welcome back to doctor MacLean explains my goal is to break down the US
healthcare system into understandable parts to clarify what is the problem
with the system and to talk about how to fix it
in the first 8 episodes we have reviewed the evolution of the US
healthcare delivery system and insurance system we have identified the relentless
growth of healthcare spending as the root of the problem and how rising costs
are literally built into the system as it is now finally we have looked at
American traditions and values that we all agree on and we identified loaded
political words and the seeming conflict between market justice and social
justice that voters disagree on based on this understanding of the US healthcare
system we are now ready to look at what I'm calling the Big Fix it is based on
the idea of setting limits fairly you'll be surprised to know that it was already
tried 20 years ago in Oregon and it worked so let me tell you the story of
the Oregon Health Plan it all starts with a Roseburg Oregon emergency room
doctor named John Kitzhaber half of his ER patients as everywhere
were not real emergencies just uninsured patients with no other place to get
health care so in 1989 when the Medicaid budget was being cut he realized that
many Medicaid patients would lose coverage and would be flooding into his
ER unless something was done he came up with an idea rather than keep the same
level of benefits and cut patients why not keep all the patients on Medicaid
but limit their benefits he formed a non-profit group to lobby for these low
income patients and this propelled him to the state Senate and eventually to
the governorship he first created a list of 709 diagnosis-treatment pairs ranked
by the dollar cost per life saved by each treatment or quality adjusted life
year but this produced some odd results for example ranking
lower-cost dental care above life-saving appendectomies and so he next organized
60 town hall meetings to reprioritize the list with common-sense consumer
input actuaries then calculated the line which turned out to be line 581 above
which the fixed Medicaid budget could cover all eligible patients the final
list gave priority to life-saving treatments such as antibiotics for
pneumonia and appendectomy for appendicitis as well as proven
effective treatments for heart disease and treatable cancers it also included
routine preventive care maternal care newborn care well child care and
preventive dental care kidney dialysis was covered above the line the list did
not cover conditions like remedies for the common cold that get better on their
own conditions where home treatment is effective like sprains ineffective or
futile care such as surgery for most back pains or aggressive treatment of
end-stage cancer for those terminal cancers it did cover comfort care here
are the other main provisions of the Oregon Health Plan by eliminating low
value health services it was able to cover 100 percent of low-income citizens
a combination of sound research and consumer input gained at public
acceptance here is the timeline for the Oregon Health Plan it actually took 5
years to gather public input and then to get necessary federal waivers approved
here is a summary of the key successes of the Oregon Health Plan Oregon was
able to extend plan eligibility of those below federal poverty level from 57% to
all 100% this meant 100,000 more Oregonians on Medicaid total uninsured
in Oregon did drop from 18% to 11% most importantly Medicaid stayed within
its budget Medicaid physicians were paid on par with others resulting in a robust
doctor participation and eighty percent of patient satisfaction let's pause to
consider a key question: is it ethical to limit health benefits for low-income
patients? philosopher Paul Menzel who I introduced in the last segment gives a
resounding yes here is his thinking the right to
prioritize health care services is especially important for lower-income
patients if they were given their Medicaid premium in the form of cash
many would spend only 33% of it on health care because they have more
pressing needs for food clothing and shelter Menzel also points out that these
low-income patients would gladly accept the package of more restricted health
services in exchange for first dollar coverage lower-income patients live from
paycheck to paycheck and don't want the uncertainty of a large unexpected
medical bill Medicaid patients want health insurance but neither they nor
society at large should pay more than it's worth to them in plain language
lower-income patients and other savvy insurance buyers need the real choice
for a lower cost package of limited health benefits that is worth the money,
not just a menu of higher deductibles and co-pays but the same old package of
exorbitantly costly low value care please take notice that this idea blends
both market justice and social justice it acknowledges that low-income patients
are not entitled to everything, no matter what the cost but it also provides for
them a package that they and society think is cost worthy and so with their
consent freely given cost worthy care is one of the key features of a fair health
system according to Menzel as we saw in the last segment and consent is a key
principle
it is instructive to look at the fate of the Oregon Health Plan over the 8
years of its existence here is what happened the legislature cut taxes
health care costs rose with inflation Oregon tried to get the poor to accept
higher co-pays but they could not afford them and so dropped out eventually these
patients went back to traditional Medicaid or became uninsured again
spelling the end of the Oregon Health Plan. What are the lessons to be learned?
first limit setting is politically feasible ethically acceptable and
pragmatically successful in controlling cost access and quality second priority
setting takes years to plan and years to implement third healthcare priority
settings should be informed by cost-benefit research but driven by
public participation respecting minority rights and protection of the sick and
vulnerable. Fourth, 2-tiered health benefits packages, one a lower cost and
one a higher cost, is politically feasible and ethically acceptable but
so-called essential benefits should not arbitrarily cut entire categories of
benefits like maternity care. Fifth, sufficient primary care provider pay is
needed to ensure doctor participation and patient access. Sixth, sustaining health
care system restraints and cost controls requires continual monitoring and
periodic updating to keep up with new medical research and changing public
values. This is a critical point because the casual observer might conclude that
the Oregon Health Plan failed in 2002. But I argue that the fact that the plan
was designed, politically adopted, implemented and sustained for 8
years proves the concept that limit setting can work but also shows that
something so big and so intricate needs ongoing political and administrative
energy to sustain it properly as is done in other countries
autopilot doesn't work for healthcare of course I have oversimplified the Oregon
Health Plan there are innumerable technical legal budgetary and
administrative details involved also adopting a plan like Oregon's today
would need us to take into account 20 more years of research since then
with some very expensive but very effective treatments newly available
there are also many ethical nuances such as, Should we budget for one patient
needing a $100,00 treatment in place of 100
patients needing $1,000 treatments or vice versa but Oregon
showed that all these issues can be managed in an orderly fashion
I have also oversimplified that merely adopting the Oregon Health Plan
cost-benefit method for a limit setting would solve the entire cost problem for
example many commentators have exposed the quirks of the US healthcare system
that result in over-pricing as discussed in Segment 5 that means that the same
drugs tests or treatments cost 2 to 10 times more in the US and in other
countries those quirks should each be addressed in policies and regulations
but the basic idea of fair limit-setting -- call it rationing if you like -- is the key
in my opinion limit setting would firmly challenge the common presumption that
all healthcare is equally cost worthy it would also put on notice the vested
interests if they play games with exorbitant pricing they would ultimately
lower their benefit for costs below the cutoff point and drop themselves off the
covered list altogether in the final segment I will talk about what each
of us can do to promote health system reform and cost control I'll see you
then
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