Tuesday, October 23, 2012

Access, Affordability and Quality: Only A Third of the Work Is Done

Access, affordability, quality
Did you know that the taxpayer costs of some versions of public transportation have proven so expensive, that it would have been cheaper to provide each rider with their own BMW

Which is why the Disease Management Care Blog, which always uses public transportation in and out of the SFO, ORD, ATL, PHL airports, ascertained that it was time for it to make its coupe selection. Unknown to the DMCB spouse, it has started to examine the trade-offs between bimmer cost, speed and comfort.

Which reminds the DMCB of the parallel universe of health care.

In its travels around Washington DC, the Disease Management Care Blog has repeatedly heard that the health reform likewise involves trade-offs between the three similar goals of 1) access, 2) affordability or 3) quality. Historically, most health reform proposals have managed to secure two out of three. A good summary of the historical travails of this "iron triangle" can be found here.

Which is why conservative-leaning Gail Wilensky's examination of Obamacare in the Oct 18 issue of the New England Journal makes for good reading. She finds the President's signature achievement wanting because it only delivers on on the single goal of access. 

Thanks to the law, 30 million Americans will soon be able to get coverage.  Approximately half will obtain subsidized private insurance  and the other half will be able to qualify for Medicaid. 

All well and good, except a substantial proportion of Americans remain philosophically skeptical of the law's merits. Whether you agree with the skeptics or not, it's still feeding a lingering partisan divide that continues to chew up precious political capital.

And, according to Ms. Wilensky, that was the easy part. Affordability and quality remain serious challenges.

That's because, despite some promising (but ultimately still unproven) innovations involving bundled payments and shared risk, Obamacare leaves Medicare's fee-for service reimbursement very much intact for years to come.  That means quality will continue to disappoint and costs (i.e. affordability) will take a greater and greater share of America's gross domestic product.

Disagree?  While Ms. Wilensky may be criticized by partisans as a market-oriented Republican shill, the DMCB has seen her up close, in-person and in action: she's smart, always makes good points and when she speaks about the Affordable Care Act, the rest of us should listen:

1) Some of the anticipated savings of Obamacare that went into budget planning included a curious item called "productivity adjustments."  This was based on the assumption that the health system would achieve greater efficiencies long before any of the Affordable Care Acts payment innovations are a) proven and b) imposed on the majority of providers.

2) The Relative Based Value Scale is fundamentally untouched and continues to reward physicians for high margin services instead of efficiency.

3) The much ballyhooed value-based payment bonuses are quite modest and an unlikely to significantly alter hospitals' approach to doing business.

4) Congress' past vulnerability to special interests and the low likelihood that the Independent Payment Advisory Board will change physician behavior does not inspire confidence.

5) While supporters believe the law will incent value-driven market behaviors, it's ultimately Washington DC - not consumers and certainly not markets - that will reward the winners and losers.

6)  The prospects surrounding the looming fiscal cliff and SGR remind us that cutting fees are not the same as cutting costs.

One third full versus two thirds empty?  Perhaps.  Depressing?  Maybe.  An accurate portrayal of bad times to come?  Maybe not.  Better, says the DMCB to know what we're potentially up against and the hard choices we still have to make between affordability, quality and access.

Addendum:  If you got here thanks to Maggie Mahar's Health Wonk Review, a friendly rebuttal to her partisan spin can be found here.  The DMCB linked that up on the Reply part of the HWR posting but it's gone missing.

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