One-Size Health Care Doesn’t Fit All

One of the downsides of paying for health care through insurance is that patients have less incentive to conserve scarce resources. For example, someone who pays for medicine with savings will consider carefully whether a prescription is really helpful, whereas someone who goes through insurance will be more likely to take whatever his or her doctor suggests. Relying on insurance can lead to wasteful health care spending; putting people in charge of their own health care resources leads to greater efficiency in the market for care.

This column by Mary Jo Feldstein in the Post-Dispatch makes the same point about the waste caused by insurance, but comes to a different conclusion from mine. Feldstein describes a study that found no benefits from living in areas where more intensive medical treatment takes place (more days in the hospital, more tests and procedures, etc.). St. Louis is one of the areas with more intensive treatment. Therefore, Feldstein writes, St. Louisans need an attitude adjustment:

Too frequently physicians see survival as the only good outcome and they try to push for every treatment, test and procedure no matter the likely outcome.

The latest thinking asks them to expand their definition of success to include a peaceful dying process. While Wennberg and Fisher’s data shows change is needed in some areas, including St. Louis, shifting regional treatment patterns is not a complete solution. Their research should continue to inspire changes in medical education and physician payments. […]

Understanding death as a natural phase of life is a cultural shift that will need to occur in the local medical community and the community at large.

In other words, because providing every procedure to every patient is wasteful, all patients need to give it up (the "cultural shift") and die graciously.

There’s a middle ground between, on the one hand, insurance paying for every available treatment, and on the other, all patients foregoing treatment and resigning themselves to their ends. People could use HSAs to cover some medical tests and treatments, and they could decide for themselves which treatments will improve their lives. It’s easy to say that too many tests are bad because a study found they didn’t improve quality of life on average. But maybe there are a few people out there who would have greater peace of mind from the extra, "unnecessary" tests. Patients differ in their willingness to take risks and try new approaches. Rather than telling physicians to cut out the risky procedures, defining risk by a single standard for everyone, patients themselves could decide what level of risk is acceptable to them. And patients differ in their attitudes towards death, too — some accept it easily, while others would prefer to try any procedure that could prolong life. There’s no need for everyone to come to a consensus; when people pay for care directly, they can vote with their feet.

We don’t need everyone to shift one way, or take the same approach to medical treatment. We should change the way the system works so that patients can express their own preferences.