The Red Queen Race is a race where to stay even, the participants have to run faster every moment. If one person maintains constant effort, that person falls behind compared to the other contestants.
This plays out in the health policy world with revenue neutral risk adjustment.
significant resources are devoted to increase the appearance of illness in the claims history without actually doing a damn thing to make a patient better off… The problem is insurance companies that elect not to chase their providers for higher diagnosis coding intensity will see their risk scores look comparatively lower compared to high intensity coding companies, and thus they’ll lose money. So everyone has to do it, or no one has to do it. Right now we are in a stable, socially negative equilibrium of high intensity claim coding for risk score optimization.
This is socially wasteful use of a Red Queen race.
However this model in and of itself is not inherently problematic. If it can be directed towards achievement of socially positive goods, a red queen race where revenue neutral transfer payments are shifted from underperformers to overperformers creates strong financial incentives for the underperformers to accelerate their efforts and the over-performers to not get lazy. If there was a set of revenue neutral transfer payments based on single period achievements of common preventive measures such as vaccinations, screenings and tests that are shown to improve individual health and lower net medical spending, rates of adherence would increase significantly.
Right now flu shot uptake is fairly low. Roughly 60% of kids get a flu shot, and 44% of adults get one as well. There are strong clinical reasons for not everyone to get a flu shot, but that clinical exclusion does not cover 40% or more of the population. If insurers with risk and SES adjusted underperformance have to pay insurers with risk and SES adjusted high vaccination rates, vaccination rates will increase. I know my CFO would concuss herself and break the ceiling on the 11th floor when she is told that we need to write a $3.5 million dollar check that will be effectively made out to the Blue Cross affiliate down the street because they did a better job of vaccinating their members than we did. That is the incentive we would want to create socially, where payments are dynamically linked to what everyone else is doing and no one entity (unless there is mass collusion) has any incentive to not vaccinate the next kid.
PS: I am trying to sketch out a system of transfer payments so some of my posts in the near future may be even more wonky/esoteric than normal.
Ruviana
Is the illustration by Bethany Spencer? And you bigfooted Betty in true Cole fashion!
MomSense
I just heard from a urologist that ObamaCare has negatively affected her income. Do you have any idea why that might be? The problem is that this person is extended family and blasted this out to all of us but I’m the OCare cheerleader so now I’m getting a lot of messages asking me to explain this.
Ugh.
Richard Mayhew
@MomSense: I would really need to examine her books to give a good answer.
The most plausible way that PPACA has decreased her income is by shifting her patient mix from a high proportion of people with high paying insurance to fewer people with high reimbursement levels and a lot more people with either Medicare, close to Medicare on Exchange or Medicaid derived payment levels.
Throw in a 2% provider payment cut on Medicare as part of the sequester, that is a plausible story.
MomSense
@Richard Mayhew:
Ok, thanks. She does just fine, btw.
UGH
MattF
I get a free flu shot at work every year, and it seems to me that this is a plausible model for how to get it done– the institution that actually suffers a significant risk from a flu epidemic (and pays, anyhow, for my health care) promotes and pays for the shots.
Punchy
@MomSense: So her $220K salary has been negatively reduced to a paltry, barely-liveable $208K?
japa21
@Ruviana: I don’t think the bigfooting matters in this instance. Most people will come read this, their eyes will glaze over, and they’ll go back to Betty’s post.
And no, Richard, that isn’t a criticism of your post.
MomSense
@Punchy:
INORITE!
hamletta
@Ruviana: No, not bspencer, a still from Tim Burton’s Alice in Wonderland. That’s a CGI-ed Helena Bonham Carter.
mdblanche
“No, no” said the red caucus. “Sentence first – verdict afterwards. Off with Obamacare’s head!”
muddy
@MattF: My work offers them free as well. They include not just your family members, but anyone you live with. So roommates are covered, this gets a lot of younger people in that would not ordinarily get one.
Uncle Cosmo
@MomSense: Sounds like someone who went into medicine less as a vocation than as a prime way to make lots of $$$ while being treated as a demigod by lesser mortals.
