Diet and Nutrition. Natural Health, and Healthy Living

for Women Under 50" title="The Cost of Mammography Screening
for Women Under 50" />

The tempest that greeted the United States Preventive Services Task Force guidelines on mammography screening for women in their 40s prompted the Senate to insert a mandate in its health care reform bill that every insurer cover every mammography screening test at no cost to beneficiaries. If it passes, it will spark an upsurge in mammography screening, especially among women under 50, and raise the nation's health care tab.

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Here’s a dirty little secret: Cutting health care costs is not that difficult, nor will it harm patients. That’s because it only involves giving up unnecessary medical care—tests and treatments patients may want but really don’t need because they don’t benefit their health.

How is this supposed to happen? In Minnesota we call it “unallotment.” When the state had to reconcile a projected multibillion dollar budget deficit this year, and the Republican governor and Democratic lawmakers couldn’t agree on how to do it, the governor simply “unalloted” billions of dollars of planned expenditures.

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There is a pervasivenotion that providers of health care can make up for lower payments received from one set of payers (e.g. Medicare, Medicaid, uncompensated care) by increasing prices charged to other payers (e.g. private insurance companies). To the extent it occurs cost shifting offsets attempts to control overall health care costs throughreducedfees paid by public insurers. It makes "bending the cost curve" harder.

However,it is a myth that providers can fully shift costs. That they could do so violates, in most cases, principles of economics. Moreover, empirical evidence suggests cost shifting, where it occurs, is done so a minimal level: only a small fraction of decreased payments by public payers shows up as an increase in charges to private payers. Losses associated with one payer are largely not recouped from another.

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Putting the political cart firmly before the horse, the Senate Finance Committee heard testimony last weekon how to pay for reform—before they had reliable estimates of how much it is likely to cost.

It’s not that there aren’t plenty of estimates to choose from. A recent Associated Press report offered ten-year forecasts ranging from “the president’s $634 billion…is likely to be the majority of the cost” (White House budget director Peter Orszag) to “$125 billion to $150 billion a year” (New America Foundation economist Len Nichols) to “$1.5 trillion to $1.7 trillion would be a credible estimate” (Lewin Group consultant John Sheils). Take your pick.

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Like the Institute of Medicine's (IOM) 2001 counterpart report, "Crossing the Quality Chasm," a new report from the National Research Council of the National Academies is complex, full of new ideas assembled from multiple disciplines, and is likely to have seminal importance in framing public policy from now on. "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions" was released last Friday, January 9, 2009 in draft, but there is so much to comment on that I think it's wise to begin with a quote from the committee that sums up the central conclusion:

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In last week’s Annals of Internal Medicine, Eric Howell and colleagues describe an innovative experiment in which the hospitalists at Johns Hopkins Bayview became the institution’s bed czars. It worked.

So should my program and yours take this one on? If you looked up “Thankless Task” in the dictionary, you might see “Active Bed Manager.” So how did they do this? And why?

Hopkins Bayview is a 335-bed teaching hospital affiliated with Johns Hopkins. The Chief of Medicine, David Hellmann, is an old friend and a gem, a graceful and eloquent man who is constantly looking for improvement opportunities. Under his guidance, several years ago the hospitalist group, led by Howell, agreed to become the medical center’s “Active Bed Managers” for medical patients. The ED sees 54,000 patients a year, and admits about one-quarter of them, three-quarters of these to Medicine.

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A few months ago, the MA Division of Health Care Finance and Policy (DHCFP) released a study that showed that mandated health insurance benefits cost insurance purchasers about $1.3 billion - or 12% of their premiums - each year. Thanks to DHCFP for publishing the study. This issue is always the source of heated debate, and it’s nice to have a piece included on it that tries to inform the discussion.

Business people read the study and said, “Ah ha! Mandates cost a lot of money!” That would be correct. Health care advocates read the study and said, “Ah ha! Mandates don’t cost that much money!” That’s correct too - sort of. As usual, where you stand depends on where you sit, how much twelve percent is worth to you for what you’re getting, and who pays the bill.

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John McCain is now the presumptive Republican nominee for president. As a result, what he thinks about health care policy will be out front in the presidential campaign this fall.

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Barack Obama’s health care plan follows the Democratic template—an emphasis on dramatically and quickly increasing the number of people who have health insurance by spending significant money upfront.

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John McCain is now the presumptive Republican nominee for president. As a result, what he thinks about health care policy will be out front in the presidential campaign this fall.

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