Managed Care - May 2008 - (Page 24) That kind of growth rate is attributable to an underlying philosophy Reinhardt sees at work in health care. Providers are given a green light to do really whatever they want to do. Manufacturers can make and sell anything they want, for whatever price it can fetch. “You do whatever you think is right,” Reinhardt summarizes the message to providers. “You’re great and the best in the world. Just give us the bill. That kind of attitude seems to be shifting ever so gradually, ever so glacially.” Reinhardt also warns of some “nasty” things going on in the economy today, primarily a surge in gas and food prices eating into the family budgets of the lower third of the population. Once the lower middle class is priced out of health care, he says, the issue becomes unavoidable. “It has to get big,” says Reinhardt. “I don’t think compassion will drive this debate.” — can afford all the care they need. Most companies that offer insurance continue to do so, while many new companies won’t ever offer it. A host of reformers, including presidential candidates, offer fine ideas for health care change. Ginsburg is skeptical that any will drive a fundamental reordering of the system. “We have some good ideas,” says Ginsburg, “but none of them can confidently say they will have a big effect on cost — not to say they’re not worth pursuing. People have vague ideas of the directions ahead, but there is no magic bullet out there. Maybe two years from now we’ll have a better sense of more striking steps that might take place.” It won’t be easy — which is part of the problem. “Managed care has really backed away from doing any serious managed care,” says Altman. “In much of this latest decade, it’s been managed care ‘lite.’ And some would say we’ve gone back to fee-for-service inLearning how to say ‘no’ surance with little bells and whistles There has been some easing in the wrapped around it. Insurers found it easier growth of particular spending categories. to let doctors and hospitals do what they Ginsburg and Wilensky both note that “Beats me,” says want, which may sound a little cynical.” CMS has reported a significant dip in drug Gail Wilensky, when Ginsburg says that few politicians are respending. “The biggest factor behind those asked when she thinks Medicare and lower trends is major blockbusters coming other payers will take ally willing to talk about costs. “It may be painful to address costs, and they’re still off patent, combined with the absence of the time to investinew blockbuster drugs,” says Ginsburg. gate the value of care telling us they have painless solutions — information technology and effectiveness reBiotech drugs may drive that up, he adds, that’s given. search,” says Ginsburg. “I don’t know how but biologics serve smaller populations, and much longer it will be before we contemplate steps steep new copayment requirements in tiers 4 and that make people unhappy. It’s one thing to conduct 5 “will constrain the use of the drugs.” effectiveness research, another to use it.” CMS isn’t projecting anything other than a temEventually, we’ll be distinguishing between what porary dip in the rate of growth of drug spending. has benefit or marginal benefit. And then comes reThe nation’s drug bill hit $231.3 billion last year and fusal to pay for services that don’t measure up. will more than double to $515.7 billion in 2017. Says Ginsburg: “We’ll be saying ‘no’ more often.” The biggest constraint on cost growth has been a shift of some of the health care bill from employers to individuals. But then another big trend Price control v. reform kicks in — as spending grows faster than income, “No” is exactly what regulators in the United more and more people can’t keep up. “You have inKingdom say regularly. In April, for example, anacreasing erosion of private coverage,” Ginsburg lysts at the National Institute for Health and Clinsays. “Some people just can’t afford it.” ical Excellence concluded that Tarceva — which So the same economic forces remain at work. boasts of greater tolerability for patients — wasn’t Employers, he says, are likely to maintain the same cost-effective at the manufacturer’s price of $3,224 percentage split on a bill that keeps swelling, maka month. ing it less and less likely that individuals — most of That decision wasn’t welcome by cancer groups whom can look forward to stagnant wage growth in the U.K., and you won’t find many advocates for 24 MANAGED CARE / MAY 2008
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