Managed Care - May 2008 - (Page 26) “I don’t have to name England,” he adds. “We support a massive improvement in quality and efficiency, universal coverage, and cost containment. Our strategy includes budgeting and rate setting mechanisms, the same as many other countries.” Cockeyed optimism? Some of the trendiest new methods for controlling health care costs are likely to inspire mirth among economists. “Wellness programs are not real,” chuckles Altman. He had hoped that disease management would work, and it may yet, “but unfortunately the evidence isn’t very supportive. There’s very little evidence that disease management justifies its cost.” If you avoid giving the government power over what will be paid for, there are still plenty of advocates for arming up with a range of weapons. “I believe that the solution to the rates of growth we see in health care requires a whole armamentarium of tactics and strategies,” says Weems, the acting CMS administrator, “including good disease management programs, including aligning incentives, and including bringing health care into a more market-oriented kind of a program.” Part of what makes Weems and others optimistic that something significant can be done comes from clear signs that health care costs in the U.S. vary widely by region, without any statistically significant variations in health care outcomes. If Americans in one area can enjoy lower cost care without worse health, applying that approach nationwide would help manage spending. “If patients lived in northern New Jersey, Medicare was two to three times as much as similar patients living in the southern part of New Jersey,” says Reinhardt. “And Congress has said we don’t For further reading want to tell you how to practice medicine, we Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, just want to regulate the price.” stupid: Why the United States is so different from other counReinhardt also points out that there’s a huge tries. Health Affairs. 2003;22(3):89–105. amount of waste built into the system, with a Draper DA, Ginsburg PB. Health care cost and access challenges persplintered group of private and public payers sist: Initial findings from HSC’s 2007 site visits. Issue Brief Cent Stud Health Syst Change. 2007;Oct(114):1-6. spending far too much money pushing paper. Emanuel EJ. The cost-coverage trade-off: “It’s health care costs, stuIn Taiwan, he says, health care spending can be pid.” JAMA. 299;8:947–949. tracked patient by patient, in real time, through Keehan S, Sisko A, Truffer C, Smith S, et al. Health spending projections through 2017: The baby-boom generation is coming to very efficient technology. Medicare. Health Aff, 27;2: w145–w155. “We’re not locked in,” says Weems. All those Reinhardt UE, Hussey PS, Anderson GF. U.S. health care spending in various management tools “hold the promise of an international context. Health Aff. 2004;23(3):10–25. being able to reduce the growth of health care spending. That’s why we have tried disease management and are trying electronic health records. It’s important to find the things that work and the things that don’t work.” “Saying it can’t be done is to doom ourselves,” says Wilensky. More money isn’t the answer, either. “When people say, here’s a new revenue strategy, I just cringe,” she adds. “If we put more money in the system we know what will happen — we’ll just kick the ball further down the road.” The way the system works now, there’s really often little data to determine the value of the care we receive. “There was a piece on the front page of the New York Times last fall about how ablation therapy is now a favored procedure for atrial fibrillation, and two thirds through, there was the comment that it’s not clear what ablation therapy does relative to more conservative medical treatment — warfarin,” says Wilensky. “My thought was that Medicare might want to invest a little money to find out.” Getting rewards from value-based medicine, or any new strategy, though, takes years to build. “We need to get going.” When will that happen? “Beats me,” answers Wilensky. “I would have thought it would have happened a long time ago.” There are no guarantees that any fundamental change in spending patterns will happen anytime soon. There’s little doubt that the debate over dealing with it is far from over. Says Wilensky: “These are not issues that are going away.” The numbers won’t allow it. MC 26 MANAGED CARE / MAY 2008
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