One of the main reasons people are pushing for a single-payer system in the U.S. (termed “Medicare for All” these days) is to achieve universal access to insurance coverage. But what about its impact on total healthcare spending? This is how I think about that question.
First, remember that there are two aspects of spending that we need to be thinking about. The level of spending is how much we’re currently spending, and the trend of spending is how much that amount is increasing over time.
Level of Spending. Even though a single-payer system will increase the number of people with insurance, it’s possible it could still reduce the level of spending overall (although estimates vary widely). How could it save money? The overall cost to administer health insurance would probably go down simply due to sheer economies of scale (of course, this is debated too). Plus, the amount of advertising done by a single government-run insurer will be less than the amount currently being spent by private insurance companies. Single payer allows greater price control as well, so that could be a huge savings (although, if it means paying all providers current Medicare rates, that could be catastrophic).
Trend of Spending. Healthcare spending continues to increase faster than inflation, mostly due to medical innovation, rising prices, and an older and sicker population. Would single payer affect our trend of spending? Well, sort of. It can refuse to increase prices, which is a very tempting spending reduction mechanism that our government has tried in healthcare before (ahem, SGR). But with the relative administrative simplicity single payer would bring to providers, there would be at least some wiggle room for price reductions. Or it could refuse to cover low-yield or really expensive drugs and treatments (rationing), which we generally don’t take well to in this country. Unfortunately, there just aren’t a lot of effective ways single payer can directly impact the trend of spending, which is ultimately the most important one.
I know I’m leaving out lots of other impacts Medicare for All would have on the level and trend of spending, but I think I’ve covered most of the major ones.
So does this mean we are doomed then? Even if we get universal coverage, there’s no way to avoid total fiscal collapse secondary to runaway healthcare spending? No! Implemented correctly, single payer could do a great job helping to avoid many episodes of care, and it could also enable the costs of delivering the care that cannot be avoided to go down immensely. I’ve explained how already.
So let’s just keep all this in mind as Medicare for All is being debated. People can quibble about the projected savings/costs and various other numbers all day long, but the important part in the long run is how it’s implemented.
I strongly believe that getting people the information and incentives necessary to choose higher-value providers and insurers is the solution to improving value in healthcare (see my Healthcare Incentives Framework). But, you say, we’ve tried that and it doesn’t work, and current efforts are a waste of time!
Here’s an example of some great research that you might use to support your opinion:
The news media would see this and report the main findings–that only 3% of enrollees used Aetna’s price comparison tool–and argue that even people who have the opportunity to shop for care will not do it, which they will interpret to mean any “consumer-driven” healthcare effort is proven through evidence not to work. People can wrest information to prove whatever they want.
But what if you actually read the study?
Sinaiko and Rosenthal found that only about 60% of enrollees even had a claim during their study period. And of those 60%, I’m guessing a large percentage of those were outpatient visits (primary care or specialty) with established providers, which are claim types that people historically do not shop for. Think about it, if you have your favorite hairdresser who knows you best, you have a relationship with that person, and you like how they cut your hair, are you going to price shop every single time you need to get your hair cut?
Now take out all the non-shoppable services (the subject of a future post), and we’re left with a relatively small percentage of enrollees who may have actually had a reason to shop for care. But, wait, what about the people whose insurance plan required them to pay the same amount regardless of which provider they chose? (Remember, people need an incentive to choose higher-value options.) I wish I had the numbers to know what percent of enrollees would be left after all those exclusions. 30%? 10%? Those enrollees would be the target audience who we want to use the price comparison tool.
I assume Aetna did a good job notifying people about this price comparison tool, so maybe 75% of people read the mailer and then half of them remembered it when it came time to shop for care. Why only half? Because people aren’t yet accustomed to shopping around for value in healthcare. They’re used to going to the lab their doctor tells them to go to, for example. It doesn’t even cross their mind that there are cheaper options out there. I think there’s also an assumption that you have to go where your doctor tells you to otherwise your doctor can’t get the results. Thanks, non-interoperable EMRs.
