Health Care Anew

Moving Responsibility from Individuals to Institutions

 Listening to the radio while driving home from a shopping trip yesterday afternoon, I was much taken by a story about how hospitals in Massachusetts are refusing to allow elective inductions of obstetrical labor or caesarean sections before the 39^th week of pregnancy.

It seems that with the great improvements in neonatal care, mothers and obstetricians have been delivering babies earlier and earlier, often as a matter of convenience rather than for medical reasons.  While most of these babies do perfectly well, a number of them need expensive intensive care and the incidence of complications is higher than it is for those delivered later.

What struck me was that the decision was being attributed to hospitals – not to individual physicians, the medical society, the Department of Health or to the College of Obstetrics and Gynecology.

The story also reported that the Texas Medicaid program is now refusing to pay for induced deliveries and caesarean sections before the 39^th week of gestation unless medically justified.

Consistent with fair journalism, the story included interviews with mothers who were in opposition, suggesting that the motive was to save money, complaining that they were being deprived of their rights and arguing that such decisions ought to be in the hands of patients and their doctors.

It all reflects the need to get used to the idea that responsibility for our health care is moving from individuals to institutions.

It may be uncomfortable, but it is inevitable. 

I have long believed that the best way, perhaps the only way, to get health care providers to become serious about cost control was to create competition that caused them to fear losing patients unless they did so.

I have also believed that because the economics of health care are unique, the forms taken by the competition would also have to be unique.

Well, we now apparently have an example.

Health insurance companies in Massachusetts have created policies that they call “tiered.”  Subscribers still have free choice of hospitals, but if they go to ones that have high cost, the deductible will be higher.  The range is something like a $150 deductible for a low-cost hospital and $1,500 for a high-cost alternative.

It seems to be having an effect.

The December 7 issue of the Boston Globe has a front page story about a cost reduction effort at Brigham and Women’s hospital – which is in the high-cost category.  Concern about the implications of the new “tiered” insurance plans was mentioned in the article, as was the Brigham’s experience last year of having Harvard Vanguard, the state’s largest medical group, shift a portion of its admissions to the nearby Beth Israel Hospital where costs were lower.

It all reminds me of the quotation that is taken from Abraham Lincoln’s second address to Congress and provides the title for this blog:

“As our case is new, so we must think anew, and act anew. We must disenthrall ourselves, and then we shall save our country.”