4 ms·

As I mentioned to Raiyner, you should really read Tim Faust’s book to understand how single-payer can drive down costs, but I’ll highlight this from one of his

As I mentioned to Raiyner, you should really read Tim Faust’s book to understand how single-payer can drive down costs, but I’ll highlight this from one of his articles: “ As the sole purchaser, the federal government is immediately able to set just prices for health care services (for example, by negotiating the cost of drugs). With the weight of the full cost of health care falling squarely on its shoulders, it has an incentive to develop infrastructure and provide accessible primary care for all people, diverting money from low-frequency crisis care to high-frequency primary and preventive medicine. It can also create evidence-driven guidelines for how to handle episodes of complex care and adjust payments based on adherence to these guidelines. This promotes good care for all patients and respects providers’ agency to provide the best care they can, instead of the current mess, where payment per-service can incentivize unscrupulous providers to bilk payers by either ratcheting up individual unnecessary services (when paid per-service) or providing less care (when paid per-patient).” https://www.jacobinmag.com/2017/10/single-payer-medicare-for-all-bernie-sanders https://www.jacobinmag.com/2017/10/single-payer-medicare-for...

tptacek 7y ago
I'm very familiar with this argument, but it's unpersuasive, because we already have a national health insurance system for the (huge) most expensive cohort of Americans, and it has been unable to contain these costs, despite playing a powerful role in the structure of the system itself. Why aren't private health insurance systems incentivized to create evidence-based care plans? Wouldn't they, if anything, be more incentivized to do that?
- claudeganon 7y ago
  If you’re referring to Medicare, it does control costs through its fee schedule, but is limited in efficacy because it doesn’t cover everyone. Nevertheless, the Trump administration is currently trying to jack up how much it pays out to non-Medicare levels to prevent even this downward pressure. And of course it’s barred from negotiating drug prices for the same reasons. As to why insurance companies don’t pursue evidence-based treatment plans, it’s cheaper and easier in the US to just deny care and profit from it. Why do something more difficult, requiring additional investment, when they can just deny more claims. ACA plans already deny 1 in 5 claims.
  - tptacek 7y ago
    Wait, Medicare covers the most expensive cohort of patients in the country, which you'll easily see in any breakdown of health costs by age. It already has responsibility and authority for prices in the most important segment of the market. Why hasn't it controlled their costs? I think your answer on evidence-based care is superficial and a little bit facile. For instance, a major component of evidence based care is in fact the denial of procedures with limited demonstrated efficacy; see, for instance, the story about cardiac stents for otherwise stable patients. If anything, both private insurance and Medicare are allowing too many of these kinds of procedures. Why?
    - claudeganon 7y ago
      Hasn’t done what? Apologies, you’ll have to elaborate. Medicare fee schedules do put downward pressure on costs, which is why they’re under attack, but lack sufficient power to push down prices because they are not universal and exclude drug costs. Japan has universal price controls (and cheaper healthcare) for precisely these reasons. As to your second question, fee for service is too perverse of an incentive. What you end up with is an arms race where healthcare providers try to extract as much value as possible through as many procedures as possible and healthcare providers, in turn, try to make money by denying as much as possible (as well as pushing sick people into the government plans). The result is poor quality, expensive care, as the two factions devote more and more resources to waging this battle and less and less on creating good quality and affordable care.
      - tptacek 7y ago
        What does universality have to do with it? They already cover virtually everyone in the most expensive segments of the market. They're not controlling costs for those patients; Medicare overpays, hugely, both compared to other countries and in historical terms (costs have skyrocketed over the last 20 years). I think the burden of proof is on you for this argument. "Excluding drug costs" can't be the problem, because drugs --- no matter what their provenance --- are a small fraction of total health care costs. Your response to my second question doesn't respond to my point. I was specific. You've responded with abstractions. Can you be more specific about what you meant by evidence-based care, and Medicare's unique ability to provide it?
rayiner 7y ago
These are just general concepts. It’s on the same level as “the market will drive down prices because hospitals and insurers will compete.” What I’m talking about is actual data about what is entailed, for example in “bilk[ing] payers.”
- claudeganon 7y ago
  Then see thaumaturgy’s comment above about how suppliers and insurances do this in the current system.

tptacek 7y ago

I'm very familiar with this argument, but it's unpersuasive, because we already have a national health insurance system for the (huge) most expensive cohort of Americans, and it has been unable to contain these costs, despite playing a powerful role in the structure of the system itself. Why aren't private health insurance systems incentivized to create evidence-based care plans? Wouldn't they, if anything, be more incentivized to do that?

claudeganon 7y ago
If you’re referring to Medicare, it does control costs through its fee schedule, but is limited in efficacy because it doesn’t cover everyone. Nevertheless, the Trump administration is currently trying to jack up how much it pays out to non-Medicare levels to prevent even this downward pressure. And of course it’s barred from negotiating drug prices for the same reasons. As to why insurance companies don’t pursue evidence-based treatment plans, it’s cheaper and easier in the US to just deny care and profit from it. Why do something more difficult, requiring additional investment, when they can just deny more claims. ACA plans already deny 1 in 5 claims.
- tptacek 7y ago
  Wait, Medicare covers the most expensive cohort of patients in the country, which you'll easily see in any breakdown of health costs by age. It already has responsibility and authority for prices in the most important segment of the market. Why hasn't it controlled their costs? I think your answer on evidence-based care is superficial and a little bit facile. For instance, a major component of evidence based care is in fact the denial of procedures with limited demonstrated efficacy; see, for instance, the story about cardiac stents for otherwise stable patients. If anything, both private insurance and Medicare are allowing too many of these kinds of procedures. Why?
  - claudeganon 7y ago
    Hasn’t done what? Apologies, you’ll have to elaborate. Medicare fee schedules do put downward pressure on costs, which is why they’re under attack, but lack sufficient power to push down prices because they are not universal and exclude drug costs. Japan has universal price controls (and cheaper healthcare) for precisely these reasons. As to your second question, fee for service is too perverse of an incentive. What you end up with is an arms race where healthcare providers try to extract as much value as possible through as many procedures as possible and healthcare providers, in turn, try to make money by denying as much as possible (as well as pushing sick people into the government plans). The result is poor quality, expensive care, as the two factions devote more and more resources to waging this battle and less and less on creating good quality and affordable care.
    - tptacek 7y ago
      What does universality have to do with it? They already cover virtually everyone in the most expensive segments of the market. They're not controlling costs for those patients; Medicare overpays, hugely, both compared to other countries and in historical terms (costs have skyrocketed over the last 20 years). I think the burden of proof is on you for this argument. "Excluding drug costs" can't be the problem, because drugs --- no matter what their provenance --- are a small fraction of total health care costs. Your response to my second question doesn't respond to my point. I was specific. You've responded with abstractions. Can you be more specific about what you meant by evidence-based care, and Medicare's unique ability to provide it?

rayiner 7y ago

These are just general concepts. It’s on the same level as “the market will drive down prices because hospitals and insurers will compete.” What I’m talking about is actual data about what is entailed, for example in “bilk[ing] payers.”

claudeganon 7y ago
Then see thaumaturgy’s comment above about how suppliers and insurances do this in the current system.