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Rolling The Rock Up The Mountain

2009; Project HOPE; Volume: 28; Issue: 5 Linguagem: Inglês

10.1377/hlthaff.28.5.1250

2694-233X

Susan Dentzer,

Primary Care and Health Outcomes

From the Editor-In-Chief Health AffairsVol. 28, No. 5: Bending The Cost Curve Rolling The Rock Up The MountainSusan DentzerPUBLISHED:September/October 2009Free Accesshttps://doi.org/10.1377/hlthaff.28.5.1250AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSCosts and spendingCost growthHealth servicesHealth reformCost reductionCost containment A modern twist on Greek myth would feature not Sisyphus, but a health policy-maker condemned to an eternal punishment of trying to tame health care costs. During rare work breaks from rolling the rock up the mountain, she’d read the report of the Committee on the Costs of Medical Care, formed in 1927 and chaired by a member of President Hoover’s cabinet. As Daniel Fox described in the Milbank Memorial Fund’s Centennial Report, the committee tackled what it termed “‘the one great outstanding question before the medical profession’: how to deliver adequate medical services to all Americans at a reasonable cost.” Then, at her next work break, our suffering policymaker would watch President Obama on television, vowing that “the [health care reform] bill I sign must reflect my commitment…to slow the growth of health care costs over the long run.” So now the nation—and this thematic issue of Health Affairs —ponder that “great outstanding question” yet again. The stakes have grown exponentially higher. As Harvard’s Michael Chernew and colleagues now project (see Research UpDate, p. 1253), at current growth rates—and at varying projected rates of overall economic growth—health spending would consume anywhere from 119 percent to 142 percent of the entire real increase in U.S. per capita income over the next seventy-five years. In other words, not only would all increased economic resources be poured into health care—but we would suck into health care trillions of dollars of resources that we’re already devoting to other valued goods and services. It seems unfathomable that Americans will actively choose this scenario, since it portends so much less of everything else we value: education, other social spending, art, science, defense. Meanwhile, to pay for government’s share of greater health spending, we’d face sky-high taxes or a gargantuan national debt. Hence, Congress’s belated efforts to instill meaningful cost controls in health reform legislation, as senior editor Aliza Marcus details.But as other papers in this volume make clear, any national moves to reduce health spending growth should be grounded in awareness of the potential implications. After all, as Henry Aaron and Paul Ginsburg write, for different individuals, the very same health care intervention can produce anything from high average returns to low marginal ones. Cardiac catheterization and balloon angioplasty save lives for those with heart attacks but may do little to help those who may have slowly clogging arteries but no symptoms. We clearly want the care with the high average returns—but are our scalpels sharp enough to remove only the low-return kind? Or would payment reforms and some of the other changes now being contemplated actually slow advance of medical knowledge, even as they reduced the growth in costs?A lesson for U.S. and other global policymakers about the tensions and tradeoffs comes from Nicholas Timmins’ interview with Sir Michael Rawlins, the head of England’s National Institute for Health and Clinical Excellence (NICE). That’s the agency that employs a “quality-adjusted life-year” methodology to tell the National Health Service (NHS)–England whether new drugs and other technologies are worth paying for (and, as such, is currently experiencing its fifteen minutes of U.S. infamy as the designated socialized-medicine bogeyman of some in Congress). But Sir Michael notes that NICE’s other job is to publish guidelines on what constitutes effective and appropriate health care. The use of those guidelines to improve care has added an estimated $2–$3 billion a year to NHS spending. Given the famed study by Elizabeth McGlynn and colleagues demonstrating that Americans receive only about 55 percent of recommended care, there’s no telling what a reformed U.S. system that provided appropriate care might actually add to its health spending tab.At the same time, there’s plenty of evidence in this volume of cost-saving interventions worth trying. Speaking for regulation, Robert Murray writes that had Maryland’s “all-payer” rate-setting system for hospitals been adopted nationwide, it might have saved $1.8 trillion over three decades. Speaking for market forces, John Agwunobi and Paul London describe how Wal-Mart seizes upon hidden profits embedded in the supply chain and diverts them back to consumers—as in the $4-a-month generic prescriptions that the retail giant pioneered in 2007. And in Report from the Field, Martha Bebinger outlines a Massachusetts state commission’s hopes for salvaging universal coverage by moving the state to pay newly created networks of providers under a new “global payments” system.Would that those old Hoover-era cost containment commissioners were watching now. Eighty years ago, Fox wrote, they recommended that health care “be provided by organized groups of practitioners and that their costs be covered ‘on a group-payment basis,’ that is, funded through insurance, taxation or both.” The more things change, the more the possible remedies don’t change. But the tough choices don’t disappear, either.We are deeply grateful to Aetna and the Aetna Foundation, which granted us lead support to make this thematic issue possible. We also thank the Commonwealth Fund, which provided additional important support for the issue. And a special note of thanks to Paul Ginsburg, president of the Center for Studying Health System Change, who served as our thematic issue adviser. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 September 2009 InformationCopyright 2009 by Project HOPE - The People-to-People Health Foundation, Inc.PDF download