This is a good article laying out the pros for "Personal Agency" in healthcare. Below are my counterarguments to "Personal Agency" in healthcare.
**RAND Health Study:**
This study is what started the idea of moral hazard and High Deductible Health Plan. In this study, deductibles ranged from $500-$1000. Today, deductibles can be anywhere between $6000-$12000.
Second, even in this study: "The one exception was low-income people in poor health, who went without the care they needed."
This is the underlying problem with vouchers and deductibles. They work in people who have (somewhat) disposable income, but not in people who live paycheck to paycheck.
Furthermore, we see the impact of high deductibles today. We have created a whole class of underinsured people who forego their visits to manage chronic medical problems. This will impact outcomes in years to decades down the line (a counterpoint to the Oregan Medicaid Experiment which followed people for an average of 17 months)
**On Paternalism:**
An example of paternalism is forcing people to see a doctor to get their diabetes under control.
Providing access to choices (such as insurance - and not vouchers) is not paternalism. It gives people the ability to choose and level the playing field. If people don't have insurance, or cannot afford their care due to deductibles, they don't have a choice to see a doctor to get their diabetes under control.
The reality today is that many low to middle-income people don't have access to the same choices to stay healthy. Personal agency does play a role, but so does having the ability to choose.
This is also a prelude to my upcoming series on Determinants of Health :)
I think we disagree on the distinction between supporting people and controlling their choices. Giving someone an HSA doesn’t deny them care, it expands their options. Nothing increases access like cash. That’s why SNAP gives people a cash equivalent to spend at grocery stores, not a government-designed meal plan. If we applied your logic to food, we’d create “food insurance” managed by middlemen with narrow vendor networks and pre-approved menus. But middlemen don’t create choice, they constrain it. Insurance is just that: a middleman. I’m arguing we should subsidize patients directly, not route their decisions through a bureaucracy.
And I appreciate your engagement. I always find it fascinating to talk and learn from people who hold a different viewpoint.
At a high level, I agree with what you are saying, my worry is the devil is in the details (similar to insurance). For e.g.
- We still have to submit a claim for insurance to count expense as deductible. Insurance already removes choice by creating a higher deductible for patients want to see docs outside a narrow network.
- Who pays for HSA?
- If people have to pay out of their paycheck, should this be mandatory contribution or voluntary. If it is voluntary, then how to care for people who live paycheck to paycheck and cannot contribute?
- For low income people, should govt just give everyone a voucher?
- Do people have to keep proof how they spent money (similar to how HSA works today)?
- We still have the problem of prior auths, as insurance may deny counting expense towards deductible!
These are just some of the tradeoffs that I could come up in 5 minutes, and there are many more.
We already have a system around HSA and insurance and they both have been gamed by large companies.
At the end of the day, I am not so sure that an HSA + catastrophic insurance will be any better. The tradeoffs will be different for sure, the dollar pool will be distributed a little differently, but based on how the HSA system works today, it will benefit the rich more than the poor.
Very thoughtful comments and I agree the devil is in the details. For Medicaid, I’m proposing publicly funded, means-tested HSAs that work like SNAP: cash earmarked for healthcare, deposited directly into accounts patients control.
We can apply the same claim rules for deductibles that go with private insurance. Having to track expenses and submit claims still beats the narrow networks that come with Medicaid. If they just want to spend from the HSA without worrying about deductibles, they can do that too. If people want to keep traditional Medicaid and forego the option, that also works.
I think Dr. DiGiorgio’s piece is very well stated. I see the discussion/critique as well. Both of you continue to be anchored to 3rd party payment schemes.
I am a primary care physician who has decided I want no 3rd party payment scheme. This the premise of DPC.
As we discuss and explore this, I submit I will see any patient for my stated fees. I’m chagrined to see that many of my patients are coming because the 3rd party is making access a huge barrier.
I’d submit if Medicaid came to my door and said they’ll stroke the check for their patient to be a member of the practice, and ASSUMING that patient wanted my care, I would save the taxpayer significant money in short order AND improve the patient’s health.
As Dr. D points out, not everyone wants care. No policy will address that. Many in our safety net class are poor specifically because of choices harmful to their well being. No amount of wishing corrects that.
DPC will win if big insurance and big brother gets out of our way. The irony is everyone will win if we break the stranglehold on a return of the profession.
