Whether paid directly by patients or by some third party entity (an insurance company, a government agency, etc.), American health care providers are typically paid on a fee-for-service basis (i.e. on a discrete/piecework basis: tests given, office visits, devices provided, etc.).
This method of payment, it is claimed, fails to hold providers accountable for the outcomes of the services or goods provided. Thus, some (perhaps many) individual services—when evaluated in terms of the results achieved—may be found to be ineffective, wasteful, perhaps even harmful.
More to the point, the “fee for service” method of payment, based as it is on medical inputs (as opposed to outputs) encourages medical providers to order unnecessary tests, to prescribe frivolous treatments and the like: that it is an uneconomical system fraught with perverse incentives that reward imprudence and, as noted, shield providers from accountability for the results achieved.
Such, at least are the arguments now being popularized by numerous critics, health care economists especially. Moreover, these concerns have been instantiated in a federally created and federally funded non-profit corporation known as the Patient Centered Research Institute (PCORI).
The purpose of the Institute is to assist “…patients, clinicians … and policy makers in making informed health decisions by advancing the quality and relevance concerning the manner in which diseases … can effectively… be prevented…” It is further charged with “research evaluating and comparing health outcomes and the clinical effectiveness, risks and benefits of … medical treatments [and] services…”
Currently, PCORI is funding 50 pilot projects (one in Minnesota) that will set the stage for its future research agenda.
Predictably, PCORI’s ultimate aim, like ObamaCare’s Independent Payment Advisory Board (IPAB) (which, for the moment at least, is focused on controlling Medicare and Medicaid costs) is to reduce costs in the American health care system by identifying the relative effectiveness of various treatment options, steering medical resources toward those clinical centers and specific clinical interventions that achieve the “best results.”
ObamaCare’s Accountable Care Organizations (ACO’s) will, it seems, be among the first health care entities to replace “volume-based payment systems” with outcome-based reimbursements.
Sounds good, doesn’t it? Who could seriously object to a health care payment system focused on effectiveness of outcomes rather than on a potpourri of tests, drugs, prosthetic devices, etc. Or object to medical research, the avowed purpose of which is to weigh the relative costs and benefits of various treatment options?
Many people, health care “experts” especially, would, of course, contend that no reasonable person could answer these questions in the negative. On the contrary, I think that reasonable people both could and should object to—or at least critically challenge—the claims and arguments of those who tout the presumed benefits of outcome based medicine.
But now that I have thrown down the gauntlet, I must now take up the challenge. So why, then, do I think that we should be wary of the promises made on behalf of outcome-based health care (OBHC)?
Interestingly, my first concern in this regard has little to do with OBHC as such. I am concerned, rather, with the ideology that, so far as I can tell, motivates the creation of entities such as PCORI and IPAB, namely the implied assumption that medical treatment decisions should be subject to bureaucratic oversight, perhaps (probably?) even heavy-handed regulation.
There is, it seems, a deep-seated suspicion of what many “experts” take to be a disjointed, haphazard and inefficient use of health care resources. Or, as one bioethicist has put it, it is, arguably, the old human desire to eliminate whatever is perceived to be random behavior, erratic activity or unnecessary error. Or, to put it bluntly, it is assumed that medical professionals do not have the benefit of, or are largely ignorant of, “best practices” (i.e.state of the art treatment options).
The solution, then, is seen as an increasingly centralized approach to medical research and a kind of cookbook medicine that shifts decision making more and more away from the physician-patient setting to various third party entities. Something that could best be described as Managed Care Writ Large.
All of which, in turn, poses another question:
What, exactly, is the desired outcome of any medical treatment or series of treatments? Is it full recovery, a complete cure? Ideally, yes.
But what if full recovery is not possible or, as in the instances of many diseases, is problematic (e.g. it often takes years to know whether or not a patient has been cured of cancer)? Or what of terminally ill patients? Success in controlling pain? Number of months or years of added life? Or what if an “approved” treatment option fails because of some extraneous factor (e.g. because of some previously undiagnosed condition)? And, of course, the fact that, the best of medical treatments notwithstanding, there is an eventual, inevitable outcome, namely Death.
This is not to argue, of course, that the work of agencies such as PCORI is inherently mischievous. It is to argue, however, that it is inherently difficult to coherently describe, much less predict and evaluate the outcomes of any medical treatment. Any attempt to do so will, I think, end in a morass of oppressive and counter-efficient regulations and confusion. It is also likely to discourage innovation and risk and, in doing so, to frustrate, not facilitate, medical progress.
Questions of centralization, suffocating regulation and stagnation are, taken alone, sufficient to raise concerns as to the wisdom or practicability of OBHC. There remains, however, a much deeper, fundamental issue, specifically a utilitarian ethos that strikes at the heart of traditional Western Hippocratic medicine. This assertion will, of course, raise a few hackles: it is, in fact, intended to do so.
In evidence I offer, then, a recent American Medical Association Journal (JAMA) article entitled “Toward an Outcomes Based Health Care System: A View From the United Kingdom.” According to this article (written by two British physicians): “The core purpose of a health care system should be to maximize the health of the population. When the main challenge is managing long term conditions, maintaining health rather than delivering health care per se should be the goal.”
Is it my fevered imagination? Or do these words call to mind that very real, well known and problematic, even foreboding utilitarian maxim: the greatest good for the greatest number?
You decide. But before you do, consider the words of the JAMA article: “in a comprehensive publicly funded system like the…National Health Service there is an overriding imperative to deliver maximum health benefit per pound spent. Quality, effectiveness and efficiency are the goals.
Traditionally, physicians and other health care professionals have regarded financial efficiency as outside the scope of their professionalism (indeed often at odds with it).
The concept of value—useful health outputs divided by the resources needed to achieve them… is relatively new and unfamiliar to many clinicians. However, the need to achieve more with less puts the need to strive for value into sharp focus… Striving for value therefore becomes an ethical imperative…”
Once again, it sounds good, doesn’t it? Who doesn’t want to get the most health bang for the buck (or the pound)? But note that the cost-benefit policies advocated here—as our British friends themselves concede—are at odds with the traditional practice of medicine.
Health care professionals are not, and should not be turned into utilitarian “bean counters.”
Making them such (as the advocates of OBHC seem to want to do) is an open invitation to utilitarian health care, to an ideology that opens the door to a new form of unjust discrimination, discrimination that should be of concern to those whose lives and health may not measure up to the “new” medicine’s cost-benefit criteria.
Sorry grandma. Fixing your hip is not cost efficient. Greatest good for the greatest number and all that, you know.
—Thomas St Martin, Woodbury
P.S. I read recently that the Obama administration is encountering difficulty in finding persons willing to serve on the Independent Payment Advisory Board. Several prospective candidates it was said have declined to serve. Were they were overwhelmed by the scope of the task involved or did they want no part of a bureaucratic health care rationing scheme?