So what are we left with? 3% of enrollees seems about right.
What about shoppable services, specifically? Considering all the factors above, the percent of people getting those services who actually shopped first blew me away. Tonsillectomy: 54%. Total knee replacement: 48%. Inguinal hernia repair: 27%. Cararact or lens procedure: 18%. Vaginal delivery or C section: 16%. Carpal tunnel release: 12%. These lower-percentage ones strike me as the ones that would more commonly be performed by a doctor you’re already established with (again, making you less likely to shop around), but I could be wrong here.
Anyway, you know what this proves to me? That price comparison tools can work! And I believe they will be used more and more as people start getting insurance plans that require them to pay more for more expensive options, and as they remember they can shop for price. The younger generation will probably drive a lot of this because they will be more used to using these tools and shopping for care and will eventually get older and start needing more services.
This study supports what I’ve written above. Here are some takeaways from it. It’s looking specifically at people who have the type of insurance plans that would give them an incentive to compare prices:
72% of people think it’s really important to shop for value in healthcare
93% of people know prices vary greatly among providers
Only 22% of people think higher prices in healthcare equate to better quality
75% of people said they don’t know of a resource they can use to compare costs among providers
77% of people who didn’t price shop for their last healthcare service said it was because they were seeing a provider with whom they were already established
Only 1% said they didn’t shop because it was emergency care
One of my favorite things is exhaustive, mutually exclusive categorizations. This was true of me even as a teenager, I just didn’t recognize it yet. So when I was taught about different types of governments in my Canadian high school social studies class (democracy, parliamentary system, capitalism, socialism, fascism, communism, etc.), it really bothered me that I couldn’t plot them all on a spectrum to compare them. Many years later, I think I’ve solved this conundrum. I have identified 5 spectra governments can be plotted on, and the best part is that they are exhaustive and mutually exclusive:
1. Political spectrum: Who makes the laws
(autocracy/single person <—-> democracy/everyone)
2. Legal spectrum: How much the laws are spelled out beforehand
(rule of man <—-> rule of law)
3. Economic spectrum: Locus of decision making about the distribution and use of resources
(planned economy/centralized <—-> capitalism/decentralized)
4. Welfare spectrum: Degree of wealth redistribution
(zero <—-> full)
5. Liberty spectrum: Degree of freedom of speech, religion, relocation, job, drugs, sexuality, etc.
(zero <—-> full)
A few comments on these:
Some of these spectra interact. By this I mean that if a government sits at one end of one spectrum, this affects where it is likely to sit on other spectra. For example, an autocracy is more likely to sit closer to the “zero” side of the liberty spectrum because autocrats often limit liberties to maintain their power.
Most of the general government categorizations we think about are silent regarding multiple spectra. For example, when we think of socialism, we usually only think of two of the spectra: the economic spectrum (government ownership of the means of production, so it’s on the “centralized” side) and the welfare spectrum (lots of wealth redistribution). These two characteristics could be instituted by very different governments and still technically be called socialism, such as by a democracy that has a very well-defined body of laws and a ton of freedom about everything else, or by an autocracy where a dictator rules by the law of himself and allows very few freedoms about most things. It helps me understand different government ideals (such as socialism and fascism) better when I try plotting them on these five spectra to see where they land on the ones they have opinions about and also to see which ones they are silent on.
Much of the confusion that occurs when discussing the merits of different governments comes from confusing/mixing these spectra. When you use a single term to refer to multiple spectra (socialism, communism, fascism, etc.), the different spectra seem to get mixed together and the conversation loses clarity. Someone may be talking about their interest in socialism because they feel that significant wealth redistribution is the morally right thing for a society to do, but they may also believe that capitalism/decentralized is the most efficient way to organize an economy to generate sufficient wealth to be able to carry out that welfare. You have to identify the different spectra individually.
