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Originally published Friday, March 21, 2008 at 12:00 AM


Better incentives could make health care safer, more affordable

WITH the presidential race in full swing, the electorate, candidates and various advocacy groups view health care as a top concern. Nearly all agree Americans...

Special to The Times

WITH the presidential race in full swing, the electorate, candidates and various advocacy groups view health care as a top concern. Nearly all agree Americans need better coverage, improved quality and more-affordable health care.

The leading Democrats emphasize building on employer-based coverage and adding a government-run health-care pool with subsidies for those who can't afford premiums. The top Republicans tout a system of new tax credits to encourage more individuals to buy their own insurance, thus boosting access to covered care.

But rarely do the candidates address a fundamental question: How can everyone, including the currently uninsured, get better care — without more money being spent? This higher-quality care must also be more efficient, evidence-based and focused on prevention. But, our nation's health-care system is built on the wrong incentives. Doctors, hospitals, drug companies and others now stand to make big money by providing care that's excessive, inappropriate or likely to do more harm than good.

Health researchers like Dr. Rick Deyo understand these incentives well. The former University of Washington professor of family medicine published research in the early 1990s that linked spinal-fusion surgery for back pain to higher costs and more complications than other back operations. In turn, angry spine surgeons lobbied Congress to cut funding to the federal agency that had sponsored Deyo's studies and had drafted guidelines for noninvasive care based on his research.

Deyo, now at Oregon Health & Science University, fought back, advocating for other scientists who face intimidation when their findings don't support profit motives in the health-care industry. In his 2002 book, "Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises," he described researchers in our community and across the nation who have been threatened with losing their livelihoods and their reputations for publishing unpopular conclusions.

Such pressure has only grown stronger in recent years, often steering the health-care system further away from the evidence-based solutions that promise to make health care more affordable, safer and more patient-centered. Problems associated with current market-based incentives can harm patients and health-care purchasers alike.

One big concern is the impact of such forces on primary care. All U.S. payers — including government and private insurance companies — now provide higher reimbursement for specialty visits than for lower-tech, high-touch care. As a result, health systems find it hard to justify investment in innovations that promote better care for chronic illnesses and more coordination of care.

Current commercial incentives are also leading to overtreatment, excessive variations in care across systems, and ill-advised "medicalization" of natural life processes and conditions, such as menopause, stress-related muscle pain, mild memory loss with aging, and death itself.

Solutions will come only when our policymakers and industry leaders realize that unfettered market forces will not fix the nation's health-care woes. If profit motives were the answer, we would not be in this current state. The United States spends more per person on health care than any other country, while ranking low among industrialized nations for such health indicators as life expectancy and infant deaths.

Tinkering with finance mechanisms alone won't solve these problems. Instead, we need comprehensive reforms that address the health and health care of our entire population. We need a system based on primary care, where doctors are encouraged to coordinate services, manage chronic conditions and educate patients on self-care strategies that prevent illness. And our nation's scientific and medical establishment should be squarely focused on finding the safest, most effective, cost-saving treatments.

As the debate over health care intensifies, I urge you to listen for such broad-based solutions — those that address the root causes of cost increases and deficiencies in quality. It's only through such systemwide changes that we'll find the resources needed to provide care and coverage for all Americans.

Dr. Eric B. Larson is executive director of Group Health Cooperative's Center for Health Studies in Seattle.

Copyright © 2008 The Seattle Times Company

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