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Loser-free health-care reform

To say another word about the fuss over the Dartmouth Atlas project, it's worth talking for a minute about why people so badly want the project's conclusions to be right.

The Dartmouth Atlas project has amassed an enormous amount of data suggesting that up to 30 percent of our health-care spending goes to items that don't do anyone any good. It's wasted money. If this is true, it's absolutely great. Or it at least has the possibility to be great. It means we don't have to ration.

We know that we're going to have to eventually cut health-care spending by quite a lot compared with what it would be if we don't do anything. There are probably three ways to do that: Make care less affordable (high co-pays, for instance), less accessible (waiting lines) or less profitable (government bargaining). All of those approaches will have losers. Lots of them, in fact.

But if the Dartmouth Atlas project is right, and if its findings can somehow be put into policy, it offers a loser-free way out of our predicament: You take away care that no one needs. That means no one loses. In fact, some people win, as unnecessary care carries risks of its own. That's much easier for politicians to sell, and it looks like it's actually true. The only question is whether we can figure out how to separate the good care from the bad. And we won't know that for years to come.

By Ezra Klein  |  June 3, 2010; 2:30 PM ET
Categories:  Health Reform  
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Surely the providers of useless care would be the losers if we stopped buying it?

And cutting back on useless care is tricky. Look at last year's mammogram report...

Posted by: Unwisdom | June 3, 2010 2:41 PM | Report abuse

ya what Uniwisdom said.

Those poor doctors that own stake in labs and radiology centers. Who will speak for them???


in one paragraph you state that "It means we don't have to ration" and then go ahead in the next and give three ways to cut spending by, UH, RATIONING.

It'll happen. Its just a matter of who gets rationed and by how much. Could efficiencies push off the start of rationing, sure. It will never end it.

The only way we win is if we become healthier. as a country. That's the ONLY way I can see rationing be put off for any serious period of time. Maybe Berwick was a good choice for CMS Director.

Posted by: visionbrkr | June 3, 2010 2:49 PM | Report abuse

Wouldn't simply eliminating health care for the unemployed reduce both health care costs and the unemployment rate? And isn't that the most efficient means of accomplishing both goals? Technically, the answers are "yes" and "yes."

The DA data is chilling in that it suggests that further involvement of the federal government in health care would bring some sort of "efficiency." I'll continue to argue that such efficiency is dangerous.

Posted by: rmgregory | June 3, 2010 2:51 PM | Report abuse

What's useless care? Given my blood chemistry & history, either I'm getting useless tests for prostate cancer & useless meds for hypertension (they lowered the BP for hypertension to my BP), &, soon, will get useless meds for cholesterol--or not. Who knows? There's no agreement on these things.

Posted by: davidpancost | June 3, 2010 2:55 PM | Report abuse

"You take away care that no one needs. That means no one loses."

Unwisdom beat me to the punch. The world has long been populated by people defending their right to continue to provide FILL IN THE BLANK that no one needs. It's a close cousin to subsidies, protected monopolies, etc.

Posted by: ostap666 | June 3, 2010 3:01 PM | Report abuse

@ visionbrkr : We ration by price right now . I agree that eliminating unnecessary treatments and diagnostics will put off rationing by need, but it will come eventually. It has to in a society where the majority of health care costs happen in the last 18 months of life.

Posted by: srw3 | June 3, 2010 3:04 PM | Report abuse

So the government is going to decide what health care is "useful" and what isn't. Hey since we're shutting down our offshore drilling, maybe we can put some of those people from Minerals Management in charge of this.

Posted by: ath17 | June 3, 2010 3:11 PM | Report abuse

Death Panels FTW!!1! Give us them now pls k thx bi.

Posted by: sparkplug1 | June 3, 2010 3:23 PM | Report abuse

"Wouldn't simply eliminating health care for the unemployed reduce both health care costs and the unemployment rate?"

I rarely ever use this term, but in this case, I simply must: LOL.

"Hey since we're shutting down our offshore drilling, maybe we can put some of those people from Minerals Management in charge of this."

Also. Too.

The Irony. It is strong with these ones.

Now, this is a big question:
"The only question is whether we can figure out how to separate the good care from the bad."

It's hard to say, but having a means of repeatedly and systematically asking the question and reassessing our practices on an ongoing basis will hopefully be the most beneficial aspect of HCR.