A constitution, when seen in the context of this framework, is simply a document that provides hard end points for how far a government can shift toward one end or the other of these five spectra.
A person’s ideas about how to fix healthcare are inseparable from their opinions about government more generally, so our conversations about both will be more productive when we communicate clearly which spectrum we are talking about.
My wife is a runner and recently improved her running form to avoid injury. Unfortunately, forefoot strikes were new for her feet, and she was going too fast and too far for her anatomy to respond appropriately. During runs, she began having forefoot pain, which progressed to hurt even with walking. This is a classic story for a stress fracture, and her workup led to an MRI.
Knowing of massive price variations in healthcare markets, I suggested she call around to shop for the best price. Here’s what she found:
Option A (20 minutes away): $500 self-pay, $850 with insurance
Option B (40 minutes away): $640 self-pay, $920 with insurance
Option C (40 minutes away): $400 self-pay,
Option D (40 minutes away): $400 self-pay,
Option E (20 minutes away): $675 self-pay,
Option F (20 minutes away): $1,480 self-pay, $560 with insurance
After Option B, she stopped writing down prices with insurance because they were always at least a few hundred dollars more than the self-pay price.
The two best options, C or D, were the same price and distance away, so how about comparing quality? Both had nice websites that talked about how well-trained their radiologists are and how great their MRI machines are, but there were no actual details that could help me determine which would be better quality. So we ultimately chose Option C because the person on the phone was the nicest.
What’s with Option F? It was the only hospital-based option we contacted, and it’s part of the same company as my insurance. I guess they give a massive discount for having their insurance. Their self-pay price is typical of what I have come to expect from hospital-based services–always crazy expensive.
The thing I learned from this experience is that, when you self-pay, that means you aren’t running the money you’re spending through insurance, so the $400 we spent on the MRI doesn’t even count toward our annual deductible! Therefore, price-conscious healthcare shoppers who self-pay are getting a short-term deal but may be subject to more than their annual out-of-pocket max if something big comes up later on.
Our insurer wouldn’t even let us submit our receipt after the fact to count that $400 toward our deductible, which makes sense from their perspective. They don’t want us self-paying potentially higher prices than they have contracted for things because it could use up our deductible faster than it would have otherwise, which would mean they’re on the hook for covering more of our costs of care than their actuaries had planned. You’d think they’d at least add a clause to their policies that says that if patients find a lower price than the insurer was able to negotiate, they will accept that self-paid amount as counting toward their deductible. But in a poorly functioning insurance market, insurers are never forced to put in the effort to make reasonable policies like that.
This blog is going to change a little bit, starting today.
Now that I’m finally done all my clinical training and am a fully licensed internal medicine physician and working as a hospitalist, I can start dedicating more regular time to my main passion–health policy. I will be releasing weekly blog posts on Tuesdays (supposedly the day of the week that needs the most morale boosting!). I will avoid any tendency to make these posts too formal, and I will try to keep them short as well.
I have two main reasons for doing this, both of which I would like to be up front about. The first is for me to keep learning. When I write, I’m forced to synthesize my thoughts more deliberately. The second reason is to get more people reading what I write, which will provide me more feedback about my ideas and hopefully (even in a small way) influence greater support for worthwhile policies.
How will regular posts help more people read what I write? My understanding is that a blog needs five things to gain traction: (1) worthwhile material, (2) a dependable timeline for when to expect new posts, (3) persistence in posting that new material regularly for a long time, (4) advertising, and (5) luck. Keeping the same URL helps, too, which I learned the hard way. I will advertise by working to syndicate my posts on other sites, plus sharing on social media.
This is the final installment of the Building a Healthcare System from Scratch series, and it begins with the same caveat as Part 7—to understand the rationale behind the ideas presented, you need to read and understand all the prior parts of the series, beginning at Part 1.
Now that I have explained the Healthcare Incentives Framework (Parts 1 through 6) and described what various types of systems would look like that have implemented the principles of it (Part 7), we are ready to look at something more complex: rather than building an optimal system from scratch, how can this framework be applied to an existing system that needs fixing? The American healthcare system will be a perfect case study for this.
