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Real, not Ryan, Market-Based Reform

On my census right now is a 70-year-old who has spent about a quarter of the past few months in the hospital due to COPD exacerbations. Thing is, her COPD isn’t that bad when you look at her pulmonary function tests. The main issue is that when she goes home, she doesn’t have good compliance with her lengthy list of pills, inhalers, and nebulizers. She either doesn’t remember to take them or how to take them.  Her private insurance doesn’t pay for the 7-days-a-week care she probably needs to prevent another hospital stay. Despite already having been set up with home-health aides and visiting nurses, my patient is unable to properly follow her prescribed regimen. Now, we want to additionally burden her by making her compare private health care plans side by side?

That’s one reason why immediately turning Medicare into a voucher-based health-insurance exchange, like Congressman Paul Ryan (R-WI) plan wants to do, is impractical. The sickest patients on our rolls don’t necessarily have the resources to properly take care of themselves much less decide between the intricacies of varied private plans. This is where the analogy to other insurance markets breaks down. Everyone capable enough to drive is also capable enough to compare quotes online and buy. But a patient with chronic hepatic failure and the resulting encephalopathy comparing quotes? Not necessarily. While in theory, years after the reforms of the Affordable Care Act (ACA) are in place, private plans will know how to provide a fair service to their clientele. But we need to choose a system for reform that works now, not years from now. 

I’m a big fan of market-based strategies for reigning in health-care costs. Someone is ultimately going to have to make the decision on when to say no to paying for a particular treatment. Between doctors, insurance companies, government, and patients to make that decision, I trust patients to make the best decision for their care. And I believe that market-based approaches will ultimately give the most power to the patient to direct their own care while allowing informed guidance by physicians. But to move immediately to a fully market-based approach right now without the regulatory reforms provided by the ACA – and do so for our oldest patients like the Ryan plan suggests – is only good in libertarian theory and not in real world practice.

In contrast, I am really excited about the planned insurance exchanges combined with the structure provided by Accountable Care Organizations (ACO). Through the Shared Saving Program of the ACO rules, providers have a strong incentive to develop ways to deliver quality care affordably. Moreover, because the sickest patients use proportionately the largest share of health care funds, ACOs may find they have the most opportunity to save by targeting services to their sickest patients, who incur the highest baseline costs. For instance, an ACO specialized to treat COPDers could save greatly by offering home medication management and engaging aggressively in smoking cessation – and find that they are incentivized to do so by sharing in the resulting savings from decreased hospital admissions. The ACA reforms provide mechanisms for both strong patient control over who provides their care and for physicians to guide that care through involvement with ACO management. That is the type of real market-based reform that could help my patient.

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