Who should drive cost control efforts in health care?

Ever since I was in medical school almost 40 years ago, we have been talking about the growth of health care expenditures and how the growth rate is unsustainable. Like the proverbial frog in the heated pot, we have adjusted to increasing costs as we approach the boiling point. I believe we are approaching the boiling imminently and payers at all levels are trying to figure out how they can remain solvent while at the same time finance needed health care spending. 

The WSJ published a piece in late March of 2018 highlighting that two major issues are creating financial challenges for state budget, pensions and health care, particularly Medicaid. (WSJ). The result is crowding out of expenditures on virtually all other state functions. The effects of growth in spending diffuse across all levels of payer, public and private. Private insurers are engaged in pitched battles with large and increasingly consolidated health systems over rates while at the same time trying to move costs back to consumers, increasing deductibles and co-pays. It is getting very ugly. We recently experienced a showdown between Piedmont Healthcare and Blue Cross within the Atlanta market which required the Governor to weigh in to get the parties back to the negotiating table.  

At the same time, CMMS is searching for innovative approaches to effectively deliver health care to its covered populations at lower costs (or at least at slower growth rates). They announced a requests for comments and information on 4/23/18 (CMMS RFI). The RFI throws out a host of ideas, driven by the theme of market based approaches. It is not especially cohesive or cogent. That is not surprising since no one knows the magic formula by which were can consistently do a good job at substantially lower costs. The request is just that: for input from interested parties who can assist them in their goals. 

The responses from the physician community are fairly predictable.  We do not want to act like insurers. We never have and it places us in a very conflicted position. It is essentially impossible to act as advocates for our patients while at the same time function as stewards of system resources. That job is unpalatable and is extremely difficult (perhaps impossible) to do. The AMA has weighed in on this (AMA cost control) and from what I can tell, they take the same tack as politicians who say they will balance budgets by eliminating fraud and abuse without recognizing the underlying structural faults. The amounts saved via the former interventions are rounding errors. The real work requires very fundamental changes in how programs are structured. To take that on means taking on vested interests directly. Professional organizations like the AMA are ill equipped to take these types on jobs on. They function as guilds and are driven by member concerns. 

The Physician community does not want to do the difficult and unpalatable work of driving cost control, acting like insurers, limiting care, and explicitly pushing costs on to patients.  However, we do not want to delegate that job to any other party. We want to be in control. It boils down to whether we as physicians want to lead and exert some degree of control over whatever processes are put in place to try to control costs or whether we present the face of resistance. It is clear to me that CMMS has no real clue as to drive cost savings but I do not think we are particularly constructive in our criticism. We are basically washing our hands of the problem for the simple reason that any solutions we can come up with will either result in transfer of costs to patients (which we believe will result in them balking at payment), decrease in the amount of care activity we are engaged with (with decreased revenue), or decrease the payment per unit of work.  We don't like any of these for obvious reasons but in my opinion, we still should come to terms with whether bending the cost curve is something which is desirable or really essential. If it is, then if not us to deal with it, who then should be empowered to address it?