“Dentist shortage leads man to superglue own tooth.”

In the most recent issue of the health policy journal Health Affairs, Duke law professor Clark Havighurst reviews Healthy Competition, authored by Mike Tanner and me. I believe the full review requires a subscription, but here are some excerpts:

“One of the book’s most interesting and original policy ideas would have Congress allow consumers to select a health plan regulated by a state other than their own…

“Healthy Competition provides extensive and creative suggestionsfor expanding the role of cost-conscious consumer choice in both Medicare and Medicaid…

“Other provocative libertarian ideas laid out in the book include the authors’ argument that federal regulation of prescription drugs and medical devices may cause more deaths than it prevents. In this case, they provide persuasive responses to concerns that an unregulated market would wreak havoc on patients, observing how private researchers and other groups already certify or otherwise test and confirm the safety and efficacy of prescription drugs for various off-label uses.

“Finally, the authors strongly criticize policies that foreclose a market for transplantable organs, citing evidence that relatively low payments would increase the supply of organs, saving thousands of lives…

“Healthy Competition…is a valuable challenge to the health policy community to take health policy debates to a moral plane where consumer welfare and individual freedom are given more than just lip service.”

Havighurst does have criticisms of the book, such as that it “ignores the challenging practical problems of integrating [health savings accounts] with various kinds of health insurance.” 

I found that part odd, since Healthy Competition spends some ink discussing how the rigid insurance requirement makes HSAs unworkable for many consumers. We argue that Congress should eliminate that requirement entirely, which “would allow anyone to combine an HSA with their existing coverage, instantly making HSAs a feasible option for millions” (p. 70). 

In fact, I’ve always regarded that proposal as eminently compatible with the suggestions that Havighurst and Mark Hall have made about integrating HSAs and managed care. 

The health insurance industry has proposed $300 billion in taxpayer subsidies for … the health insurance industry. 

We are shocked. 

Self-only coverage:

• Minimum deductible: $1,100
• Maximum HSA contribution: $2,850
• Out-of-pocket maximum: $5,500

Family coverage:

• Minimum deductible: $2,200
• Maximum HSA contribution: $5,650
• Out-of-pocket maximum: $11,000

Thanks to Business Insurance for the info and HSA Insider for the pointer.

Q: Should the lame-duck GOP Congress, as its final act, implement the recommendation of the Federal Accounting Standards Advisory Board that deficit estimates include the cost of future Social Security and Medicare benefits as well as current benefits?

A: ?

Earlier, Michael Cannon blogged about a recent discussion between him and Harvard’s David Cutler on the health outcome effects of increasing consumers’ price sensitivity for the costs of their care. (Translation: Have consumers deal directly with some of the costs of their care, using such mechanisms as co-pays, HSAs, etc.)

Cutler worries that increasing consumers’ price sensitivity will worsen Americans’ overall health. Though heightened price sensitivity has the positive effect of reducing the use of expensive health care of dubious value, it also reduces consumer use of health care that is of value — an outcome supported by the landmark Rand Health Insurance Experiment. The undesirable result, Cutler says, is worse health outcomes.

Cannon responds that a broader use of price-sensitivity mechanisms would invoke supply-side market responses such as lower prices. The undesirable result of worse health outcomes may thus be avoided (and, perhaps, better outcomes might result).

In following this discussion, I have a question: Is worse health outcomes necessarily undesirable, especially in this circumstance?

The value of having consumers deal directly with some of the costs of their care is not simply because doing so will reduce the use of dubious health care. The real value is that it increases consumers’ appreciation of the costs and benefits of their care and allows them to decide the tradeoffs between those costs and benefits.

Suppose an extremely expensive treatment would provide a consumer with a modest, but very real, positive health outcome. Some consumers may quite rationally choose to put their money toward other uses (ranging from necessities to a “Last Holiday”). On the “health outcome” measure, that decision would be a negative one, but on the “overall welfare” measure, that would be a positive.

Under a zero-price-sensitivity health care model, consumers wouldn’t have that choice. They would have already paid for their health care through their insurance premium (or worse, elected to forgo insurance because the premium was too expensive), and so any health care benefit they could receive under their health plan would be “use it or lose it.” So why not take the expensive treatment that yields modest results? Whereas, in a sensitivity model, consumers could quite rationally elect to keep their co-payments and HSA money in some situations.

This is not to say that people are wrong to worry about worse health outcomes, or about consumers making questionable choices. But the worriers do have an intellectual IOU outstanding: Do worse health outcomes necessarily mean worse welfare, if consumers can put their health care money toward other uses?

Better health outcomes are preferable to worse outcomes ceteris paribus. But, with price sensitivity mechanisms like co-pays and HSAs, the ceteris isn’t paribus. (My apologies to Latinists).

At yesterday’s Cato policy forum on pay-for-performance (P4P) in Medicare, I argued the Medicare bureaucracy should stay out of P4P largely because Medicare would ruin the idea. A Medicare-administered P4P program would be less flexible than private efforts, more likely to harm patients, and the very providers that P4P aims to discipline would have way too much say in a Medicare P4P program. I recommended confining P4P to private Medicare Advantage health plans. Read my full argument here.

Harvard’s David Cutler argued that Medicare should get involved in P4P because private insurers didn’t have the purchasing power to really force providers to change. At the time, I was unaware of this study by Meredith Rosenthal and her colleagues in this week’s New England Journal of Medicine. They report:

More than half the HMOs, representing more than 80%of persons enrolled, use pay for performance in their providercontracts. Of the 126 health plans with pay-for-performanceprograms, nearly 90% had programs for physicians and 38% hadprograms for hospitals.

That probably doesn’t match Medicare’s purchasing power. But it does suggest that P4P can gain a toehold through the private sector.