The challenge with HSA for Medicaid is that it likely will not solve the underlying physician network problem as it does not change the fee schedule. The only difference is that instead of getting paid by the State, the patient is paying you directly (which is both a pro and a con in itself).
Means testing to decide who gets Medicaid is a big gamble in tradeoffs. The 2 vectors of tradeoffs are:
- Burden of proof vector: reduces fraud/encourages people to find work but also working people lose insurance because the burden may be too onerous (esp as these people also have many other socioeconomic stressors to deal with leading to decision fatigue)
- Cost of care vs cost of administration: To implement means testing, we need a bureaucratic apparatus in place, which carries a significant cost. Are we just shifting costs from caring for people to bureaucrats (or worse, hospital visits down the road as people lost insurance and their chronic diseases were uncontrolled)?
And finally, there is the fundamental challenge that are we making people "dependent on the State" for their healthcare (shifting the curve slowly from people in poverty to everyone). That gets us into the whole discussion of whether we should have "insurance for all" and how we pay for it as a country.
DPC is a whole different issue with pros and cons, and functions like mini-HMOs. They are great when physician-led and small, but not scalable.
Small DPCs allow docs to take some control back, but when the bargaining starts/matures (e.g. in employer-led space) --> employers will push the price down and want quality metrics-->Increasing cost for DPC-->consolidation-->changing ownership structures (e.g. PE)-->back to square one.
The underlying problem is not DPC vs FFS but the death of small practices.
What we need is a way to protect small practices (currently we protect large health systems by paying them more than small practices).
Having said that, I have considered switching to DPC model, if FFS/VBC that I am currently in, becomes too much to handle--but I also know that I will be in the same boat down the road with DPC (which keeps me from switching!).
Since when does a physician practice have to be scaled? Why have we accepted this idea that you need to bring your wares to an insurance pool? I’ve been third party free for 8 years now and guess what? Every aspect of my professional experience is far better off since kicking all these clowns out of my life. I’m happy to help you achieve escape velocity whenever you are ready. Our mindset has to change to get out of Stockholm.
This is a good article laying out the pros for "Personal Agency" in healthcare. Below are my counterarguments to "Personal Agency" in healthcare.
**RAND Health Study:**
This study is what started the idea of moral hazard and High Deductible Health Plan. In this study, deductibles ranged from $500-$1000. Today, deductibles can be anywhere between $6000-$12000.
Second, even in this study: "The one exception was low-income people in poor health, who went without the care they needed."
This is the underlying problem with vouchers and deductibles. They work in people who have (somewhat) disposable income, but not in people who live paycheck to paycheck.
Furthermore, we see the impact of high deductibles today. We have created a whole class of underinsured people who forego their visits to manage chronic medical problems. This will impact outcomes in years to decades down the line (a counterpoint to the Oregan Medicaid Experiment which followed people for an average of 17 months)
**On Paternalism:**
An example of paternalism is forcing people to see a doctor to get their diabetes under control.
Providing access to choices (such as insurance - and not vouchers) is not paternalism. It gives people the ability to choose and level the playing field. If people don't have insurance, or cannot afford their care due to deductibles, they don't have a choice to see a doctor to get their diabetes under control.
The reality today is that many low to middle-income people don't have access to the same choices to stay healthy. Personal agency does play a role, but so does having the ability to choose.
This is also a prelude to my upcoming series on Determinants of Health :)
I appreciate your engagement!
I think we disagree on the distinction between supporting people and controlling their choices. Giving someone an HSA doesn’t deny them care, it expands their options. Nothing increases access like cash. That’s why SNAP gives people a cash equivalent to spend at grocery stores, not a government-designed meal plan. If we applied your logic to food, we’d create “food insurance” managed by middlemen with narrow vendor networks and pre-approved menus. But middlemen don’t create choice, they constrain it. Insurance is just that: a middleman. I’m arguing we should subsidize patients directly, not route their decisions through a bureaucracy.
And I appreciate your engagement. I always find it fascinating to talk and learn from people who hold a different viewpoint.
At a high level, I agree with what you are saying, my worry is the devil is in the details (similar to insurance). For e.g.
- We still have to submit a claim for insurance to count expense as deductible. Insurance already removes choice by creating a higher deductible for patients want to see docs outside a narrow network.
