosed. Accelerated and batched reimbursement for claims that come in on/under tariff, more paperwork for those that exceed it. Patients get quoted “tariff plus $X” by providers.

    And yeah, IP reform and rational rationing and greater incentives for expanded general practice primary care instead of being sent off to specialists and the magic MRI machine for anything more than a case of the sniffles.

    I mean, really? I know that wonks wanna wonk, and they’ll come up with ‘uniquely American’ approaches, but this is not unbroken ground.

  10. 10
    MomSense says:

    @The Ancient Randonneur:

    Right that would be a help but I also think we need information that is provided by a neutral party. Let’s say I’ve been told by an ob/gyn that I need a hysterectomy, I would like to be able to go to a website run by NIH or some neutral entity and go through a decision making program where I answer questions about my symptoms and then I answer yes or no to trying medication, trying IUD, and so on. At least then I might know what the options are and what to ask my doctor.

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