Posted by: slag | June 3, 2010 3:31 PM | Report abuse


yes we ration by price now.

And in about 20-30 years I'm betting we'll still be rationing by price. Who can afford to go to the "good doctors" that won't take single payer and who won't.

Posted by: visionbrkr | June 3, 2010 3:37 PM | Report abuse

Don't the comparisons between the U.S. and all other advanced nations with universal care make it apparent that equal or better results can be had for less money — and by less money, I'm talking in some cases about half as much money?

Posted by: jeff01 | June 3, 2010 3:56 PM | Report abuse

There's an old marketing/business joke where the guy says: "I know half my advertising is useless. The problem is, I don't know which half."

Posted by: bsimon1 | June 3, 2010 4:20 PM | Report abuse

"The only question is whether we can figure out how to separate the good care from the bad."

This is definitely the key point. Or for that matter, how to define 'bad' care. A treatment that works 1% of the time for $100,000 seems to be a pretty bad value proposition, except for that 1% of course. You don't want to be in that position where you hear 'yeah, there is a treatment that has a small chance of working, but let's be frank these type of things cost society $1 trillion extra and save only a few people, so we decided on your behalf it isn't worth it.'

That said, it's a lot easier to tell grandpa that the government is putting its foot down and saying no than to have to tell him you decided putting a second mortgage on your house for his experimental treatment wasn't worth it to you...

I'd rather the government give people a reasonable amount of cash for serious/chronic conditions, so that there wouldn't be (as much) 'price rationing' or third party payments, although determining what conditions merit a payment and the size of that payment would be political footballs...

Posted by: justin84 | June 3, 2010 4:40 PM | Report abuse

Well, then, very clearly we need to turn over our entire lives to the federal government since liberals have told us that they know best. Why would they lie?

Posted by: josephpturner | June 3, 2010 5:08 PM | Report abuse

The definition of unnecessary health care is health care being given to someone else.

Posted by: jnc4p | June 3, 2010 5:15 PM | Report abuse

"But if the Dartmouth Atlas project is right, and if its findings can somehow be put into policy, it offers a loser-free way out of our predicament: You take away care that no one needs. That means no one loses."

I have to say, I have a problem with this logic. The fact is that you can't separate "healthcare people 'need'" from "healthcare people 'want'" without making some judgments as to the value and efficacy of that care. And the minute you do that, you will automatically be accused of rationing.

It's certainly possible that cutting costs could be "loser free" in terms of outcomes. But that's not what the fear of rationing is really about. On the personal level, people are concerned that a doc will subjectively want to use an MRI or try out an procedure, but that cost controls won't let them. And that's a situation that will happen even with smart, efficient management. Cuts are never painless.

Posted by: NS12345 | June 3, 2010 5:34 PM | Report abuse

Well the problem with this logic is that it's not loser-free because it is the same as paying doctors (and medical device manufaturers, labs, etc) less. The "unnecessary" care that Dartmouth Atlas points out is care administered because there is financial incentive to do so. For example, a hospital that just bought an expensive MRI machine will over prescribe MRI's to patients. If Dartmouth Atlas is right, then we develop best practices and make note that this type of care is extraneous. If they are wrong, we still have to cut spending and these things will be cut anyway as doctor's pay decreases and they try to trim their own fat. Either way, we reach the same conclusion and that is that the medical field needs to take less.

But to go along with your previous post and my previous comment about best practices THIS IS WHY WE NEED DON BERWICK IN CMS now more than ever. If the Republicans block him it will be a devastating blow to the health reform that just passed and the health reforms that need to pass in the near future.

Posted by: megankeenan | June 3, 2010 9:37 PM | Report abuse

This is what insurance companies are doing in the US already. They research studies about efficacy and decide what to pay for or not. Also how much they want to pay for it. I believe that national systems of various types all do this in different ways as well. In the US this leads of course to your doctor arguing with someone at the insurance company back and forth and maybe getting it approved. And each doctor and each hospital dealing with numerous companies with their own ideas of what is approved and how much they think it's worth, all of which adds, on both the insurance and provider sides, to several of the percentage points of extra GDP we pay for covering a lot lower percentage of people. Plus, among other things, drug companies being able to advertise and charge us two or three times what everyone in the rest of the world pays. And doctors owning a piece of the radiology place or whatever is just ridiculous.

