COST: GAO Joins the "We Can't Go On Like This" Health Care Spending Choir

Joanne Kenen — Thu, 26 Jun 2008 13:42:00 -0400

More gloom and doom on the health care economics and fiscal sustainability front. Or, choosing a more cheerful perspective, more great incentives for fixing our health care system.

The GAO in a recent report to the Senate Finance Committee added its voice to the Washington choir (in which CBO chief Peter Orszag and Fed chairman Ben Bernanke are the star soloists) warning that we are on an unsustainable fiscal path, and "over the long term, health care spending is the principal driver." That "we" is a big "we"—federal, state, and local governments, as well as the private sector. Like other top government agencies and experts, the GAO has recognized that the challenge is not merely demographics. Yes, with the Boomers retiring, we will have more older people, and older people develop health problems. But it's how they use costly (and sometimes unnecessary) health services, what the GAO calls "increased costs per beneficiary" not just sheer numbers of people that counts.

Growth in health-related spending is the primary driver of the fiscal challenges facing state and local governments as well. Unsustainable growth in health care spending also threatens to erode the ability of employers to provide coverage to their workers and undercuts their ability to compete in a global marketplace. Public and private health care spending continues to rise because of several key factors: (1) increased utilization of new and existing medical technology; (2) lack of reliable comparative information on medical outcomes, quality of care, and cost; and (3) increased prevalence of risk factors such as obesity that can lead to expensive chronic conditions. Addressing health care costs and demographics—and their interaction—will be a major societal challenge.

Rethinking patterns of utilization. Developing comparative effectiveness. Promoting wellness, controlling obesity and managing related diseases. Sounds like an agenda. And from all accounts, Senate Finance is listening.

QUALITY: "Improving Care for Chronic Conditions" Event

Tom Emswiler — Tue, 01 Apr 2008 16:12:00 -0400

People are not getting the health care they need in America. They aren’t getting enough of the treatments that we know work and they may be getting too much of treatments with questionable value. This problem and how to resolve it is at the heart of reforming our health care delivery system, which is why we were glad it came up at last Friday's Alliance for Health Reform briefing on the topic of "Improving Care for Chronic Conditions."

Nora Super from Kaiser Permanente zeroed in on this issue after listening to Harvard's David Cutler present his last slide: "Implications: Under-utilization of effective, cost-efficient therapies continues to be a major public health challenge." She asked Dr. Cutler if he would agree that many patients are receiving unnecessary treatments, and more robust comparative effectiveness research is needed to examine what is over-utilized and what is under-utilized.

Dr. Cutler had a very thoughtful answer: "It is the great irony of American health care" that we provide too little preventative and chronic disease care, but when a complication occurs many individuals end up receiving too much acute care. He also said that all the studies he's aware of conclude that more chronic and preventative care and less acute care would save the U.S. money and result in more health. (the Alliance is examining the topic this Friday).

This was especially interesting to me as last week Paul Testa and I were discussing his great blog post on the health care "Starting Nine" which cites a disturbing statistic that we are providing only about half of needed care (according to Steven Asch, Elizabeth McGlynn and colleagues at RAND). This is confusing given another well-respected statistic from the Dartmouth Atlast Project cited in Shannon Brownlee's book Overtreated: we are getting too much. As Dr. Cutler explained, this apparent conflict is the difference in measuring preventative/chronic care versus acute care.

We were pleased that Claudia Williams of the Markle Foundation asked the natural follow-up question about how to change this too much-too little trend. She asked about how to build patient behavior change into care by altering payment structures and organization delivery models.

Dr. Cutler, again, had a thoughtful response: simply explaining what is best for a person's health won't work, and we have to find something closer to a default option for staying healthy. He mentioned the success of auto-enrolling new workers in a company's 401(k). For me, the new Healthways headquarters comes to mind: employees will be encouraged not only to take the stairs, but also decorate them with their diplomas and family pictures.

At the New America Foundation, we acknowledge and are grateful to the states and organizations that are offering real incentives for people to seek preventative care, implementing the concept of the "health home" to encourage primary care physicians to coordinate patient care, and reducing costs by managing patients' treatment of chronic diseases.

Although better ideas/systems will come along (we hope), two things are worth considering when it comes to increasing patient behavior: motivational interviewing and the American Academy of Family Physicians' "Five Tips for Generating Patient Satisfaction and Compliance." Also, during our Hill Physicians site visit (our case study will come out this spring), they shared their research on the topic; they've found that expectation of success is a huge factor in determining actual success.

In addition to Dr. Cutler, the Alliance event included Robert Greczyn from Blue Cross and Blue Shield of North Carolina, Kenneth Thorpe of Emory and the Partnership to Fight Chronic Disease, and was moderated by Ed Howard from the Alliance.

Utilization

COST: GAO Joins the "We Can't Go On Like This" Health Care Spending Choir

QUALITY: "Improving Care for Chronic Conditions" Event