October 12, 2005
Tommy, Can You Hear Me?
When I read the Health Cartel’s response to the idea of Health Savings Accounts (HSA), it makes me think they are speaking about the main character in the Who’s rock opera, Tommy. Traditional medicine seems to believe that consumers are too impaired to figure out how to take care of themselves--much less play pinball. I wonder who plays Uncle Ernie in this case?
In the most recent issue of the New England Journal of Medicine (NEJM) are two thoughtful articles on the subject of HSAs. They are excellent examples of the basic views and resistance to change by vested interests on the delivery side of healthcare.
First, let’s get one thing straight. Every dollar spent on healthcare starts from consumers’ pockets. Whether it is paid directly or is passed through the government in the form of taxes or is passed through an employer in the form of foregone income in exchange for a “health benefit” with tax advantage, it all starts from the same source.
The existence of the financial and administrative third party is the genesis of much of the inefficiency in our healthcare system. Another fundamental inefficiency is the confusion between finance and delivery, with government and others trying to do both and doing neither all that well much of the time.
The healthcare system in the US can never be fixed until the service and financial transaction take place between the same two people.
This axiom highlights the fact that there is not now nor has there been for at least sixty years a “market” in healthcare. Since the advent of third-party intermediaries of all stripes, the healthcare system has become progressively ignorant of true market feedback as to price, quality, customer need and access/capacity.
As highlighted in the piece by James Robinson, PhD in the NEJM, governments around the world and not individuals have generally performed the task of setting healthcare priorities which are accomplished primarily by price controls and capacity limits (i.e., limits to access) to restrain expenditure.
This is an usually candid admission, though clearly true. Is this what we all want for healthcare? Price controls and limits to access?
Much of this approach is a remnant of the central planning, command and control dependence upon experts from the last century.
The Abramson Family Center for the Future of Health holds as its core belief the equalization of the knowledge-need proposition in healthcare. This is accomplished by being attendant to the four principles of the Center: Transparency, Visibility, Decisioning, and Distributed Healthcare.
Dr Robinson gives an excellent overview of HSAs. He rightly points out that HSA’s lead to increased choice for consumers, removing discretion from the provider to the patient in many cases. He concludes by pointing out that the debate is really about central planning and control of healthcare versus one controlled and financed by individuals.
Again I say, all healthcare is already financed by individuals and will always be so.
Dr. Robinson’s worry seems to be that a collectivist sense of “responsibility” is required in order to look after society’s most vulnerable members. It seems to me that enlightened self interest is just as good a motivation as a “collectivist responsibility”. Further it is likely this self interest could be expressed as the government having a rightful role in the finance but not delivery of healthcare to these members of our society. If the government focused only on the provision of finance for healthcare—e.g., developing and providing access to financing vehicles including HSAs—and removed barriers to access of the delivery of care, it would be far more cost efficient than today’s complex and costly system of finance-delivery muddle.
The second piece in NEJM by Thomas Lee, MD and Kinga Zapert, PhD asks the question "Do High-Deductible Health Plans Threaten Quality of Care?" Based on the title it wouldn’t take too much to guess the answer expressed in the article. Objection. Leading the witness!!
Quoting in some case decades old information about patient behavior, they spin a weak case for the status quo and against HSAs. Human behavior being what it is, the re-setting of expectations and the provision of useful decisioning tools will take some work.
Another part of it, however, is attitude. This article recites a litany of patients just won’t do the “right” thing if they have to pay for it “evidence”. Part of caring for one’s self is the belief that you can (self-efficacy) and is in part created by attribution. To whom or what do you attribute the power of health? To the government? To the physician? To yourself? To a combination of self plus others as needed and requested by you?
Buried in the depths of the article is the admission that just because patients who have to pay more out of pocket and who may skip treatments and tests doesn’t mean they have worse outcomes. Aha!!!! And they point out that although the data are recent so far no decrease in “quality” has been seen with HSAs.
Parts of the argument not addressed in these two articles and familiar to anyone who reads this blog include the benefits vs. cost of pursuing maximum utility in healthcare at all times, the costs vs. benefits of delivering care at the margin of benefit, the true value of universal application of so-called evidence based medicine, and the idea that patients may want to satisfice and not maximize all the time.
And most of all who decides?
HSAs are clearly a needed step in the finance of healthcare to restore to individuals choice, control, and access and to allow them to test for value and convenience. They should also be a helpful step in making the system a bit less ignorant.