Posted by: emjayay | June 3, 2010 10:25 PM | Report abuse

To those who are obsessed about rationing: be aware that no one is talking about rationing in the traditional sense of making it illegal to get care that doesn't pass muster. It is only that such care would not be included in insurance benefits.

Presumably, when the government is deciding, this restriction of coverage would only cover government programs. Private insurers would get to choose whether to cover treatments that have a low QALY value. Of course, once the Feds make this decision, private insurers are going to by and large drop the most wasteful treatments or make them harder to get. But people will still be able to buy them if they want on their own, and can afford it. That surely should be better if you're a conservative than having the government pay for everything!

It is most peculiar that on the one hand we get the right complaining that government health insurance will be wasteful and the benefits too rich, and on the other hand the right complains that government will ration and unjustly remove benefits, or complains that the government has no right to decide what is covered. That these complaints are inconsistent is no matter; what matters is that conservatives get to criticize government insurance no matter what it does.

Posted by: jdhalv | June 4, 2010 12:16 AM | Report abuse

"But if the Dartmouth Atlas project is right, and if its findings can somehow be put into policy, it offers a loser-free way out of our predicament:"

This is where the statist mindset traps you. There is no need to make this a policy, we just need to educate people that much health care does not effect health outcomes very much and give them control over their own health dollars. If I hear that glucosamine or some other supplement isn't effective, I don't spend my money on it. If we start looking at doctors and pharma as the salespeople that they are, and stop looking at them as healers, modern miracle workers, we'll all be better off. HSA FTW.

I am sick of paying for all of the hypochondriacs out there that go to the $200 doctor every time they get a headache, pay a $15 co-pay, beg for a prescription, and raise my damn rates. Whatever happened to take two aspirin and a glass of water and call me in the morning?

Posted by: staticvars | June 4, 2010 1:10 AM | Report abuse

NS12345 wrote, "The fact is that you can't separate "healthcare people 'need'" from "healthcare people 'want'" without making some judgments as to the value and efficacy of that care."

I have no issue with this as long as those who "want" care pay for it out of their own pockets rather than using other people's money via a third party payer, a.k.a., insurance.

Even though up to 30% of care may be unnecessary, eliminating it will result in losers. The money for that care is paying someone and that means, if the care is not provided, someone will be out of a job. This may not be a bad thing from the perspective of holding down health care costs, but it does mean there will be losers and that, in fixing one problem, we had better be prepared to fix the new problem that fixing the original problem will cause.

The bottom line with the cost of health care is that it is being run on the wrong economic model. Free enterprise and charging what the market will bear for services is largely responsible the ever increasing cost of care. A whole new approach to the economics of this sector of the economy is what is needed.

Congress needs to step aside so that new approach can be developed. Then, after it has been developed, it might be appropriate for Congress to enter the picture. Until then, legislative intervention will only serve to hamper and confound any meaningful progress.

Posted by: dscluley | June 4, 2010 8:44 AM | Report abuse

dscluley --

I agree with what you're saying. But my$ point is that making that initial determination between legitimate needs and "wants" will necessarily involve tough decisions that much of the public simply will not accept. Someone is going to have to differentiate between care that's so essential it deserves third party coverage and care that's essentially a luxury. Patients don't have the expertise to separate the two, and we've seen that docs have little incentive to inform them about the true cost benefit analysis. Even when patients subjectively know the long odds against any given test or procedure's effectiveness, they're unlikely to accept that there's a chance for treatment out there that they can't access (and for many patients, out of pocket treatment means NO treatment).

So the person who makes and enforces this decision is going to be unpopular. The insurers have been trying it for years, but it's just made them unpopular AND they've been ineffective. The government's got enough payment leverage to make it work, but I guarantee that the whole process will be despised. The Atlas findings were never going to save us from that.

Posted by: NS12345 | June 4, 2010 11:02 AM | Report abuse

This assumes that it will be easy to identify (in real time, not hindsight) the 30% that isn't needed.
This sounds like a variation on the 'cutting waste, fraud and abuse' magic piggybank that politicians trot out when asked how they are going to pay for something.

Posted by: invention13 | June 4, 2010 11:42 AM | Report abuse

When you take care away that no one needs, politicians lose. See: recent mammogram kerfuffle.

Try telling people that they should have less biopsies because biopsies are over used and, because they are invasive, cause more harm than they prevent.

Politicians lose.

Posted by: roquelaure_79 | June 4, 2010 1:14 PM | Report abuse

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