The Revolution in Health Care Is in Delivery : Reform: Managed care is the future and the signs look good, but government and media must remain vigilant on quality.
Over the next few months, the health-reform agenda for Congress will begin to come into focus. While comprehensive federal reform is now highly unlikely, there is a revolution under way in the practice of medicine in many parts of our country that is profound and probably unstoppable. The challenge ahead for government will be to decide when to step in and set the ground rules, and when to stay out and let the market do its thing.
Large managed-care plans in such disparate places as Southern California, Georgia and New York are now delivering care with vastly fewer hospital days, visits to specialists and diagnostic tests than the national averages for similar populations. Just one example: In the United States as a whole, commercially insured populations average just under 500 hospital days for every 1,000 people; for some managed-care plans in Southern California, the average is under 150 hospital days per 1,000 enrollees. The differences for older people on Medicare are equally startling: 2,900 hospital days per 1,000 across the United States, as compared with less than 1,000 hospital days for some of these plans. It’s a harbinger of the future and at least on the surface it appears to be getting results. Premium costs per member per month are way down in these plans.
Are these dramatic reductions in hospital care good or bad? Do they really save money or just skim healthier patients or shift costs to ambulatory care? Are people getting the care they need? The truth is that we don’t know, and we have not really taken the steps necessary to find out. What some see as better coordinated, more cost-effective care, others see as “cook book” medicine and profiteering at the expense of sick people.
The year ahead will see a fierce debate in Congress about taking savings from Medicare and Medicaid to reduce the federal deficit. We will see the return of the health-reform debate, most likely in the form of incremental rather than sweeping proposals. And we will see an intensifying struggle between the states and the federal government about state health reform, with the states demanding federal financial participation in their reform programs and increased flexibility to carry them out. Those policy debates will dominate the attention of government and the media, but the changes occurring in health delivery deserve equal attention.
Just as the national health-reform debate was covered by the media as a political rather than a people story, coverage of the changing health-care marketplace is usually left to the business pages, where stories emphasize the implications of mergers and acquisitions for investors. Much greater attention needs to be given by the media to how the changes occurring in the health delivery system are affecting people.
Congress and state governments need to begin to resolve a long list of tough questions. Do we want the nonprofit orientation of our health-care system replaced by an increasingly concentrated for-profit sector? Should managed-care plans be able to pick and choose only the doctors they feel provide the most cost-effective care, or should all qualified doctors be assured the right to practice in the plans of their choice? Should government require benefits to be standardized, so consumers can compare apples to apples when they buy? Should government require that employers offer their employees multiple choices, and should there always be a fee-for-service choice? Should big city public hospitals, community clinics and other nonprofits be afforded special protections so they won’t lose out in the market shuffle? Should managed-care plans be required to take their fair share of the poor, the uninsured and the higher-cost chronically ill? The questions are big ones that we have barely begun to confront.
There is much that is good in the changing health system, including the potential for delivering much more cost-effective care. But there is also a need for government and the media to be the watchdog when the market goes wrong. Many elected officials felt they dodged a bullet when comprehensive reform died, but if the majority of Americans end up with a system that seems to them inflexible and unfair, there will be a political price to pay for those who failed to serve as their watchdogs.
