Quantum Windbag
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- May 9, 2010
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- #41
You make the same mistake here that liberals often do: taking the patient-payer relationship as the fundamental unit of analysis in understanding health costs, instead of the payer-provider relationship and, to some extent, the patient-provider relationship. There are some gains to be had from ordering an insurance market and prompting insurers to compete on price and quality (which, incidentally, doesn't mean an incomprehensible market that aims at infinitely customizable insurance products, but rather one that features variation within standardized categories).
The idea behind the Ryan plan is to make the patient into the payer. You bandy around the terms and argue from the position that all of the various aspects here are, and will always remain, separate.
But more important is the structure of the system that actually delivers care and the influence payers have over providers. Simply giving seniors a choice between private insurers is not a panacea--they already have the choice of competing private insurers if they prefer that to traditional Medicare. Yet the partially privatized portion of Medicare has turned out to be more expensive than traditional Medicare, despite precious little of that extra spending trickling down into additional consumer surplus for seniors.
Could that be because we still operate with the disconnect between payers and patients? Why have costs in every sector other than health care generally gone down over time?
The goal of the Republican plan is very simple: cap what the feds spend on health, and let somebody else worry about it. If the goal is simply to get the feds off the hook for paying for seniors' medical expenses, the Republican budget would (theoretically) achieve that, since it ends Medicare's role as a payer for health services on behalf of the elderly. Most folks, however, don't seem to believe that's the primary goal we should be pursuing.
The goal of Obamacare is also simple, to cap the expenses of the government. Some people want to argue that it will do this by controlling costs, but have put forth nothing but sound bites to explain how that works. Instead they point to a list of items that will supposedly accomplish miracles that have never before been possible in the history of the universe.
- Value-based purchasing in Medicare.
- In the vein of paying for value, building on quality measure advancement begun for children two years ago under CHIPRA by extending it to adults and expanding public reporting on quality.
- Incentives for accountable care.
- Upping AHRQ's role in health care delivery system research and building technical assistance capacity to assist providers in implementing them.
- One of the largest patient safety initiatives in recent memory, aimed at curbing unnecessary expenditures due to preventable errors and hospital-acquired conditions, is not a price control.
- Supporting community-based prevention efforts, particularly those aimed at chronic illness (one of the big cost drivers in our system).
- Financial incentives for Medicare and Medicaid providers who adopt electronic health records with clinical support tools and quality measurement capabilities.
- Seeding models of advanced primary care aimed specifically at high-utilization, high-cost beneficiaries.
- Payment reforms to discourage unnecessary spending.
- Improved care coordination, particularly for those needing the most complex and expensive care regimes (and thus likely to benefit the most from it).
- Transitioning enrollees from institution-based long-term care to community-based care where possible.
- Determining which treatments are the most effective.
- A body dedicated to testing payment and delivery system innovations to determine which ones improve quality an reduce costs, and a mechanism for using that knowledge.
Just like that.
There's nothing wrong with using the existing waiver processes in federal level (waivers are extremely common within Medicaid), if that's what a state decides is the best course of action. Flexibility, within limits (i.e. preventing the race to the bottom you're talking about), is desirable. Pushing every state into a block grant that they could already seek through the normal 1115 waiver process if they wanted one, on the other hand, goes beyond letting the states decide what system works best for them.
I would be more likely to agree with this if the administration would explain exactly what the process is, who is eligible, and the reason for denying waivers when they do. Can you point to where they are doing that?