Thursday, February 17, 2011

Question for Progressives

Why is it that with health care, the presumption is that we need an intermediary for routine predictable transactions? Or even non-routine care but that isn't necessarily of the urgent life threatening variety (an MRI, a colonoscopy, etc.)? Why is that a more efficient process than giving people either cash or something akin to an in-kind benefit along the lines of food stamps where people would have a debit card that has restricted purchasing abilities*?

If you insist that there is an intermediary to each transaction, then there will be a considerable amount of overhead costs to facilitate transactions that in other industries don't exist. On its face this is an inefficient set up. Why should someone that practices family medicine need anything more than one staff member who functions effectively as his bookkeeper and scheduler. That additional overhead gets passed on to you in the form of premiums to pay for more staff at the providers office to chase reimbursements and more staff at the insurer to process claims. But additionally, the only possible avenue for cost control is top down as opposed to a bottom up manner that we find in most industries. If I am spending my money directly then I have an incentive to minimize my expenses. For instance, if I have to get a colonoscopy, something that does constitute a significant and expensive procedure, but not urgent, I can research prices and reputation and make a more informed decision. If we make price information available I think initially we will find a wild variance in pricing but that will come down, resulting in significant savings to the average consumer. None of this I think is terribly controversial but it seems that we view health care in such a manner that all rules that apply to other goods and services don't to health care.

* I think the non-paternalistic alternative to providing lower income folks with free or massively subsidized insurance is to just give them cash. The obvious criticism here is that lower income folks having many needs and wants and very little cash will forgo care for other things both wise or unwise. I think there is a middle ground to providing cash and a strictly in kind benefit and that would be something along the lines of a medical debit or credit card that has strict restrictions on purchasing. To a doctor this would be as good as cash but to a grocer it would be worthless thus it would seem to address the fear with someone forgoing necessary care but still retain the efficiency of reducing the parties to a routine transaction.


Jeffrey said...

Well, you're partially right - health care is an area in which the same rules that apply to other goods and services don't apply. Health care isn't a simple commodity that people can choose to buy or not buy based on taste or whims, it's fundamental to basic existence. Plus, its costs are related to societal forces above and beyond market pressures - if beef gets too expensive, I can substitute chicken or tofu. If colonoscopies get too expensive, I can't really substitute a guy in a back alley sticking his finger up my rear end.

xtra said...

good points, though, i would say that deciding between a colonoscopy and getting anally probed in an alley is probably a false choice. My guess is that right now there is pretty significant dispersion in prices amongst providers and even amongst consumers at a single provider due to differing negotiated reimbursement rates. Providing someone with an incentive to comparison shop would provide more pressure for pricing transparency and ultimately yield greater information thus pushing prices down... Or getting anally probed in an alley.