Dynamist Blog

Better Management for Health Care?

As part of The Atlantic's State of the Union lineup, I chatted via instant messaging with Shannon Brownlee, author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. Read the (slightly cleaned up) conversation here. An excerpt:

VIRGINIA POSTREL: However you pay for it, the cost of health care won't go away. The fundamental question is the one you started with: Where do we get the incentives and feedback we're used to in other industries? I don't want to overemphasize this, but one problem is simply that patients expect health care to be free to them. Why don't I pay my primary care physician like I pay my hairdresser or plumber and save insurance for very expensive, unexpected events like cancer? (I'm ignoring the issue of chronic disease, which is a serious one, for the moment.)

SHANNON BROWNLEE: Returning to your previous comment about patients shopping around, I can only think that people who argue that the ill should be able to control their own care can't possibly know any really sick people. In particular, they can't possibly know anybody with a complex, chronic illness — which is, of course, just the kind of patient who is costing us the most money.

VIRGINIA POSTREL: People don't necessarily want their primary care physician coordinating their care. In fact they hate it when HMOs make them gatekeepers. But they want SOMEONE coordinating. Maybe we need more use of the role you see with transplant coordinators for kidney transplants — a highly organized physician's assistant (at least when I was a donor) who makes sure everyone gets what they need and the patient stays in the loop.

SHANNON BROWNLEE: I think that's a perfectly reasonable model — pay out of pocket for primary care, either on a per visit basis or per month, and then have catastrophic care. There are a couple of problems with this model, however. 1) A lot of people don't have the money to pay for frequent visits to their PCP. 2) Patients aren't particularly rational about the way they decide what's needed and what isn't. Probably a better model is the capitated, per month payment.

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