This commentary is by Lee Russ of Bennington, a retired legal editor who was the lead editor/author of both the third edition of “Couch on Insurance” and the Attorneys Medical Advisor.
The dire state of primary care in Vermont is now serious news, drawing the attention of everybody from the Legislature to the Vermont Medical Society to Vermont Public Radio to the Green Mountain Care Board.
We can add that problem to the problem of the outrageously high cost of health care that discourages even insured Vermonters from seeing a doctor because they can’t afford their deductibles and co-pays.
Our health care problem is deepening and expanding because it’s virtually impossible to solve a problem when you ignore all the facts about that problem. Rather than diligently searching for the best solution to the health care problem, whatever that solution might be, we have been trying to find an answer that is politically acceptable, one that won’t unduly upset the people and businesses that profit from the current system.
The “acceptable” answer we have landed on is that we need to get away from fee for service and arrive at some goal called “value-based care.” That’s now pitched as the cure-all for everything.
But there is no real-world evidence that fee for service is the major culprit in either the overall cost of health care or the shrinking number of primary care doctors. None. And, frankly, no one can really define that vague goal of “value-based care.”
Back in 2012, for example, Dr. Steven Kemble went looking for evidence that fee for service was America’s health care problem. The result was an article titled “Fee-for-service is not the problem,” in which he concluded that “it is extremely unlikely that this is the root of our health care cost problem.”
Notably, fee for service is still employed in other countries that have far lower costs than the U.S. and no shortage of primary care doctors. How could that be if fee for service was the problem? Also notable: The accountable care organization mechanism, which is designed to “improve” things by getting rid of fee for service, is failing both in Vermont and nationally.
And while “value-based care” makes a great mantra that can be endlessly repeated, it has little actual meaning out here in the real world. The one thing that seems certain about it — since it’s viewed as the solution to fee for service and the objection to fee for service is that it results in too much care — is that value-based care means less care.
The real-but-unacceptable answer to our health care problem is that we need to do something about the absurd amount of time and money that our health care system wastes on administrative costs.
There is a mountain of real world evidence that the administrative complexity of our commercial health care system, which is absolutely riddled by middlemen and endless paperwork, is the problem. A 2019 article in JAMA reported that administrative costs amount to the biggest waste of U.S. health care spending: $265.6 billion a year.
To really grasp the absurd amount of administrative effort required to keep the U.S. system going, think about this conclusion in a 2011 Commonwealth Fund report: “In the U.S., nurses and medical assistants spent 20.6 hours per physician per week on administrative tasks related to health plans, nearly 10 times the 2.5 hours spent by Canadian nursing staff.”
Will the $5 million that the Green Mountain Care Board recently requested from the Legislature to fund studying a change in direction for Vermont’s health care actually benefit Vermonters? If experience is any judge, it won’t, not any more than the many millions already dumped into the “all-payer” system did. Because we’re trying to solve the wrong problem. Still.
If all our efforts go toward banishing fee for service and it turns out that’s not the problem, what kind of future misery are we inflicting on ourselves? How much money will we have wasted on a doomed effort?
I can’t believe that all of us — legislators, regulators, people paying ever more for ever less medical care — aren’t angry enough and determined enough to insist that we finally examine whether we’re marching toward disaster while whistling a fee-for-service tune.