Where it sits right now, the American healthcare system seems to land somewhere in between the libertarian-type system and the single-payer system described in Part 7, except that it fails to implement the majority of the principles of the framework. It is also overly complex, which contributes greatly to its impressive administrative expenses. So what could a much-simplified American healthcare system look like that also maximally implements the principles of this framework? With consideration for and much guessing about Americans’ preferences regarding healthcare, here is an imagined description . . .
The United States eventually chose to strengthen its individual mandate. The government now mandates all people, without exception, to have a healthcare insurance plan that covers all services included on its list of “essential health benefits.” For those who forego insurance coverage, they pay a tax penalty that ends up being nearly the same as the premiums they would have paid. If uninsured individuals receive care that they cannot afford, they usually end up having to either go on long-term repayment plans or declare bankruptcy because there is no bailout available for them.
The website healthcare.gov has become the ultimate source for healthcare insurance shopping. All qualified insurance plans (i.e., plans that cover all the essential health benefits) are listed there, along with their coverage level (according to the metal tiers), prices, and a short description that highlights any other benefits the plan offers that may help prevent healthcare expenditures.
Premium subsidies are available to all whose premiums will exceed a certain percentage of their income, and the subsidy amount is pegged to the second-cheapest qualified insurance plan available to them. The subsidies are automatically applied at the time people are choosing a plan on healthcare.gov. Because this system worked so well and was basically duplicative of Medicare and Medicaid, both programs were slowly phased out, which decreased insurance churn and increased time horizons. However, a vestige of Medicaid remains in that, depending on an individual’s annual income, there are also limits on how much they can be required to pay out of pocket for care.
The government also did away with the employer mandate and somehow found the political willpower to repeal all tax breaks for healthcare expenditures, which eventually led to employers getting out of the business of providing healthcare insurance for their employees and just giving that money to employees directly as regular pay.
Altogether, these changes mean that all Americans shop for their healthcare insurance on healthcare.gov. For anyone who is unable to do this themselves, there is a phone number to call to connect with someone who can assist them in selecting the plan that seems best for them.
A few changes were also made to encourage more insurance options. First, many regulations were eliminated, including the medical loss ratio requirement and state insurance department approvals of rates. These became unnecessary after people began to be able to compare the value of different insurance plans and choose based on that because overpriced or low-value plans (either from too much overhead or too high of rates in general) lost market share and profit. State-specific insurance regulations were standardized so that insurers can easily expand to new markets. And a law was passed requiring transparency of all price agreements between providers and insurers, which made the process of forming contracts with providers in a new region easier. These policies led to almost all markets having multiple options for each coverage tier.
In this way, the United States achieved universal access to affordable healthcare insurance relying on the private market while preserving the ability and incentive for all people to select the highest-value insurance plan for them. As a result, insurance plans aggressively innovate to find ways to prevent care episodes so that they can offer lower premiums and attract higher market share. Insurers also found that implementing differential cost-sharing requirements led people to start choosing lower-priced providers, which also enabled the insurer to lower premiums further. Finding provider prices has become easier ever since the price transparency law was passed.
The government has had to help overcome the problems caused by a multi-payer system by enforcing some standardization, including uniform insurance forms/processes, standardized bundles of care that all insurers in a region either agree or disagree to implement together, and standardized quality metrics that providers are required to report. These quality metrics are not used for bonuses, so they have been changed to be more focused on what patients need to know to choose between providers for specific services.
These quality metrics are now reported on an additional section on healthcare.gov that lists all providers, their quality metrics, and their prices (seen as your expected out-of-pocket cost if you log in) in an easy-to-compare format. Due to patients’ differential cost sharing requirements for most services, as well as broad common knowledge of the existence and utility of this website, most patients have begun to refer to it before choosing providers. This part of healthcare.gov has even been developed into a highly rated smartphone app.
