Saturday, March 9, 2013

Planning "solutions" to Bitter Pill by Steven Brill

If you haven't read Steven Brill's Time cover story that made all sorts of news these past weeks, you should check it out for yourself.  If you don't have 2-3 hours to devote to reading all 24,000+ words that will make your blood boil, let's see if I can quickly summarize it for you:
Brill brilliantly asks the question, not who should pay for medical bills, but instead, why are health care costs so high?  He takes a mix of experiences had by people who all have encountered bills that break the bank.  Two starkly different scenarios are a guy with cancer and another person who is rushed to the ER after falling.  The common thread is the unsubstantiated price of service trapping the unwilling buyer now stuck with a bill that offers little transparency or accountability.  This is a pricing luxury not shared by many sectors of the economy where most industries have sacrificed and are doing more with less.  It's as if the medical industry exists in another economy.  Hospitals across the country, whether not-for-profit or for-profit, are recording huge surpluses of cash off the backs of small insurance providers/customers and those without insurance -- only Medicare, the largest buyer of health care, seems to pay prices based off of what the care actually costs to provide.  Brill mentions CEOs of not-for-profit hospitals who make over a million dollars a year.  This compensation, Brill mentions, can easily be rationalized for running complex hospitals that save untold numbers of lives.  But he scoffs at the fact that any hospital can charge $77 for a gauze pad (one of many exorbitant prices for simple medical supplies) or thousands of dollars for one treatment of a cancer super drug that sells in other countries (with the use of price controls on these monopolized/patented drugs) for less than half the cost paid by his example of the cancer patient.  Even in countries with price controls on these monopolized life-saving drugs, companies are still happy to operate profitably.  In other articles I've read about drug price controls, it's understood that the patent protecting new drugs is a monopoly power that ought to be checked by regulators. If these prices aren't checked, who else is left to keep the prices from reaching the point where greed costs lives?
In a nut shell, Brill highlights the unique power that Medicare has with negotiating realistic prices and thinks highly of its powers to save us in the real economy from being abused by the monopolistic powers found in all parts of the health care industry (ambulance, hospitals, drug companies, machinery, ect.).  He argues that more could be done if Medicare wasn't "handcuffed" by Congress from negotiating on tests and other things.  And thanks to the test loophole, tests maybe ran more frequently than necessary (but why leave expensive machinery sitting around unused when it could be utilized and pay for itself?).
Other fine responses to Brill's work (but none from a planning perspective): here here here here and here

After reading Bitter Pill, and reading responses by various authors, and hearing Brill's interviews -  I was convinced that the solution to affordable health care is going to be a multifaceted one.  So the question for planners is, what can planning/zoning/urban design contribute?  What can land use do to help relieve this monopoly power that regional hospitals have?  Here I raise more questions than answers (but I try to interpret what some planning concepts will mean for our health care costs).

Part of the problem, as Brill points out, is that health care consumers are coerced customers that are buying before they know the price by simply taking their doctors advice.  Many times, in an emergency situation, the hurt are at the mercy of responsive care and are then bound to pay the bills at the end.  The lack of transparency and choice makes for a natural monopoly.

Here's an untested idea: what if planning policy encouraged regional hospitals to be less concentrated and more geographically dispersed?  This would allow the physical breaking up the monopolies (competitors who wouldn't have to share the same space) to be more practical and/or give greater accessibility to health care facilities to everyone (from a proximity perspective).  There may be drawbacks to this concept, such as a loss of efficiency with breaking up the regional hospital or the monopoly power - perhaps price controls are a better option and leave monopolies alone (maybe).

What solutions are there in EMS routing and making travel more responsive, safer, and faster?  I know they use traffic signal overrides currently, but maybe there's more that can be done.

Are there impacts from our other land uses?  Is suburban sprawl (or density) increasing the cost per capita for health care?  Would more mixed use offer any benefit, cause complications, or have no effect?  What are the effects of road diets?

Perhaps active transport and space for active recreation need to be prioritized according to health impact assessments.  I know there is a lot of recent research in this area, what are the payoffs?  What specific health care services will likely increase/decrease if active communities become standard?

What can local produce and urban gardening do for people's nutritional health?  How might that influence the demand for certain health care services?

How many ER cases are the result of car accidents?  What advancements in transportation will effect the costs to people from ER bills?  It is suspected that computer driven cars will be safer.  How much money will such car technology save us in lives and in ER bills?