Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Cost, Convenience, Quality: Paying for Healthcare in the U.S.

At the moment I am sitting in a hotel in mid-town Manhattan, between speaker slots at a convention and wishing I’d accepted a less ambitious schedule. Typical of me when away alone, I’m trying mightily not to get on an early flight home. Still, as predictably homesick as I may be, it is good to once again be out “in the wild” among my tribe of eye peeps as we seek more and better ways to stamp out all manner of blinding disease.

While we rail against the vagaries and insults rained upon both patient and doctor by the healthcare payment “system” that exists in the U.S.

Last night I had a very illuminating conversation about some of the maddening nuances that exist in the endless games played by the government and health insurance companies as they plot to thwart the makers of pharmaceuticals and devices from being paid for the use of their products. These producers of products respond with gamesmanship of their own. This, in turn, creates vast inequities in access to both drugs and devices for patient that need them. Safe Harbors compete against Most Favored Nation clauses while middlemen called PBM’s extract a toll at every juncture of the process. Doctors (and their staffs) bend under the weight of misdirected blame and bile for treatment roadblocks they neither built nor can they demolish. Frustration rules the day.

A while ago Beth and I had a rather spirited discussion about how we in the U.S. might be able to pay for the healthcare of our citizens. Being ever practical, and also owning the job of writing the checks that pay for the “health insurance” our company offers its associates (including us), Beth in effect is arguing for a national consensus on something we might describe as a baseline ‘value’ for healthcare. Others would label her concept a ‘floor’, but you get the idea.

What Beth intuitively understands is the tension between cost, quality, and convenience. You pick a baseline or a floor and offer that to everyone. With training as a nurse and 15 years in healthcare administration, her idea of what constitutes the sum of cost, quality, and convenience naturally overweights the integers for cost and quality: outcomes should be essentially equal across the board at both the baseline or floor level, as well as any level that might be considered “luxury”. The costs of achieving that should be in some way equitably shouldered by something we could describe as “society”. Very practical. A strategy that lends itself to being observable and measurable. What’s the rub? Well, only two of the three elements that make up value are covered. To obtain an agreed upon level of medical outcomes (mortality, morbidity, longevity, etc.) the cost is covered.

Ah, but HOW you obtain those outcomes is still a variable. It is the FLOOR of value that is guaranteed. The cost of achieving that baseline universal outcome is covered, the “what you experience” in doing so is not. Our family experienced a bit of this with Beth’s Mom. She was living in a setting that provided excellent care at a reasonable cost, but in a setting that did not provide any extras; it was old, not very pretty, and had we not moved her she would have had a roommate. Her (and her daughters’) experience, what we might call “convenience” in our formula, was found to be lacking.

Therein lies the problem with any discussion about literally anything that we might discuss as a “right”. If we examine food, something we are very conscious of in the White house (Beth and I stopped eating meat 1 1/2 years ago) we find something quite similar. No one among us would say that X Million people should go without food. Indeed, we don’t even really talk about true hunger in the U.S. anymore, we talk about “food insecurity”, the concern that we may become hungry. By the same token, though, no one asserts that everyone is entitled to the same food experience. Not even a little bit. Even the most extreme in the “equality” set do not assert that EVERYONE gets swordfish if ANYONE gets swordfish; it’s the protein that matters and you can get that from a can of tuna. No, quite the contrary, all that is discussed is cost and convenience (access).

Now, of course, in my old CrossFit world (and to a degree in the medical world) it is argued that quality is an ineluctable part of nutrition, that one must extend the equation outside of food alone so that an explicit choice is made that prioritizes quality calories over other purchases. While this is accurate and proper we can reasonably define adequate nutrition as consisting of comparable protein, complex carbohydrates and beneficial fat and keep it separate from other needs, at least for the purpose of our discussion. “Quality” here would be more accurately be called the food “experience”.

How about medications? After all my conversation was with a team from a pharmaceutical company. A complete description of the morass that prescription coverage has become is way beyond the scope of this essay. Hewing closely to Beth’s proposition, each individual should have the right to obtain a medication (or device) that works. Consistent with my further interpretation of the three components of value, the floor of the care continuum is just that, the medicine that works. One should expect to shoulder the cost of more convenient forms of treatment. A 4 time per day pill versus once daily, for example.

The interplay between cost, quality, and convenience holds true in nutrition/food on a global, grand policy making level: From the value components quality, cost, and convenience, you can pick any two, but only two, when you are declaring what is the minimally acceptable level. As Beth intuits, this is similar in healthcare.

My formulaic approach to the coverage of healthcare needs has a little wrinkle that should be mentioned: quality cannot be increased ad infinitum. In all examples we might evaluate there is a practical limit to the ability to improve quality. The law of diminishing returns arrives in the form of asymptote as quality rises. For example, there is little statistical difference between 0.03% and 0.035% when we discuss the risk of a surgical intervention; it becomes similar to chance.

On the other hand, cost and convenience are unbound and can rise almost infinitely. Using an example which is more dramatic than my swordfish/canned tuna offering, alcohol in moderation is consistently shown to reduce mortality. Note that it is the alcohol in a drink that confers the health benefit; the same outcome occurs no matter what you drink. One person’s jug wine from Costco is another person’s Chateau Lafite served in the Gulfstream V.

You get the picture.

What will become of our conversations about issues such as healthcare? Will we arrive at a similar juncture to the one we have now in food, clothing, and shelter? Where quality (outcomes) and baseline cost are addressed and everyone is left to make their own call on convenience/experience (e.g. private or shared convalescent care room, filet mignon or a burger)? Beth can’t see how it can be any other way.

Me? I’m much less optimistic. That old “want vs. need” thing just keeps popping up. Confusion arises when a truly generous people confuse what people WANT with what they NEED. Need is measurable, and therefore finite, whereas want is neither. We can, and should, work to pick up the check for the true needs of each: equal outcomes at a universally affordable cost. “Want”, on the other hand, is the proverbial “free lunch”. I’m all for “a chicken in every pot” , but if you want yours to be Coq au Vin, you gotta buy your own wine.

There ain’t no such thing as a free lunch.

I’ll see you next week…

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