At the end of Atul Gawande’s terrific article in The New Yorker on the factors that drive up American health care costs without improving health, Gawande talks about ideas for health-care reform with a surgeon named Lester Dyke who is critical of how the profit motive has corrupted health care. Dyke thinks neither a single-payer system, nor an all-private-insurer system, will do anything to control costs. Then Gawande talks about the individual “medical savings account” concept pushed under many Republican proposals over the past few years.
The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”
He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
Obviously, Gawande and Dyke are misrepresenting the Medical Savings Account model here. The idea isn’t that patients will haggle over whether to get three or four valves bypassed. The idea is that Dr. Gawande will offer to perform the quadruple-bypass for $40,000, while Dr. Dyke will say he can do it just as well for $30,000. The patient will go back to Dr. Gawande, who will move his price down to $35,000 but say his bypass is of much higher quality and can’t really be compared to that low-rent charlatan Dyke down the road. Then the patient will go back to Dr. Dyke, who will take his own final offer down to $28,000. Finally, the patient must walk out of Dr. Dyke’s office — this is the most crucial part of the negotiation, patients! Never buy any major medical procedure without letting the doctor see you’re willing to walk away from the deal! — and Dr. Dyke will run after her and make her a final, final offer of $26,000. The patient comes back, Dr. Dyke operates, and if Dr. Dyke’s services really turn out to be inferior and she dies, then next time she’ll go to Dr. Gawande.
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