Brattleboro Reformer

Ms. (Dr.?) Wallack states that the purpose of OneCare is to replace fee-for-service medicine, which she argues “is, in large part, responsible for the unsustainable growth in health care costs in the U.S.”

But is it? If so, then why is Canadian medicine so much cheaper than ours, when it too relies on fee for service? In Canada, “Doctors in private practice are generally paid through fee-for-service schedules that itemize each service and pay a fee to the doctor for each service rendered” (https://www.canada). In 2018 per capita expenditure for health care in the US was $10,586 while in Canada it was $4974. Life expectancies were 78.69 years in the US vs 82.20 in Canada. In short, Canadians pay less than half what we do for better results and something other than “fee-for-service” must account for this difference.

The best rationale I’ve heard behind the attack on fee-for-service is that practitioners are incentivized to do more and provide more tests than necessary, since they can then make money on these additional tests and procedures. There are certainly plenty of anecdotal examples of tests and procedures being prescribed when most objective observers believe they shouldn’t have been. (In many cases, this is due to misplaced faith in medical technology — e.g. excessive stents and bypasses for heart patients — rather than financial avarice.)

But are over-testing and unneeded procedures really so rampant as to more than double the cost of keeping people healthy? That might make some sense in a system where there were more practitioners than required, that is, where the supply of medical procedures significantly outweighed demand. But in fact, in the US, the exact opposite is true: the demand for primary care medicine vastly exceeds our ability to provide it.

So there’s no financial incentive at all to do more for each patient when practitioners can make still more by seeing more patients and there are more than enough patients out there requiring care (as we can see from ER visits) to fill any practitioner’s schedule way beyond what he or she can provide. Succinctly put, medical demand vastly overwhelms supply.

If my reasoning is correct, then OneCare is solving a problem which isn’t really significant, while ignoring the problem which really matters, which explains why, despite the benefits Wallack points out in her column, the costs (which her column silently ignores) have vastly exceeded the benefits. Again, if my logic is correct, there is no reason at all to believe that this will change in the future as OneCare “settles in,” so to speak.

One last thought. It seems to me that the most salient difference about the US system when compared to other systems is the cost of administering a system where every payer has different rules and regulations about what it will or will not pay. Doctors’ offices are now full of people whose sole job is billing patients, not to mention the hospital staff doing similar work. None of these jobs makes patients any healthier, but they all add significant cost to the system. Unless I’m mistaken, that is where the excess cost is and OneCare is actually exacerbating it, rather than fixing it.

I don’t have any expertise in this area, so I’d be most grateful to anyone who can respond to the issues I’ve raised and show me the error of my ways. Otherwise, it seems to me that it’s time to end the OneCare experiment and to focus on providing universal primary care in Vermont.

John Greenberg writes from Marlboro. The opinions expressed by columnists do not necessarily reflect the views of Vermont News & Media.