NEJM’s Fundamentals of U.S. Health Policy, Part 3: Do We Spend Too Much?

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This next part in The New England Journal of Medicine’s fundamentals of health policy series is written by my favorite health policy writing duo–Drs. Baicker and Chandra. They both do amazing research independently, but when they work together to write an article, it seems to be extra insightful and interesting.

Their task with this article is to help people think deeper than the simplistic sentiment, “The U.S. spends way more than every other country on healthcare; we need to cut back, and any increase in spending is wasteful!”

Key insight: Only looking at the aggregate number obscures many important facts about our healthcare spending; digging a little deeper totally changes the conversation.

Here are my favorite examples of this from their article:

  • As nations grow richer, they spend more on healthcare. So, based on that alone, the U.S. would be expected to spend more than nearly every other country. Of course, this doesn’t explain all the difference between our spending compared to other countries, but it explains a lot of it, and it’s not a bad thing. A related side point they make about this is that it “highlights the challenge of putting all Americans, with very disparate incomes, into a single insurance plan.”
  • Studies that conclude our higher spending is purely due to higher prices (rather than higher quantity) aren’t able to account for all the inter-country differences in quality or intensity of care. This one was news to me, and you’ll see in my prior writings that I didn’t know this. You see, I thought that if a study shows that we generally have the same number of hospitalizations, doctor visits, prescriptions, imaging studies, etc., they would have controlled for differences in what kind of doctor visits (primary care vs. specialist) and scans (a 0.5-Tesla MRI vs. a 3-Tesla MRI) and such were being delivered. But that’s wrong–researchers don’t always have the data they would need to be able to do that. This means we need to look closer at exactly what we’re getting when we are paying a higher price than other nations, which will help us distinguish if it’s just plain overpriced in the U.S. or if it’s a substantially better service.
  • If we look at specific health outcome domains, we find out that we overspend on some of them and actually underspend on others. This means that sometimes increasing spending is actually a good thing, like for vaccines or other preventive care. When we look at spending this way, we can start to evaluate whether reforms’ spending impacts are effective not based on whether they increase or decrease aggregate spending, but instead we can base our assessments on how well they do at reducing overspending on the low-value care and increasing spending on the high-value care.

I hope that helps you think a little differently about (i.e., be a little more critical of) aggregate health spending references like it did for me.

And, to close, here’s a thought-provoking statement they drop in the middle of their article: “The debate about whether health care is a right sidesteps the more difficult and important question of how much health care is a right that should be ensured through public programs.”

2 thoughts on “NEJM’s Fundamentals of U.S. Health Policy, Part 3: Do We Spend Too Much?”

  1. Dr. Christensen, I love your posts. And thanks for featuring this series from NEJM! Their claim — that some services have higher value than others — was the central thesis of my own blog, FixUSHealthcare.blog. My blog has highlighted the Oregon Health Plan of 1994, which used cost-benefit analysis to guide public policy in a tight-budget atmosphere. I will point out that Gov. John Kitzhaber (M.D.) began this plan as a purely economic project, but soon encountered the political reality that citizens assigned some values based on non-monetary (ethical, social) criteria! I invite you and your followers to check out: http://fixushealthcare.blog/2017/10/24/segment-9-the-big-fix/ and http://fixushealthcare.blog/2018/01/03/the-problem-of-diminishing-marginal-benefit-in-healthcare/

  2. Reblogged this on Fixing U.S. Healthcare and commented:
    Dr. Christensen, I love your posts. And thanks for featuring this series from NEJM! Their claim — that some services have higher value than others — was the central thesis of my own blog, FixUSHealthcare.blog. My blog has highlighted the Oregon Health Plan of 1994, which used cost-benefit analysis to guide public policy in a tight-budget atmosphere. I will point out that Gov. John Kitzhaber (M.D.) began this plan as a purely economic project, but soon encountered the political reality that citizens assigned some values based on non-monetary (ethical, social) criteria! I invite you and your followers to check out: http://fixushealthcare.blog/2017/10/24/segment-9-the-big-fix/ and http://fixushealthcare.blog/2018/01/03/the-problem-of-diminishing-marginal-benefit-in-healthcare/

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