What is health care reform? The debate's convolutions expose extreme differences in priority and understandings of what exactly the problems are, and what legislation should accomplish.
We read a lot about cost as a priority issue. But how should we define this? As price, volume – or how about intensity of use?
Another cornerstone is access. Does this constitute a right, a privilege or maybe an economic good?
A third contention is quality. But what is quality? Is it something consumers should determine for themselves, or should agencies and third-parties decide it on a top-down basis?
The attempt at universal health care prioritizes access. The consequences of the Congressional Budget Office's scoring this week, however, indicate that cost now supersedes it as an issue. (Recent polls suggest that the electorate concurs.)
These consequences are also defining health care as an economic good, which happens to coincide with some of the discussion on quality. For example, MedPAC, a favorite among reform odds-makers to assume an enhanced role, argues repeatedly for accountability and transparency in its recent biannual report.
The report, importantly, advocates an economic resolution:
"To increase value for beneficiaries and taxpayers, the Medicare program must overcome the limitations of its current payment systems. A reformed system would pay for care that spans across provider types and time (encompassing multiple patient visits and procedures) and would hold providers accountable for the quality of that care and the resources they use to provide it." (From the executive summary)
It stops short, though, of calling for a turned-over system. Even in its advancement of "accountable care organizations", the report still assumes a critical role for Medicare in payment decisions. Of course, if MedPAC were to argue for a complete surrender to consumers as purchasing decision-makers, it would put itself and Medicare's $80 trillion liability out of business.
Let's assume the debate does shift to address quality as the absolute priority. One, this increases the possibility of legislators actually accomplishing something, because it centers the discussion not just on value, but also the payer-provider dynamic.
Hot-button items such as comparative effectiveness and health IT would all come into focus without the risk the CBO not scoring them. Remember, the CBO is only giving credit to tax and payment policies, which these past few days have proven politically unpalatable. Not including access would eliminate both, and the CBO as a factor.
Two, quality-based resolutions that incorporate value could serve as stepping stones to access and cost. That's because they’re likely to result in more accountability and transparency, neither of which can occur without consumer participation. And the more consumers engage, the more likely access will expand in a cost-efficient way.
Perhaps, one day, supply (physicians) and demand (consumers) might actually transact with each other.
Now that would be a noble goal indeed.
Disclosure: No Positions