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There is no magic wand to fix health care


Silver bullets are especially attractive to politicians on the campaign trail — the cost of health care has been a hot topic during the presidential debates.

For decades, the magnitude of U.S. health-care spending and the portion of our public budgets it consumes (now nearly 18 percent of the U.S. economy) have drawn attention, with a spectrum of ideas proposed to reduce the growth in spending. Recent reports indicate that health spending is accelerating to about 5 percent growth per year. The latest outcry is around prescription drug spending, which is the area with the greatest growth.

American health care seems particularly susceptible to silver bullet thinking: delivery reforms, programs or policies that will reduce spending or increase access without hurting the patient experience, reducing quality, or reducing access to choices about our care. But there is no free lunch in health care. It will be nearly impossible to reduce health spending without affecting one of these areas. 

Empirical research has left many of these proposed plans debunked. Examples include the idea that if we insure more Americans, they will get care at a primary care office and not an emergency room, reducing spending overall. (Spoiler, those who gain coverage increase their emergency department use). 

Other examples involve information technology decreasing service duplication, high deductible health plans reducing wasteful care while maintaining valuable care, or broad use of preventive care reducing later spending.

Unfortunately, two additional programs have recently been further discredited. Care management and wellness programs have grown by leaps and bounds in the last decade, with improvements in technology to support their use and providers and employers looking to improve care and decrease spending. 

The path to investment in care management as an improvement tool makes sense. 

Most health-care spending is concentrated in a relatively small number of patients; the top 5 percent of Medicare beneficiaries account for almost 50 percent of spending. We also know that more fragmented care delivery is associated with greater spending and worse quality

Pilot studies showed potential for savings and improvement. However, on average, on a broad scale, improvements and especially spending reductions have failed to materialize as a result of care management.

Our recent study is another building block in this evidence base — in Medicare accountable care organizations, where health-care providers have financial incentives to improve quality and reduce spending — greater care management activities were not associated with lower spending or better outcomes. The hope that better coordinating patient care across the health care delivery system would improve quality and reduce spending has not materialized at a broad scale. 

In 2018, 82 percent of large firms offered a wellness program., such as smoking cessation, weight management, exercise, nutrition, or behavioral/lifestyle coaching. Some of the early evidence on workplace wellness programs was promising — and employers are smart to think about approaches to employee health that don’t involve the health care system.

However, a randomized controlled trial recently found little benefit from a multi-component wellness program in a large employer. Despite increases in employees reporting exercise and weight management, the program found no significant differences in self-reported health or other behaviors; clinical markers of health; health care spending or utilization; or absenteeism, tenure, or job performance after 18 months. 

We repeatedly learn in health care that context matters: the chosen approach, the implementation, features of the environment, support from leadership, and the financial incentives faced. In each of these cases, there were single site, small scale successes leading up to more definitive negative studies on a broader scale. On average, the win-wins have failed to materialize.  

To be sure, we need less fragmented care, and we need to include non-health care solutions in our conception of health. Wellness programs improve employee satisfaction in a tight labor market. Care coordination programs help patients navigate a complex system and may improve patient experience

The follow-up periods for these studies are short and they have other limitations, yet they build on a growing evidence base. While care coordination and employee wellness programs may have benefits in certain populations or contexts, the preponderance of the evidence suggests they do not save money. Focusing on other potential benefits of these programs, and the costs at which they occur, makes for a more realistic discussion and subsequent set of investments. 

There are other examples of silver bullet thinking around “Medicare for all.” There is no question that in the United States we have the greatest health-care administrative costs in the world. 

Certainly, some of these do not contribute to health and may be purged with a single payer system. However, it is magical thinking to presume that we can pay for health care for everyone through Medicare for all, with no cost sharing, out of current administrative costs or reforms without significant additional investment. 

Politicians in office and on the campaign trail offer silver bullets and suggest no one will have to compromise. This simply isn’t the case; our recent study shows yet again why silver bullet thinking is misguided. Real spending reduction in health care will require tradeoffs along at least one dimension: access, patient experience and choice, or quality. 

Carrie Colla is a health economist at The Geisel School of Medicine at Dartmouth and a public voices fellow of the OpEd Project.

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