In response to article by Carrie H Colla, PhD, N Engl J Med. 2014; 371:1280-1283, October 2, 2014. “Swimming against the Current – What Might Work to Reduce Low-Value Care?”
Controlling healthcare spending in our broken fee for service model is certainly comparable to swimming upstream. Fee for service is not the primary force behind that current. Until recently, patients have not been concerned about costs, and providers as well as third party payers have had incentive for higher spending. How could we expect anything other than out of control spending?
Dr Colla concludes that the best solution for our broken system lies in educating the patients with tools such as “Choosing Wisely”, and putting providers on the hook with risk sharing models such as accountable care. In this construct, costs are not open for discussion, and patients are left out of the decision making process. From the consumer standpoint, ACO is “prix fixe” healthcare.
Alternatively, educating patients and doctors about cost (since neither one knows much about this now), putting the patient on the hook for some of the costs (this is already happening with cost sharing insurance policies such as high deductible and co-insurance), educating patients with “Choosing Wisely”, and rigorously measuring quality, is a more patient-centered strategy. Consumers will learn to distinguish between providers that guide them toward high value, and away from low value care versus those that do not. Quality scores of wasteful providers will tell the story.
Transparency of cost is coming and will be needed to define low vs high value. An MRI may be a high value for a given condition at $400 but low value at $4000. An honest assessment of value cannot be made without full disclosure of costs. Let’s start swimming with open eyes.