Three questions on the road to sustainability

If we ever slow health care cost inflation to a sustainable pace, it will be because we learn how to ask 3 simple questions when thinking about a medical treatment:

  • Does it improve quality of life for the patient?
  • Does it extend the patient’s life?
  • How much does it cost?

Asking the questions are of course much simpler than figuring out the answer, and far far simpler than deciding what to do with the answer.

The first step is not demonizing even the asking of the questions. This would represent a profound shift in our culture, and is needed. We need to grow up and learn how to talk about limits in medicine. Then we will have to learn how to give practical answers to these questions, and the answers will have to be knowable and usable at the bed side as doctors and nurses are caring for actual people–you, me, my parents, grand parents and kids. These are not just technical policy questions, but need to become cultural ones as well, asked by all of us, no matter what type of insurance we have.

Then we will have to decide what to do with the answers. None of this will be easy.

The good bad news is that there is a good deal of care that is non-productive, which I would define as care that does not improve quality of life or extend life. We should start there. I don’t know how much health care spending could be reduced by stopping care that didn’t improve quality of life or extend life, but this is the correct way to think about our attempts to slow health care cost inflation. We might have to get into the very hard business of deciding that some care that was productive but very expensive shouldn’t be done. But, we might not; we won’t know until we start asking these 3 questions. Matt Miller and Austin and Aaron have been talking about this today.

The Independent Payment Advisory Committee (IPAB) is a vehicle that could be used to begin to ask these questions. I have been amazed at the level of vitriol against IPAB given past Republican support of similar boards with far more proposed power than what IPAB has. However, if we are forgetting about the past, lets forget about it and reach a bipartisan way to ask these questions, using IPAB as the vehicle since it has the advantage of having been enacted into law.

One practical solution would be for the President to say he is going to name one of the Republican members of Congress who is a physician to be the chair of IPAB. I believe Tom Coburn is retiring in 2012, and he co-sponsored the Patients’ Choice Act that proposed IPAB-like boards. And he uttered the most profound statement of the entire Blair House health policy summit in February 2010 when he said that 30% of medical care is non productive (I don’t know if this figure is correct, but IPAB could start figuring it out). Senator Coburn could even say exactly how the boards he proposed in the PCA were good policy ideas, but the current structure of IPAB is not, and we could enact a bipartisan tweak of IPAB.

I am being totally serious. Anything that moves us in the direction of beginning to ask these questions, to begin to depoliticize the recognition of limits, and to get to the policy. I am not sure I can take another election based on ‘I am not as bad as the other guy’ while serious problems go unaddressed.

About Don Taylor
Professor of Public Policy (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute), and Chair of the Academic Council at Duke University . I am one of the founding faculty of the Margolis Center for Health Policy. My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

6 Responses to Three questions on the road to sustainability

  1. steve says:

    I dont think that a first term president can talk realistically about limits in medical care. Part of the role of the POTUS is presenting sunny optimism about the US. Supposing that a second term president is willing to address this, we are still left with private insurance costs rising.


  2. Floccina says:

    I do not think that politicians can setup system that acts on the answers to those questions until we are a crisis point were the median voter feels the crisis. IMO we are not there yet.

  3. Floccina says:

    BTW these decreases, like monopsony, would most likely produce a one time lowering of spend but that spending could start up again after they were enacted. For example spending in Canada is rising even with monopsony and some of he controls mentioned.

    If we ever slow health care cost inflation to a sustainable pace, it will be because we learn how to ask 3 simple questions when thinking about a medical treatment:

    So the above is, in a way, wrong.

  4. Shangwen says:

    Floccina, you are optimistic (?) about Canada. We don’t ask those questions here, and we don’t like to talk about limits in medicine either. Those of us who do meet the familiar hooting about life being precious, the miracles of medicine, the sacrifices of health care providers, etc etc.

    The rationing that takes place in Canada really takes place behind the scenes, and people lump it because they know it’s the only available option that they can afford. It’s a bit of a ham-fisted strategy for keeping costs down, but then you are absolutely right that we have about the same rate of excess cost growth as the US. Monopsony is only efficient if you can change expectations.

  5. The first hyperlink in your article doesn’t work.

    Please advise.


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