9/19/2023 0 Comments Elsewhere brooklyn nyePalliative care caught on “despite poor reimbursement and physically and emotionally arduous workdays,” Meier wrote in a 2009 article for The Journal of Palliative Medicine. Palliative care is better for patients and their families and saves money, but it took a concerted campaign to change medical norms so that it became a subspecialty at hospitals across the United States. As an example of the latter, the Rebitzers recount the story of Diane Meier, a geriatrician who with foundation money started the Center to Advance Palliative Care. They’re helpful when they lead those physicians to do the right thing for patients even when it doesn’t help the physicians. They’re harmful when they lead physicians to ignore cost-saving innovations. Norms and narratives can be helpful or harmful. Robert Shiller, a Nobel laureate economist at Yale, wrote a whole book about the importance of the stories we tell one another, “Narrative Economics: How Stories Go Viral and Drive Major Economic Events.” They told me that when economists read drafts of the book, they said that norms and narratives were “outside of their professional competence.” Which, if true, is unfortunate. So they also call for changing the norms and narratives that sometimes produce dysfunction. The Rebitzers acknowledge that in health care, especially, economic incentives don’t always work. Another idea: “Trusted third parties could manage and attest to the validity of payments, as with credit card payments.” Standardizing and simplifying benefits would reduce the paperwork. But they would naturally worry about being cheated. A lot of costs could be saved if insurers simply paid bills as they came in. The adversarial approach to health insurance, in which insurers spend huge sums scrutinizing claims, is enormously wasteful, the Rebitzers wrote. The Rebitzers laud Choosing Wisely, a campaign of the American Board of Internal Medicine’s ABIM Foundation, which has identified more than 700 tests and treatments that are of little or no value to patients. For example, Europe used cheap antigen tests for Covid long before the United States, which relied on tests that were more accurate but cost up to $150 each and took days to produce results.Įqually problematic are treatments that are expensive but provide little benefit. Health care is one of the few parts of the economy where “slightly worse but much cheaper” is not even on the mental map, the Rebitzers wrote. Doctors have even fewer incentives to look for cost-saving solutions. Patients’ incentives to restrain health care spending are limited to whatever they spend on deductibles and co-pays. And for the drugmakers, some revenue is better than none. It wasn’t aiming to promote innovation, but the subscription plan ensured patients’ access to innovative treatments that otherwise would have been prohibitively expensive. Louisiana successfully used a sort of subscription model to ensure access to antiviral drugs against hepatitis C for people on Medicaid and in prison, the Rebitzers wrote. Solutions? One idea is a subscription model that would pay drugmakers for the availability of new antibiotics rather than for their use. There’s a term for this: “life-cycle management.” The improvements restart the clock on the patent life, giving the drugmakers more time to earn profits. In contrast, the patent system works just fine for improvements - sometimes minor - of existing pharmaceuticals. That helps explain why as of 2021, only four major pharmaceutical companies had antibiotic research programs, they wrote. So for drugmakers, there’s a risk that the new antibiotic won’t be sold until its remaining patent life is short or gone. Wise stewardship says that you don’t start prescribing a new antibiotic as long as existing ones remain effective. “Saving lives by developing new antibiotics ought to be a profitable business, but this turns out not to be true,” they wrote in their book. To promote the right kinds of innovation, they favor an approach that’s close to the hearts of economists, namely changing the incentives of the various players - doctors, patients, hospitals, insurers, pharmaceutical companies, regulators and so on - so they’re motivated to do the right things for society.ĭevelopment of better antibiotics to replace ones to which bacteria become resistant is a case in point. “A healthy system should produce innovations that provide increasing value to patients and society at a lower cost.” “We want to add a fourth vital sign, innovation,” Jim wrote in his email. Jim compared them to the ruts in a dirt road that a wagon’s wheels keep getting drawn into. Those three concerns so dominate the policy discussion that trying to change the subject even a little is almost impossible, the brothers said.
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