Tag: doctors

The Importance of Incentives

NPR reports on more doctors giving up private practices and going to work for hospitals. Hospitals think they can manage care better and get more patients, and doctors like being relieved of administrative headaches. But it isn’t a perfect solution. Reporter Jenny Gold notes one of the problems:

GOLD: This isn’t the first time hospitals have gone doctor shopping. In the 1990s, hospitals bought up as many practices as possible. Dr. Bill Jessee is the president of the Medical Group Management Association. He remembers the ’90s as something of a disaster.

Dr. BILL JESSEE (President, Medical Group Management Association): The first thing a lot of physicians did was took a vacation. And when they came back, they weren’t working as hard as they were before their practice was acquired.

Indeed. This is a standard insight of economics. People work harder when they have something to gain. There are real benefits to the division of labor, including corporations where salaried employees contribute to a joint product, but there are also risks that employees won’t work as hard when their compensation isn’t directly tied to their output. Managers and economists have searched for solutions to the “shirking” problem. In this case the hospitals are experimenting with bonus systems based on how many patients the doctors see. The problem is much more significant, of course, in government, which is far more restricted in its ability to use merit pay, bonuses, or other performance-related pay systems. Thus the widespread impression that government employees don’t work as hard as private-sector employees – and one reason that it’s a good idea to leave as many services as possible in the private sector.

The NPR story also reminded me of Malcolm Gladwell’s New Yorker article on Philo T. Farnsworth, the inventor of television. Gladwell dismisses the romantic notion of the lone inventor and says that Farnsworth would have been better off working for a big corporation, where other people would have worried about raising capital, fending off lawsuits, and all the little details of management and left Farnsworth free to invent:

Farnsworth was forced to work in a state of chronic insecurity. He never had enough money….he did not understand how to raise money or run a business or organize his life. All he really knew how to do was invent, which was something that, as a solo operator, he too seldom had time for.

This is the reason that so many of us work for big companies, of course: in a big company, there is always someone to do what we do not want to do or do not do well–someone to answer the phone, and set up our computer, and arrange our health insurance, and clean our office at night, and make sure the building is insured. In a famous 1937 essay, “The Nature of the Firm,” the economist Ronald Coase said that the reason we have corporations is to reduce the everyday transaction costs of doing business: a company puts an accountant on the staff so that if a staffer needs to check the books all he has to do is walk down the hall. It’s an obvious point, but one that is consistently overlooked, particularly by those who periodically rail, in the name of efficiency, against corporate bloat and superfluous middle managers. Yes, the middle manager does not always contribute directly to the bottom line. But he does contribute to those who contribute to the bottom line, and only an absurdly truncated account of human productivity–one that assumes real work to be somehow possible when phones are ringing, computers are crashing, and health insurance is expiring–does not see that secondary contribution as valuable….

Philo Farnsworth should have gone to work for RCA. He would still have been the father of television, and he might have died a happy man.

Broder: Health Overhaul Likely, Because Hardest Part Lies Ahead

Yes, you read that right.  And I had to do the same sort of double-take when I read David Broder’s op-ed in The Washington Post this morning.

Broder writes, “Obama has steered the enterprise to the point that odds now favor a bill-signing ceremony.  But the hardest choices still lie ahead….”  Whaa??  How can the odds be better than 50-50 if the biggest fights haven’t even happened yet?

Broder’s optimism continues, “Two things will be needed to reach [a majority in the House and 60 votes in the Senate]: first, a plausible plan for making affordable and comprehensive health insurance available to millions…. And second, a way of financing the coverage….”  But that’s been the whole challenge all along.  Is Broder actually acknowledging that Democrats aren’t any closer to a signing ceremony than they were six months ago?

Broder says Democrats can meet the second challenge by taxing high-cost health plans – “a step that would require Obama to face down his labor union allies.”  You mean Obama should lean on Democrats to tax a crucial part of their own base?  One that’s already activating to block that tax?

Broder also thinks Obama should lean on his fellow Democrats to roll the doctors and hospitals in their states/districts by including more (some? any?) “delivery system reforms” in the legislation.

Sure.  No problem.  What could go wrong?  This is practically a done deal.

(Cross-posted, sarcasm and all, at Politico’s Health Care Arena.)

