Buttonwood on coverage, cost, choice of public services

From the June 23 Buttonwood column in the Economist:

POLICYMAKERS must juggle three priorities when offering a public service: coverage, cost and choice. They almost always have to sacrifice at least one of the three. As austerity bites, this equation is going to lead to very tricky decisions.

Health is an area where the trilemma clearly applies. Britain’s National Health Service offers universal coverage but as a result has to limit patient choice in order to control the costs. The American health system historically gave a high priority to patient choice at the price of ballooning costs and the exclusion of the uninsured from the system. Having increased coverage, the Obama reforms will have to restrict choice if they are to control costs.

There is certainly a relationship between coverage, cost and choice in health care, but there is something equally important missing from this formulation: the outcome or effectiveness of care. It is impossible to tell how important limits in the types of care patients may choose without knowing the relative effectiveness of the care in question. Determining how to systematically provide information on whether a given care option improves quality of life and/or extends life is a top priority. Only then can you evaluate the value of coverage, cost and choice and make the hard decisions described in the Economist in a meaningful way.


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 https://academiccouncil.duke.edu/ . 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

8 Responses to Buttonwood on coverage, cost, choice of public services

  1. Cycledoc says:

    There is an irrationality in health care decisions, particularly when the illness is life-threatening and when the decision maker is shielded from the financial consequences of the decision. Patient’s believe that they are the ones who will benefit greatly even if only 10% of people get a response and the response is minuscule.

    As such comparison studies unless combined with a financial consequence will have very limited effect on the decision process.

    What’s under-reported in our health care mess is the unmitigated gall of technology companies who price gouge our most seriously ill patients. Is there any drug whose true costs + a healthy profit is in the range of $100,000/year? Can any system of care afford a drug costing $100,000/year that offers a few months, if that, survival benefit?

  2. Mark Spohr says:

    “Britain’s National Health Service offers universal coverage but as a result has to limit patient choice in order to control the costs.”

    How does the NHS limit choice?
    As far as I know, the NHS provides all necessary medical care to everyone in the UK. Are they limiting a patient’s ability to choose ineffective, unnecessary and damaging medical care? … perhaps, but this is a good thing. Are they limiting a patient’s access to effective, necessary medical care? … I don’t think so.

    I think this statement needs to be supported with some facts and I haven’t seen anything reputable… just sensationalist fear-mongering.

  3. Don Taylor says:

    @Mark Spohr
    In the NHS you have absolute choice of GP. When I lived there, said so right on the back of my card. Most people in the neighborhood where I lived choose the GP office in the neighborhood.

    I agree with you that the editorial is surprisingly clumsy. NHS rations via waiting list. maybe that is what they mean….if you have to wait for a knee replacement….those with resources and que jumping private insurance do that, while others must wait for elective procedure.

  4. Tiffany says:

    In many other countries, if the health insurance does not pay for a $100,000 treatment in order to add 4 month worth of life to patients with metastatic cancer, it is understood and okay with them. It is well accepted by the society.

    In US, if the same thing happens, many of us complain. People begin to call it rationing /death panel, and eventually such treatment gets done and money spent.

    That’s the difference. It’s the culture!

    • Don Taylor says:

      when I teach comparative health systems, your point is one of the hardest to get across. If you describe waiting lists in the NHS the students seem to think that Martians flew down and imposed that system….when in fact the culture invented it. It is also a challenge to motivate learning by comparison, while realizing that the U.S. couldn’t copy another system if we wanted to. We have to figure out our own system.

      • steve says:

        “It is also a challenge to motivate learning by comparison, while realizing that the U.S. couldn’t copy another system if we wanted to. We have to figure out our own system.”

        I often puzzle over this as a meta-issue. If you are interested, I would like to see you write a more fully fleshed out piece on why this is true. I understand that issues with size and culture prevent the wholesale importation of many other plans, but we seem set on not accepting or incorporating almost anything from other countries.


      • Don Taylor says:

        I will think about this and see if I can come up with anything useful. I am teaching comparative health systems again in the fall….so will be good for me to think this through.

      • steve says:

        Thanks Don. I look forward to your ideas.


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