Proposed Reform Leaves Unanswered Questions

In the runup to reform, here's a list of several questions Congress is forgetting

August 7, 2009 -- If we are to have a regulatory bend to our health policy and believe this is the road to controlling costs, then why are we not discussing the following:

· Regulating the available supply of physicians according to population needs? Kaiser operates with a ratio of physician to population that has 40 percent fewer physicians than what’s available in the general market.
· Regulating the personal incomes of the industry as the vast majority of expense.
· A public takeover of the ownership of all hospitals as already quasi-public facilities that will be 100 percent funded by a highly regulated financing system? How does it make sense to highly regulate financing while preserving a largely unregulated source of supply?
· Extending single payer logic to single provider where there is far more economic leverage?
· If we wish to spend less on healthcare, why don’t we know which sectors will feel that constraint? How can we possibly know the merits of any strategy if we do not know the specific costs to be controlled and how to measure those results?
· Is it good positioning to defer this matter to a government process given its own financial ruin, intense politics, vested interests and historical role in creating the problem?
· Is our tolerance for public cost shifting a device to obscure real costs? Why do we embrace the logic of enhanced public leverage on provider prices while lamenting cost shifting to the private sector?
· Is subsidized free care conducive to lowering healthcare costs? If nearly half of all care rendered delivers no medical benefit and we wish to remove financial barriers to access, what will replace those barriers?
· Is changing how we pay providers going to alter economic destiny given the history of all the unsuccessful efforts along those same lines? What is the difference between a failed gatekeeper concept and the yet to be embraced medical home?
· Pay for performance is all about giving providers more upside to compensation levels that are in many cases multiples of their counterparts in European and Asian countries. Why aren’t we just de-licensing providers at the low end of the performance chain? That would be too mean. If we are to incent providers, why not members? If you have a $20,000 claim this year, your premium obligations go up to 35 percent next year. Conversely, if you have little or no claims, why shouldn’t your premium be reduced?  
We need to come to terms with the profound evasiveness of controlling costs. Most people can recognize there’s no credible strategy in the reform movement. Instead there’s lots of unproven beliefs that in retrospect could be viewed as a “con job” when reality rolls onto the stage.

When are we going to take complete stock in how we got to where we are based on the well meaning policy of the day that magnified downstream problems?


Stephen Gregg is a retired hospital administrator and health plan chief of staff. He can be reached at [email protected].

For a list of Gregg's previous commentaries, click here.


Dear Steve Gregg, Will you add material to clarify what you have written about the "failed gatekeeper", and whether you are talking about executive salaries or caregiver salaries? What well-meaning policy of the day are you talking about and whose is it? In your view, what are the unproven beliefs about this issue?