Mr. President, Here Is Our Answer

President Obama continues to portray the debate over health care reform as a choice between his plan for a massive government-takeover of the US healthcare system and “doing nothing.”  Those who oppose his plan are said to be “obstructionist” or in favor of the status-quo.  Yesterday, the President again said, “I’ve got a question for all those folks [who oppose his plan]: What are you going to do? What’s your answer? What’s your solution?”

Well, I can’t speak for all his critics, but the Cato Institute has a long record of supporting health care reform based on free-markets and competition.  If the President wanted to know more he might have read my recent op-ed in the Los Angeles Times or Michael Cannon’s piece in Investors Business Daily.  He could have read our book, Healthy Competition.  Or he might have just gone to healthcare.cato.org and read our plan:

  • Let individuals control their health care dollars, and free them to choose from a wide variety of health plans and providers.
  • Move away from a health care system dominated by employer-provided health insurance. Health insurance should be personal and portable, controlled by individuals themselves rather than government or an employer. Employment-based insurance hides much of the true cost of health care to consumers, thereby encouraging over-consumption. It also limits consumer choice, since employers get final say over what type of insurance a worker will receive. It means people who don’t receive insurance through work are put at a significant and costly disadvantage. And, of course, it means that if you lose your job, you are likely to end up uninsured as well.
  • Changing from employer to individual insurance requires changing the tax treatment of health insurance. The current system excludes the value of employer-provided insurance from a worker’s taxable income. However, a worker purchasing health insurance on their own must do so with after-tax dollars. This provides a significant tilt towards employer-provided insurance, which should be reversed. Workers should receive a standard deduction, a tax credit, or, better still, large Health Savings Accounts (HSAs)  for the purchase of health insurance, regardless of whether they receive it through their job or purchase it on their own.
  • We need to increase competition among both insurers and health providers. People should be allowed to purchase health insurance across state lines. One study estimated that that adjustment alone could cover 17 million uninsured Americans without costing taxpayers a dime.
  • We also need to rethink medical licensing laws to encourage greater competition among providers. Nurse practitioners, physician assistants, midwives, and other non-physician practitioners should have far greater ability to treat patients. Doctors and other health professionals should be able to take their licenses from state to state.   We should also be encouraging innovations in delivery such as medical clinics in retail outlets.
  • Congress should give Medicare enrollees a voucher, let them choose any health plan on the market, and let them keep the savings if they choose an economical plan. Medicare could even give larger vouchers to the poor and sick to ensure they could afford coverage.
  • The expansion of “health status insurance” would protect many of those with preexisting conditions. States may also wish to experiment with high risk pools to ensure coverage for those with high cost medical conditions.

Mr. President, the ball is back in your court.

Ed Crane Describes a Libertarian Approach to Health Care Reform

Last week, Cato hosted an all-day conference on health care reform, which included expert opinions from across the political spectrum.  Cato Founder and President Ed Crane started the event with a talk about a libertarian approach to reforming health care, which would reduce federal involvement, increase competition, decouple health care from employment and increase the amount of doctors available.

You can find all of Cato’s reasearch on health care reform at Healthcare.Cato.org.

Samuelson: Obama Would Increase, Not Reduce, Health Care Costs

Columnist Robert J. Samuelson, writing in this morning’s Washington Post:

It’s hard to know whether President Obama’s health-care “reform” is naive, hypocritical or simply dishonest. Probably all three. The president keeps saying it’s imperative to control runaway health spending. He’s right. The trouble is that what’s being promoted as health-care “reform” almost certainly won’t suppress spending and, quite probably, will do the opposite…

The president summoned the heads of major health-care groups representing doctors, hospitals, drug companies and medical device firms to the White House. All pledged to bend the curve. This is mostly public relations. Does anyone believe the American Medical Association can control the nation’s 800,000 doctors or that the American Hospital Association can command the 5,700 hospitals?…

The main aim of health-care “reform” being fashioned in Congress is to provide insurance to most of the 46 million uncovered Americans…But the extra coverage might actually worsen the spending problem.

How much healthier today’s uninsured would be with that coverage is unclear…

The one certain consequence of expanding insurance coverage is that it would raise spending…

It’s easier to pretend to be curbing health spending while expanding coverage and spending. Presidents have done that for decades, and it’s why most health industries see “reform” as a good deal.