Declaring a full-scale revamping of health-care quality and population health while lowering costs is a daunting task. That tension is highlighted by what Yale University professor William Kissick calls “the iron triangle” of health care: quality, cost and access. Each component competes for resources at the expense of the others. Costs can be cut but, if that is done unwisely, quality and access suffer. Access can be broadened, but it inevitably will cost more and may harm quality. Improving quality also likely will cost more and may restrict access.
Put differently, it is a version of the project management triangle: cheap, good, fast …pick two.
There is a growing sense that, regardless of the implementation of the ACA, the U.S. is running out of time to deal with the pernicious nature of health-care costs. They are approaching 20 percent of the U.S. economy—crowding out other government priorities, diminishing workers’ wages, businesses’ profits and household savings.
There is no shortage of proposed solutions to this mess. Physician Harvey Fineberg, IOM president, compiled an outstanding laundry list in a 2011 lecture at the Massachusetts Medical Society: “single-payer system, an all-payer system, increased competition, reduced fragmentation, a change in physician payments, technology assessment, information technology, increased oversight, decreased regulation, malpractice reform, consumer choice, patient-centered care, systems to ensure patient safety and increase quality, lean design principles of production, systems engineering, managed care, educational reform and a new professionalism.”
Most practitioners and policy wonks have heard each of these ideas proffered at one time or another as silver-bullet answers to health care’s inefficiency or ineffectiveness.
Bruce Vladeck, former administrator under President Clinton for what is now the Centers for Medicare and Medicaid Services, wrote about the false hope of managed care in the 1990s. He said the myopia that surrounds a transcendent idea begins when a “modestly successful innovation is hyped as the unique and unitary solution to some complex, persistent problem.”
Urban Institute fellow Dr. Robert Berenson and colleagues, attempting to dampen what they considered unrealistic expectations about the immediate potential of patient-centered medical homes, said, “It would not be the first time a promising policy idea was judged a failure because of premature promotion.”
Yale Professor Emeritus Theodore Marmor and University of North Carolina Professor Jonathan Oberlander are even blunter about these seemingly simple solutions: “The United States has been singularly unsuccessful at controlling health-care spending. During the past four decades, American policymakers and analysts have embraced an ever-changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing.
“Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical-care spending… [A]ccountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern… [T]he United States persistently pursues health policy fads—despite their poor record—and the promotion of panaceas obscures critical debate about controlling health-care costs. Americans spend too much time on the quest for the ‘holy grail’—a reform that will decisively curtail spending while simultaneously improving quality of care—and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, system-wide fee schedules, and concentrated purchasing.”
They conclude that “the American quest for cost-control fads hasn’t worked—which helps explain why the U.S. keeps searching for more panaceas.”