Controlling Health Care Costs
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In their recent articles on rising health care costs, economists Paul Ginsburg (Oct. 14 issue)1 and Joseph Newhouse (Oct. 21 issue)2 and presidential candidates John Kerry and George Bush (Oct. 28 issue)3 do not directly address the well-known fact that approximately 10 percent of patients account for 70 percent of costs.4 To control costs we must acknowledge this skewed distribution and honestly address the major factor driving costs: the growth of technology.5 Managed care's lack of candor undermined its efforts to control costs and led to patient backlash.6 Since rationing is politically untenable, government has retreated from these issues. And current efforts at patient cost-sharing with caps will not curb spending for those with high utilization.
However, in order to obtain basic health care, some patients are willing to accept limits on care. We need efficient insurance systems in which patients willing to accept such limits are linked with caring physicians who use innovative practice styles and consider both costs and benefits as they care for their patients. Although this approach may make some uncomfortable, it is both ethical and necessary.
Elmer D. Abbo, M.D., J.D.
University of Chicago
Chicago, IL 60637
eabbo@medicine.bsd.uchicago.edu
References
Ginsburg PB. Controlling health care costs. N Engl J Med 2004;351:1591-1593.
Newhouse JP. Financing Medicare in the next administration. N Engl J Med 2004;351:1714-1716.
Bush GW, Kerry JF. Health care coverage and drug costs: the candidates speak out. N Engl J Med 2004;351:1815-1819.
Berk ML, Monheit AC. The concentration of health care expenditures, revisited. Health Aff (Millwood) 2001;20:9-18.
Newhouse JP. An iconoclastic view of health cost containment. Health Aff (Millwood) 1993;:152-171.
Havighurst C. How the health care revolution fell short. Law Contemp Probs 2002;65:55-101.
To the Editor: Dramatic advances in medicine and technology have resulted in widespread benefits from lifesaving but expensive devices and drugs such as implantable cardiac defibrillators, drug-eluting coronary stents, and new chemotherapeutic agents. Interestingly, three of the four options for reducing rising health care costs proposed by Dr. Ginsburg would require people to obtain less medical care. If our society continues to reject limitations on health care acquisition, one reality must be faced by all: whenever technological advances occur, there are increased costs to individuals (for example, automobiles cost more than horses and buggies, televisions cost more than radios, and air travel costs more than rail travel). Our hope is that, over time, cost containment can occur as a result of three mechanisms: reductions in the price of technologies through free-market competition, medical-liability reform (which will reduce the practice of defensive medicine),1 and the growth of information technology, leading to a more efficient system.2,3 Until then, the American people must assume some personal responsibility for financing the most advanced health care system in order to continue to reap its benefits.
Steven G. Coca, D.O.
Elliot Ellis, M.D.
Yale University School of Medicine
New Haven, CT 06520
Kirk N. Campbell, M.D.
Mount Sinai School of Medicine
New York, NY 10029
References
American Medical Association. Medical liability reform: a compendium of facts supporting medical liability reform and debunking arguments against reform, December 3, 2004. (Accessed January 6, 2005, at http://www.ama-assn.org/ama1/pub/upload/mm/450/mlrnowdec032004.pdf.)
Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003;139:31-39.[Abstract/Full Text]
New Democrats Online. Health information networks to improve safety and reduce costs. May 2004. (Accessed January 6, 2005, at http://www.ndol.org/ndol_ci.cfm?kaid=139&subid=275&contentid=252620.)
Dr. Ginsburg replies: Dr. Abbo correctly points out that the large proportion of spending for the relatively small group of patients with high medical expenses limits the role that patient cost-sharing can play in containing costs, and his point about some patients' willingness to accept limits in return for access to important care is well taken. However, I must disagree with the prediction of Dr. Coca and colleagues that we can contain costs without some sacrifice — that easy gains in efficiency are possible if only we pursue them. Inevitably, the gains do not pan out. Today's promises are that expanded information technology and malpractice reform will yield large enough savings that trade-offs will not have to be faced. These steps are worthy ones, but we should not oversell the likely cost savings.1
The challenge of effective cost containment is to encourage access to new medical technologies that provide important improvements in outcomes while discouraging the use of high-cost treatments with small or unknown benefits. Too often, our health care system allows the rapid diffusion of new technologies without rigorous examination of their effectiveness in comparison with that of existing treatments. Sometimes, much-heralded new technologies turn out to have small benefits or even to cause harm — Vioxx comes to mind. The reality is that we as a society do not have the resources to provide all the care that patients might want and physicians might want to provide. Without effective cost containment, the result will be increased rationing on the basis of ability to pay, rather than rationing based on clinical effectiveness. In the end, we have to answer this question: Is it better for many to do without low-value services or for the few who cannot pay to go without important care?
Paul B. Ginsburg, Ph.D.
