You might be interested in this article at Empire Center about New York State’s unsuccessful attempts at controlling Medicaid spending in the state, twice as high per insured as in most states:
More than money is at stake. Much of the inefficiency of New York’s Medicaid program is a symptom of underlying mismanagement – of programs that deliver fragmented, wasteful care, put the interests of providers ahead of patients and leave the state vulnerable to abuse and fraud.
Medicaid plays a critical role in the lives of millions of New Yorkers, including its most disabled and vulnerable citizens. It’s incumbent on state leaders to get it right.
The article is interesting and informative but I think it has a flaw common to many analyses of health care policy or economic policy more generally. The authors appear predisposed to think of health care spending as a physical phenomenon like gravity. I think it should be viewed more as a game or a transaction. One party (the state) moves. Then the other party (providers) moves.
If I’m right the implication of that is that, unless you change the rules of the game pretty substantially, cost control must be a continuing process. There is no master stroke which will resolve the problem for all time.
WRONG! 100% transparency would solve the problem permanently, just as Amazon transparency and Uber transparency have solved our Post Office and taxi cartel problems.
You do realize that this goes beyond Medicaid? The private insurers change their rules all of the time. Providers scramble to optimize revenue. Sometimes providers move first, but not often as they need insurers to pay. So insurers play a large part in determining what we do. As an example, insurers largely do not pay, or pay very minimally for acute pain services, the kind that would keep people from getting addicted to opioids to begin with. It is just easier to order lots of narcotics. One of my current ongoing projects is to find a way around that. Our network is taking a loss and subsidizing us to provide the kind of care we need, but I am finding ways, along with keeping costs low, to take advantage of what they do pay for to cover some of the costs. (We are utilizing NPs a lot and Skyping for our outlying hospitals, plus we are double training people. Skyping is cheaper than actual telemedicine though we are right at the edge of what the rules allow.)
Steve
“WRONG! 100% transparency would solve the problem permanently”
When transparency has been tried it has not cut spending. Goodly bit of literature on it, not that you would care. You could also talk with some real live patients to see why it doesn’t work so well.
Steve
Price transparency is most effective in commodity health care. Since most health care is artisanal rather than commodity the effectiveness of transparency is limited.
It has been most effective for care where there are near perfect substitutes, like Lasik, or where the care is not needed, like cosmetic plastic surgery of the completely elective kind. In areas where you think it might be effective since it is more like a commodity (think MRI or CT scans) transparency still hasn’t helped much. Add in a second factor, like value based insurance, and you can get some effect.
Steve
stave
In Florida medical marijuana shops are springing up like 7-11’s. A stated reason is their ability to prescribe and dispense a pain management agent not called “narcotic.”
What say ye?
Inefficiency and waste are the price of activity. They cannot be eliminated. It is a second law thing. They also increase in time as institutions accrue regulations that protect the institutions workers and managers from its customers. Part of this occurs because within any institution nearly all person-to-person interactions occur among the workers and managers, and these increase as n-square. Those interactions come to dominate all managerial effort.
The problems of Medicaid recur everywhere in both private and public institutions. In the private sector, when things get bad enough the bankruptcy courts intervene and dissolve or forcibly restructure the company. It is important to note that the company cannot reform itself. There is no equivalent court for government agencies, except, I suppose for defeat in war or revolution.
Drew- I think its effects in managing pain are modest, mostly limited to a few chronic pain conditions. It may also have some efficacy as an anti-emetic when using opioids. I dont think it has much efficacy for acute pain. My caveats would be that federal laws made it difficult to do good studies for a long time so I dont think we know everything we could know yet and chronic pain is hard to treat. So I think we will get a lot more people claiming it is helping than we could show if we did any kind of objective study, understanding that objective studies about chronic pain are difficult. Part of that will be people fibbing just so they can obtain marijuana, but a lot of it is just because many patients with chronic pain are desperate for anything to work.
Steve
I think that’s basically correct. Having suffered through serious nerve impingement pain (throttled only to a dull roar by Vicodin; dilaudid is a different story) I don’t see hootch as a viable substitute)
Shorter: taxable and an available high.