Uwe Reinhardt responds to Kip Sullivan's last comments:
Kip:
I think we can put this baby to bed as follows:
1. It is agreed that, relative to keeping the elderly in the traditional Medicare (enhanced by a drug benefit), funneling the same tax dollars through private health plans will either not buy the elderly the same health care services or the elderly have to put extra money on top. Thus, for the health plans or anyone else to sell that idea, they would have to convince us that for the same money, we will get different services that will represent higher quality care (e.g., through disease management). That is a hope but not a reality.
2. On the role of managed care during the 1990s, I agree that there is something to all of your arguments--the insurance cycle, the Hillary effect, and so on--but I am struck that when I plot real health spending per capita from 1965 to 2000, how smooth that line basically has been, in spite of insurance cycles and preemptive lying-low in the face of cost-containment talk in the past several decades. There has never been such a dramatic bending down of that curve as occurred during 1922-1997-8. Furthermore, I find it hard to believe that the discounts the plans wrung out of providers and the reduction in ALOS did not yield at least some savings.
Thus, I conclude that this argument is not settled and that the data allows us each to our maintain hypotheses.
3. As to Luft and Miller, they presented a truly detailed revisit of their earlier study last year at a conference. Once again, the results were inconclusive. I will not accept it as a working hypothesis that managed care lowered the quality of the patient's health care, although it did probably lower the quality of some providers' life.
Best regards,
Uwe
Sullivan responds to Reinhardt Kip Sullivan responds to Uwe Reinhardt:
From Uwe Reinhardt's last message:
<< As to Luft and Miller, they presented a truly detailed revisit of their earlier study last year at a conference. Once again, the results were inconclusive. >>
Kip Sullivan:
Uwe, Do you know if Luft and Miller's new review excluded studies that didn't control for coverage differences? If it did not, why do you give its conclusions any credability
The most galling of the studies cited by Miller-Luft in their 1994 and 1997 reviews were studies that compared doctors treating Medicare patients in HMOs with doctors treating patients in FFS Medicare without controlling for coverage differences. The complete scam works as follows:
(1) Taxpayers overpay Medicare HMOs,
(2) Medicare HMOs use the subsidy to pay for better coverage (e.g., cancer screens),
(3) researchers with a fondness for HMOs come along and examine whether Medicare HMO docs are better than Medicare FFS docs on process measures (e.g., use of cancer screens) and outcome measures (e.g., stage of cancer at diagnosis) likely to be affected by the coverage difference and,
(4) lo and behold, the HMO docs come out looking better.
I think the scholars who wrote these studies, the editors who accepted them for publication, and others like Miller and Luft who describe them as unusually good studies, are guilty of thought processes so flabby their behavior rises to the level of malpractice.
Evidence-based medicine is now the new religion within the American health policy community. But the health policy community has yet to apply the same standard to itself. If a group of doctors conducted a study comparing the effectiveness of Drug A to Drug B, and they deliberately set it up so that the group getting Drug A took drug A on schedule because they had excellent drug coverage, while the group getting Drug B took Drug B erratically because they had no health insurance, they would be laughed out of the profession. Not so in the health policy community. Health policy analysts who design such shabby experiments are held up as scientists par excellence.
Do you agree with my statement that studies that compare docs treating un- or under-insured FFS patients with HMO docs treating fully insured patients are studies so flawed they shouldn't be published, much less held up by Miller-Luft as among the 44 best studies published between 1980 and 1997? Can you tell me if Miller-Luft's new review examined only those studies that controlled for coverage differences?
Thanks.
Kip