Center for Studying Health System Change
Washington, DC 20024
References
Congressional Budget Office. Limiting tort liability for medical malpractice: economic and budget issue brief, January 8, 2004. (Accessed January 6, 2005, at http://www.cbo.gov/ftpdocs/49xx/doc4968/01-08-MedicalMalpractice.pdf.)
However, in order to obtain basic health care, some patients are willing to accept limits on care. We need efficient insurance systems in which patients willing to accept such limits are linked with caring physicians who use innovative practice styles and consider both costs and benefits as they care for their patients. Although this approach may make some uncomfortable, it is both ethical and necessary.
Elmer D. Abbo, M.D., J.D.
University of Chicago
Chicago, IL 60637
eabbo@medicine.bsd.uchicago.edu
References
Ginsburg PB. Controlling health care costs. N Engl J Med 2004;351:1591-1593.
Newhouse JP. Financing Medicare in the next administration. N Engl J Med 2004;351:1714-1716.
Bush GW, Kerry JF. Health care coverage and drug costs: the candidates speak out. N Engl J Med 2004;351:1815-1819.
Berk ML, Monheit AC. The concentration of health care expenditures, revisited. Health Aff (Millwood) 2001;20:9-18.
Newhouse JP. An iconoclastic view of health cost containment. Health Aff (Millwood) 1993;:152-171.
Havighurst C. How the health care revolution fell short. Law Contemp Probs 2002;65:55-101.
To the Editor: Dramatic advances in medicine and technology have resulted in widespread benefits from lifesaving but expensive devices and drugs such as implantable cardiac defibrillators, drug-eluting coronary stents, and new chemotherapeutic agents. Interestingly, three of the four options for reducing rising health care costs proposed by Dr. Ginsburg would require people to obtain less medical care. If our society continues to reject limitations on health care acquisition, one reality must be faced by all: whenever technological advances occur, there are increased costs to individuals (for example, automobiles cost more than horses and buggies, televisions cost more than radios, and air travel costs more than rail travel). Our hope is that, over time, cost containment can occur as a result of three mechanisms: reductions in the price of technologies through free-market competition, medical-liability reform (which will reduce the practice of defensive medicine),1 and the growth of information technology, leading to a more efficient system.2,3 Until then, the American people must assume some personal responsibility for financing the most advanced health care system in order to continue to reap its benefits.
Steven G. Coca, D.O.
Elliot Ellis, M.D.
Yale University School of Medicine
New Haven, CT 06520
Kirk N. Campbell, M.D.
Mount Sinai School of Medicine
New York, NY 10029
References
American Medical Association. Medical liability reform: a compendium of facts supporting medical liability reform and debunking arguments against reform, December 3, 2004. (Accessed January 6, 2005, at http://www.ama-assn.org/ama1/pub/upload/mm/450/mlrnowdec032004.pdf.)
Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003;139:31-39.[Abstract/Full Text]
New Democrats Online. Health information networks to improve safety and reduce costs. May 2004. (Accessed January 6, 2005, at http://www.ndol.org/ndol_ci.cfm?kaid=139&subid=275&contentid=252620.)
Dr. Ginsburg replies: Dr. Abbo correctly points out that the large proportion of spending for the relatively small group of patients with high medical expenses limits the role that patient cost-sharing can play in containing costs, and his point about some patients' willingness to accept limits in return for access to important care is well taken. However, I must disagree with the prediction of Dr. Coca and colleagues that we can contain costs without some sacrifice — that easy gains in efficiency are possible if only we pursue them. Inevitably, the gains do not pan out. Today's promises are that expanded information technology and malpractice reform will yield large enough savings that trade-offs will not have to be faced. These steps are worthy ones, but we should not oversell the likely cost savings.1
The challenge of effective cost containment is to encourage access to new medical technologies that provide important improvements in outcomes while discouraging the use of high-cost treatments with small or unknown benefits. Too often, our health care system allows the rapid diffusion of new technologies without rigorous examination of their effectiveness in comparison with that of existing treatments. Sometimes, much-heralded new technologies turn out to have small benefits or even to cause harm — Vioxx comes to mind. The reality is that we as a society do not have the resources to provide all the care that patients might want and physicians might want to provide. Without effective cost containment, the result will be increased rationing on the basis of ability to pay, rather than rationing based on clinical effectiveness. In the end, we have to answer this question: Is it better for many to do without low-value services or for the few who cannot pay to go without important care?
Paul B. Ginsburg, Ph.D.
Center for Studying Health System Change
Washington, DC 20024
References
Congressional Budget Office. Limiting tort liability for medical malpractice: economic and budget issue brief, January 8, 2004. (Accessed January 6, 2005, at http://www.cbo.gov/ftpdocs/49xx/doc4968/01-08-MedicalMalpractice.pdf.)