- Who pays for HSA?
- If people have to pay out of their paycheck, should this be mandatory contribution or voluntary. If it is voluntary, then how to care for people who live paycheck to paycheck and cannot contribute?
- For low income people, should govt just give everyone a voucher?
- Do people have to keep proof how they spent money (similar to how HSA works today)?
- We still have the problem of prior auths, as insurance may deny counting expense towards deductible!
These are just some of the tradeoffs that I could come up in 5 minutes, and there are many more.
We already have a system around HSA and insurance and they both have been gamed by large companies.
At the end of the day, I am not so sure that an HSA + catastrophic insurance will be any better. The tradeoffs will be different for sure, the dollar pool will be distributed a little differently, but based on how the HSA system works today, it will benefit the rich more than the poor.
Very thoughtful comments and I agree the devil is in the details. For Medicaid, I’m proposing publicly funded, means-tested HSAs that work like SNAP: cash earmarked for healthcare, deposited directly into accounts patients control.
We can apply the same claim rules for deductibles that go with private insurance. Having to track expenses and submit claims still beats the narrow networks that come with Medicaid. If they just want to spend from the HSA without worrying about deductibles, they can do that too. If people want to keep traditional Medicaid and forego the option, that also works.
I think Dr. DiGiorgio’s piece is very well stated. I see the discussion/critique as well. Both of you continue to be anchored to 3rd party payment schemes.
I am a primary care physician who has decided I want no 3rd party payment scheme. This the premise of DPC.
As we discuss and explore this, I submit I will see any patient for my stated fees. I’m chagrined to see that many of my patients are coming because the 3rd party is making access a huge barrier.
I’d submit if Medicaid came to my door and said they’ll stroke the check for their patient to be a member of the practice, and ASSUMING that patient wanted my care, I would save the taxpayer significant money in short order AND improve the patient’s health.
As Dr. D points out, not everyone wants care. No policy will address that. Many in our safety net class are poor specifically because of choices harmful to their well being. No amount of wishing corrects that.
DPC will win if big insurance and big brother gets out of our way. The irony is everyone will win if we break the stranglehold on a return of the profession.
The challenge with HSA for Medicaid is that it likely will not solve the underlying physician network problem as it does not change the fee schedule. The only difference is that instead of getting paid by the State, the patient is paying you directly (which is both a pro and a con in itself).
Means testing to decide who gets Medicaid is a big gamble in tradeoffs. The 2 vectors of tradeoffs are:
- Burden of proof vector: reduces fraud/encourages people to find work but also working people lose insurance because the burden may be too onerous (esp as these people also have many other socioeconomic stressors to deal with leading to decision fatigue)
- Cost of care vs cost of administration: To implement means testing, we need a bureaucratic apparatus in place, which carries a significant cost. Are we just shifting costs from caring for people to bureaucrats (or worse, hospital visits down the road as people lost insurance and their chronic diseases were uncontrolled)?
And finally, there is the fundamental challenge that are we making people "dependent on the State" for their healthcare (shifting the curve slowly from people in poverty to everyone). That gets us into the whole discussion of whether we should have "insurance for all" and how we pay for it as a country.
It’s much simpler than you are making it. My prices are posted and I welcome anyone from any class in society who wants my services.
The second you price fix the market you guarantee shortages.
DPC is a whole different issue with pros and cons, and functions like mini-HMOs. They are great when physician-led and small, but not scalable.
Small DPCs allow docs to take some control back, but when the bargaining starts/matures (e.g. in employer-led space) --> employers will push the price down and want quality metrics-->Increasing cost for DPC-->consolidation-->changing ownership structures (e.g. PE)-->back to square one.
The underlying problem is not DPC vs FFS but the death of small practices.
What we need is a way to protect small practices (currently we protect large health systems by paying them more than small practices).
Having said that, I have considered switching to DPC model, if FFS/VBC that I am currently in, becomes too much to handle--but I also know that I will be in the same boat down the road with DPC (which keeps me from switching!).
Since when does a physician practice have to be scaled? Why have we accepted this idea that you need to bring your wares to an insurance pool? I’ve been third party free for 8 years now and guess what? Every aspect of my professional experience is far better off since kicking all these clowns out of my life. I’m happy to help you achieve escape velocity whenever you are ready. Our mindset has to change to get out of Stockholm.