In response to these changes, providers found that their value relative to competitors largely determined their market share and profitability, which unleashed an unsurpassed degree of value-improving innovation. The cost of care in the United States was previously so high that the majority of those initial innovations led to much cheaper care, which led to much lower insurance premiums and eased the premium subsidy burden on the federal government. Thanks to these changes, the federal deficit has begun to sustainably diminish quicker than any budgetary forecasting model could have predicted, which has also helped stabilize the American economy.
There are still barriers to people being able to identify and choose the highest-value insurers and providers. There are many important aspects of quality that are unmeasurable. Many people do not have the health literacy required to figure out which insurance plan or provider would be best for their situation and preferences, despite the ease of comparison enabled by healthcare.gov. There are medical emergencies that do not allow shopping (although the number of these has turned out to be much less than was previously thought because most of what used to present to emergency departments were not actually emergencies).
In spite of these lingering barriers, enough patients are choosing the higher-value options that providers and insurers still have a strong incentive to innovate to improve their value so they can win the market share and profit rewards available to higher-value competitors. And the result is that Americans are being kept healthy more often and are receiving care that is higher quality and more affordable.
That concludes my imagined description of how the American healthcare system could look with the principles from the Healthcare Incentives Framework fully applied. Just as a reminder, it represents merely a guess of how it could end up given the current system. This is by no means the only way to apply the principles of this framework, nor is it my secret idealized version of how it could end up. But I hope it was useful and thought provoking as a case study!
We have come a long way in this series. Throughout it, I worked hard to make the principles of the Healthcare Incentives Framework clear, and I hope the concrete examples have helped solidify those as well as demonstrate their potential for sustainably fixing healthcare systems around the world. If you want a more academic treatment on this framework (at least the part of it that applies specifically to providers), I published that as a medical student.
I intend to help policy makers of all types find ways to apply the principles discussed in this series. Please contact me if you have questions or would like me to help work through potential applications. Contact info is on my About Me and This Blog page. In the meantime, I hope you will follow along as I continue to blog about how to fix our healthcare system!
In Part 5, we talked about the three requirements for getting market share to flow to the highest-value options, which is necessary if we want higher-value parties (insurers and providers) to be rewarded with profit. The context for why this is the crucial feature of our optimal from-scratch healthcare system is discussed in parts 1, 2, 3, and 4.
As a reminder, those three requirements were for patients to have (1) multiple options, (2) the ability to identify the highest-value option, and (3) incentives to choose the highest-value option. Let’s look at examples of the common barriers to each of them so we will know what to avoid when we build our optimal healthcare system.
Our goal: Avoid any policies that directly or indirectly limit the number of competitors in a market.
For providers, this means allowing them to build hospitals and clinics whenever and wherever they want. They will not do this with reckless abandon because they will know that, if they choose to build in a new region and end up delivering lower value than the incumbents, they will not get many patients and their new endeavor will not be profitable.
For insurers, this means avoiding regulations that make it difficult for them to enter new markets. Nationally standardized regulations will simplify the process of selling insurance in multiple markets, but this does nothing to ease insurers’ greatest challenge of entering new markets, which is the challenge of negotiating prices with providers in that region. But having many provider options in a region should help with this.
And as for things that affect both providers and insurers, we will need good antitrust laws to prevent too much consolidation. And we will need to avoid policies that limit the freedom of them to vary their price and quality so that they can offer unique value propositions (otherwise we end up with many options that all are effectively the same, which defeats the purpose).
Identifying the Highest-value Option
The barriers to this are different for providers and insurers.
On the insurer side, the most difficult aspect of identifying the highest-value option is being able to predict which mixture of premium, copay, deductible, coinsurance, etc. will cover what you need in the cheapest way possible, as well as identifying/predicting which services will be needed and whether they are covered in the benefits. Having some standardization can make this much simpler (but still challenging), such as what healthcare.gov does with multiple standardized quality tiers of insurance plans and grouping all those options together to be compared apples to apples.
