Tag: fee for service

Healthcare and Markets – why don’t they work together?

A consistent chattering point in American discussions of healthcare is the claim that if we can only bring transparency and competition to healthcare we will drive prices down and bring sanity to healthcare. The rest of the world knows that this is not the answer but we seem to remain in the thrall of universal free-market thinking.

To answer this question lets start with an example of a market that works reasonably well and which we all know very well. In our little patch here in Hudson we have four supermarkets within about a six mile radius servicing roughly 20 thousand people. I can choose to shop at Price Chopper, ShopRight, Hannafords, or Walmart. There are also farmer’s markets and roadside stands. I have lots of suppliers to choose from. Generally I shop at two places, but I certainly stop at all of them with some frequency. When I step inside I regularly pick up the green and red peppers, the onions, and other vegetables that I like to chop up for my cooking. Now, I do not hold a degree from CIA (Culinary Institute of America) so I am not exactly expert, but I generally can identify a fresh vegetable when I see one. Unlike some Presidents I do know how much things generally cost and there are price points for green peppers, for example, that reduce how many I pick up from three or four to one or none.

So,  a functioning market has a number of suppliers (sellers) and lots of buyers. The product for sale is understood by the buyers and they can examine it for quality readily. Prices move up and down in reaction to supply and demand. Market capitalism in action.

Health is not a green pepper

Health is complex and above all it is about life and death of the buyer, me and you. It is inherently emotional. Generally, people will do whatever is necessary to avoid pain and discomfort. This is not a choice between green and yellow peppers. Further, diagnosis and treatment options require many years of advanced education and training to understand. It is simply not true, and never will be true, that people without this training can make well informed decisions about which treatment path to take. Then, unlike our supermarket example, here in Hudson there is one supplier of health services, Columbia Memorial Health, the local hospital. To choose a different supplier I can drive an hour north to Albany or 45 minutes south to Rhinebeck. Even in Boston where I lived for many years, the choices were broader but then I was faced with the fact that the appearance of choice confronted me with my lack of expertise to make a well informed optimal decision. Health is not green peppers. Doctors and hospitals are not grocery stores. I did not graduate from Harvard Medical School.

Fee for services not for health – perverse incentives in action

In reality our market based healthcare system operates just as one would expect given the imbalance of expertise and relative small number of suppliers.  The suppliers have enormous power and they are taking advantage of the buyers, us. They set the prices as they wish. Through historical accident we have added a mixture of government and private insurance that obscures what is going on. Worse, this market is not selling health at all. In a self-enriching cycle, the doctors and hospitals are incentivized to use as many tests, procedures, and prescriptions as possible. They are paid for these; not for health. This is the pay for service model.

Every other developed country in the world understands all of this very well and has for decades. Each country has evolved systems to establish a national or regional budget per capita for health. This is done in negotiations between the government, other stakeholders, and the medical providers. The providers are expected to deliver health. Markets and profits enter, if at all, only peripherally. It is up to them to determine how many tests, procedures and drugs to prescribe. They can decide that preventive medicine is more effective than costly technology intensive treatment. They  optimize the mix.

The proof is in the pudding

Here are a set of facts that speak loudly to both the cost and poor quality of the American healthcare system. The US spends $9,800 per capita on healthcare. Our developed country cohort spends approximately one half of that (excepting Switzerland the outlier at approximately 70% of our spending). These countries all achieve a life expectancy between 81 and 83 years while the US is at 79 years. This numerically small gap in fact represents a very significant gap in performance. According to the most recent CIA World Factbook: “The US ranks 56th in infant mortality out of 225 countries; 48th in maternal mortality out of 184; and 42nd in life expectancy at birth out of 224.“ These facts should outrage all Americans.

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