Regarding the editorial “At a turning point,” I think you need to look at the situation we are facing a little more deeply than is evident in your editorial.
Yes, we are aging; yes, we are a more sedentary society and a richer, less-disciplined one. But I would question “the healthcare system's best efforts to create a healthier society.”
We have some quality issues; we have some service issues. In the direction we are heading, correcting those issues will be part of what separates the survivors from the also-rans.
But the cost issue is most compelling. There is an upper limit on the percentage of gross domestic product that healthcare can absorb. If healthcare is effectively free (low deductibles and copayments) and no other restrictions are put on access, consumers will, by and large, consume all that is offered.
Changing provider payment incentives to some type of per-capita basis rather than a fee-for-service basis will probably reduce the amount of healthcare offered, which is one form of rationing. Upping the deductibles and copayments will also act as a form of rationing in that the public will not consume certain services if the perceived out-of-pocket price is too high.
Reducing the cost of healthcare (percentage of GDP used) will not be significantly changed by incremental efficiency improvements among providers. While a healthier population will require less healthcare, this is only true up to the end-of-life stage, where we spend an awful lot of money. If we don't do something about end-of-life costs, all a healthier population will do is delay the end-of-life expenditure somewhat. It would be a one-time savings.
Given the above assumptions, there are two routes to containing healthcare costs.
The first is attacking the lifestyle issues that contribute to the current level of general health. Smoking, drinking, poor eating habits, lack of exercise are the low-hanging fruit. That should reduce healthcare demand in the general population up to end of life.
The second route is rationing of healthcare. This can be done in a lot of ways. But whatever name you put on it, it is rationing.
There are three players here, and any or all of them can be the rationers: government payers, nongovernment payers (employers or insurers) and patients. All have a large stake in the outcome. None of these options is very pleasant, but one of the underlying issues that needs to be explored is how does society at large want to go about this. After we work through that thorny question, then we can start to work on how we will actually create the incentives and legal structures to make it so.
John D. Starr
Board chairmanLittleton (N.H.) Regional Healthcare
