What the Future of Medicine May Look Like in the United States

Nov 9, 2017 (San Diego) The Affordable Care Act is still the law off the land, In spite of the repeated efforts to repeal it. Now the Trump White House is doing its level best to undermine it by cutting the enrollment period, and the marketing budget to tell people this is the enrollment period. This period lasts until December 15. 

Federal data reveals that 600,000 people have already enrolled, outpacing previous years. One quarter of the people getting insurance though the federal exchange are new enrollees. 

This speaks to the desire for health insurance on the part of many Americans. However, the ACA does have some issues. Part of it is directly connected with how we pay for health care in the United States. The system chiefly uses fee for service as a model, meaning that you pay each time you see the doctor. Sicker patients might benefit doctors and insurance, since they get more money from those patients. Very sick patients do not because they cost more than the insurance will get as payment, or doctors for that matter, why Medicare takes the sickest among us out of the pool insurance pool. 

In some cases, such as managed care groups, the payment to family physicians is done though what is called capitation. The service provider is not paid for each doctor office visit, but annually. It is defined as follows:

Capitation payments are used by managed care organizations to control health care costs. Capitation payments control use of health care resources by putting the physician at financial risk for services provided to patients. At the same time, in order to ensure that patients do not receive suboptimal care through under-utilization of health care services, managed care organizations measure rates of resource utilization in physician practices. These reports are made available to the public as a measure of health care quality, and can be linked to financial rewards, such as bonuses.

These bonuses can include things like a diabetic patient who is well managed, reducing the cost of managing that patient. Or a patient that loses weight, or participates in other wellness activities. This is common, and in theory this system increases preventive care. The ACA was supposed to encourage some of these activities and to pay for primary health care such as annual checkups.
Critics of this system point out that it introduces economic considerations to care. Such as a doctor who prescribes a cheaper generic drug instead of a patent drug. There is also the belief that this kind of care also encourages the use of conservative treatments, that tend to be cheaper, than aggressive treatments. This is especially obvious with things like cancer treatment. 

Of course, it must be pointed out that there always have been economic considerations in giving care, and that fee-for-service health insurance coverage has long been criticized for encouraging excessive and unnecessary care (i.e., a physician will order a whole battery of extra tests, knowing they are unnecessary or of marginal value, because the doctor will be paid extra for doing those tests for the patient). But in some markets, there is a danger that, improperly handled and managed, capitation could create some disincentives to care, rather than encouraging the most efficient care possible.

Medicine, and the delivery of medicine, has always had ethical considerations and costs associated with it. In military and emergency medicine there is a well knowing principle called triage. It means to do the most good for the largest number of people. It is especially obvious in emergency care where resources can be limited. Meaning some patients will not get the care that otherwise they would. This helps to stabilize the largest number of patients, that would not survive is a critically injured patient took personnel to do CPR for example. That same patient would receive that care if he, or she, was alone. 

As the United States continues down a path of a medical system where cost continues to explode, sooner or later it will have to take the path so far resisted. This is single payer. How that system is set up will speak to efficiencies of scale in patient care. 

Humans are self serving and want to improve their personal economic well being. This is what is called in economics the rational actor. How efficiently we care for patients will also depend on whether we continue to use fee for service, pure capitation or a hybrid system. . 

The United States has the most expensive medical system in the world. Outcomes are hardly the best either. For example, our infant mortality rate is the highest of advanced economies. Some developing countries have better outcomes than we do. 

Infant mortality has declined more slowly than comparable economies, according to the Kaiser Family Foundation

According to the Commonwealth Fund, 

Despite progress since passage of the Affordable Care Act, adults in the United States remain more likely to go without needed health care because of costs compared to adults in other high-income countries.

So in time we will have choices to make a society. Some of these choices reflect the needs of a pubic health system that will not be able to respond to a major crisis. Or our response will be weaker than it should. Being able to enact basic health prevention measures is part of it. But so is the ability to provide quality care to all. This is partly good policy. A healthy society is a far more productive society. 
This is also part of a fair economy, and single payer must have universal access. This is the only way to ensure it is fair, and acceptable to all. However, how it is implemented matters as much as to why. These questions of policy are just as critical as the idea of single payer. 


Categories: ACA, Health, policy

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