The New York Times has an article about the inevitability of expanding cost controls in health care. The core of the discussion is this:
For all of managed care’s problems, national bankruptcy would be considerably worse, and that’s where we’re heading if we don’t rein in health costs. We are already experiencing some preliminary symptoms. In addition to the financial burden of Medicare and Medicaid, rising insurance premiums in employer-provided plans are absorbing a large share of what might otherwise be wage increases. That makes us poorer and keeps us from buying safer cars, eating healthier food and investing as productively as we can. Health gains that accompany prosperity are largely invisible, so we tend to neglect them.
Conceived in its broadest form, managed care can be run by the government, as in Britain, or left in the hands of a regulated private sector. Because the United States already has substantial private-sector capacity, and because many Americans are suspicious of government controls, the private route is the most likely option. Individuals would choose among competing providers — and those providers would try to offer the most appealing bundles of services, relative to cost.
There are ways to encourage cost controls while maintaining or improving quality of service. Some of the best clinics in the country use these systems. The first thing you need in any system that controls costs is a single point of contact who is responsible for your care. Just as it makes little or no sense for someone who wants to build a house to decide to be their own general contractor if they have no project management or contracting experience, so it is unwise for patients to be their own general practitioner. Going from one doctor to another, from one clinic to another, gives you more expensive and possibly worse medical care than you would get in a single clinic that coordinates services, even if you actually went to superior doctors each time.
People don't. They go to a doctor that a friend recommended. They don't look for a Gregory House (not that they should), they look for Marcus Welby. The general patient population has shown that it is not competent to evaluate anything about their doctors other than bedside manner. Manner matters some, but quality of care is generally independent of that. The best way to improve quality of care is to have excellent documentation of health history and treatments, a single point of contact for a controlling physician for the patient and strong interaction with that physician even if the patient has been sent to an out-of-town hospital or clinic. Cost-saving comes from knowing which tests to do, knowing what treatments have been tried, what medicines for chronic problems are being taken, finding workable regimens of self-help health maintenance, e.g. exercise that the patient is willing to continue to do not only because it is healthy but because the patient enjoys it, and otherwise knowing everything that the medical community has learned about the patient. Each patient needs a personal physician who will do this and great documentation so another doctor can take over if necessary.
This is not what we see today in most places. Doctors, particularly specialists in other clinics, don't think of themselves as being responsible to the primary care physician. They need to. If they won't get back to the original doctor, they need to be cut off. This is about treatment of patients, not their own vanity. The tools for doing this have improved tremendously over the past couple of decades. Notes, test results, scans, can all be e-mailed or linked to the primary physician. The tools are available. Now we need the will to follow up.
Also published at Insurance Matters.