On the provider side, one of the first challenges is getting people to recognize that they have multiple options that are of very different value. In almost every other industry, people are great value shoppers, but they have been conditioned historically not to even think about it when choosing healthcare providers, which is probably a consequence of the chronic unawareness of the huge variations in the quality of providers as well as the third-party payer system that so often causes people to pay the same no matter which provider they choose. This is one reason why healthcare provider quality reporting websites are so infrequently used even when they are available.
The other issues with identifying the highest-value providers can be divided into barriers to knowing price beforehand and barriers to knowing quality.
Barriers to knowing price beforehand: The biggest one is uncertainty about what services will be needed—for example, most people do not present to the emergency department with a diagnosis already, nor can they predict what additional complications might arise during a hospitalization. But for specific, well-defined episodes of care, such as an elective surgery, there are great ways to make prices knowable beforehand (look up bundled pricing for an example).
Barriers to knowing quality: People do not know where to find quality information even if they do go looking for it. And if they find it, most of what they find are quality metrics geared specifically toward comparing providers for the purpose of allocating bonuses rather than quality metrics that actually provide metrics that are relevant to helping a patient choose between providers. For example, a hospital’s overall mortality rate or readmission rate has little bearing on the quality of care a patient will receive for something like a straightforward elective gallbladder removal. Standardized, easy-to-understand, appropriately risk-adjusted, patient decision-oriented quality data are needed.
And the last thing to mention in this section are the barriers to identifying the highest-value option that will not likely be overcome. For example, medical emergencies don’t allow time to make a thoughtful decision about which hospital to go to. And low health literacy is a barrier for many people. And there are many important aspects of care that cannot easily be measured, such as a primary care doctor’s ability to diagnose the cause of ambiguous symptoms. Does the presence of these more insurmountable barriers mean that no health system will ever be able to get market share to flow to the higher-value options? No—even if many decisions about which provider to go to are not particularly logical or value-focused, as more people start choosing providers based on price and quality information, higher-value providers will begin to win more market share and the desired incentive scheme that motivates value-maximizing behaviors will arise.
Incentives to Choose the Highest-value Option
Even when people (1) have multiple insurer and provider options and (2) are able to identify the highest-value options, there are still barriers to them choosing the highest-value options.
The first barrier is when anyone but the patient is acting as the decision maker. These alternative decision makers typically have a financial stake in the decision and want to choose the cheapest option without regard for quality. For example, insurers that offer very narrow networks act almost like a first-cut decision maker to narrow patients’ possible provider choices down to only providers that are willing to accept the lowest prices. Patients/patient advocates should be the decision makers because only they will adequately weigh the quality aspects that are most important to and impactful on them.
But even when the patient is the decision maker, they will ignore prices if they are required to pay the same amount regardless of the provider or insurer they choose. This is usually not an issue with insurance plan selection, but it is a major issue with provider selection. For example, flat copays require the same payment from the patient regardless of the full price of the providers. High-deductible plans solve this problem for any service below the deductible, but, once that deductible is surpassed, they have the same problem. Ideas such as reference pricing, multi-tier provider networks, or even paying patients for choosing lower-cost providers can help with this.
If the above discussed barriers to the three requirements for getting market share to flow to the highest-value options are minimized, the healthcare system will naturally and continuously evolve toward higher value because it will motivate providers and insurers to perform their jobs in value-maximizing ways. Government interventions may still be considered for areas where natural incentives will not motivate those parties to do all the jobs we want them to do (particularly in the area of equitable access), but the “healthcare market” will start functioning to benefit patients and what they value.
This concludes the big-picture explanation of this Healthcare Incentives Framework. In other words, we have now discussed all the ingredients that need to go into an optimal from-scratch healthcare system. In Part 7, we will solidify the implications of this framework by imagining up a few examples of different types of healthcare systems with the Healthcare Incentives Framework implemented to show how all those ingredients can come together.