Something that IMHO gets overlooked in the constant struggle to control costs is how limiting the number of slots in med school tends to restrict the number of MDs available–& how charging astronomical tuition tends to provoke money-grubbing amongst them once graduated*, which iterates back to the motivation for fighting one’s way into med school in the first place.
* Cf. Tom Lehrer’s classic comment (in the live-performance intro to “In Old Mexico”) in re Dr. Samuel Gall, the “inventor of the gall bladder”, whose
Kylroy
@Uncle Cosmo: I can’t help but wonder how much better our healthcare costs would be controlled if the current glut of law school grads had instead been trained as doctors.
JCJ
@MomSense:
There are lots of ways income can go down unrelated to Obamacare, but of course the easy/lazy explanation is to say that is the cause. A big decrease in revenue for urologists predates Obamacare – the decreased reimbursement for leuprolide injections (anti-androgen treatment for prostate cancer) happened a while ago but that was a sweet source of easy money for urologists. The fact that more men (appropriately) choose active surveillance for prostate cancer has lessened the number of procedures done. Even when treated some men might opt for stereotactic radiation for prostate cancer over surgery. In my world there have been some billing codes that have been eliminated since Obamacare was passed, but that has been happening for years and is nothing new and certainly not attributable to the ACA.
WarMunchkin
This sentence struck me as interesting because a lot of doctors I know are getting frustrated by having to code everything up. I’m young, and my friends, who are matching and entering the field for the first time often send around things like this:
I’m wondering whether an issue is that doctors just provide a lot of unskilled labor along with skilled labor, and replacing that with automation frameworks of some kind are the future for bending the cost curve.
gene108
@Kylroy:
Most people become lawyers, because they do not want to do the math / science required to be a doctor.
I doubt you can re-purpose law school students to do medicine very easily.
@Uncle Cosmo:
Take away the earning potential from doctors and why would someone go through 4 years of med. school, followed by a minimum of a couple of years of residency?
You’re 30 years old before you can think of settling down and use your skills to make a living.
That timetable is a big barrier to entry for a lot of people, as it is.
Mnemosyne
Studies have shown for decades that the best way to prevent the elderly from dying of the flu is by vaccinating schoolchildren. But of course we can’t mandate that because every child should have the FREEDOM to inadvertently kill their grandparents.
Mnemosyne
@gene108:
I think that if the prospect of getting stuck with $200K in medical school loans was reduced or eliminated, people would still flock to medical school. Not everyone who goes into medicine is motivated by money, and right now the high cost is steering some people away from it because they can’t afford to take on that kind of debt.
Ruviana
@hamletta: Thanks!
Uncle Cosmo
@gene108: Well, how about if they didn’t have to mortgage their entire future for tuition money? We might end up with more MDs who are seriously interested in helping people get & stay well.
I remember my days as an upperclassman headed for grad school. Most of my friends were majoring in physics or chem or math. None of us were looking to get rich–we thought that being paid a decent salary (enough to support a family & save for a comfortable retirement) to do work we thought was significant & interesting (including teaching the cohorts following) was a goal worth enduring th relative penury & hard work of getting a doctorate. I have no doubt the same motivation applies to many potential MDs.
@Mnemosyne:
And the fewer people who go into medicine looking to get rich (& for that matter, tripping on being treated like a deity, though I don’t know how to fix that one), the better IMHO.
Another thing we can do (& AFAIK there is progress in this direction) is to diffuse the ability (from both knowledge & legal standpoints) to diagnose & prescribe downwards toward physicians’ assistants, nurses-practitioner, etc.
gene108
@Mnemosyne:
The high cost of medical school is another barrier.
It is does not eliminate the time it takes to become a doctor as being another factor keeping people from medical school.
You end up being 30 before you can settle down, whereas other college grads, will have jobs, houses, starting up families, etc., while you are still eating “raman noodles”, while slogging away at 16 hours shifts doing a residency.
Even if you can afford medical school, the opportunity cost of what you give up to become a doctor does influence people’s decision making.
Mnemosyne
@gene108:
It may for people who are interested primarily in making money, but most people who want to go into medicine, whether as a doctor or a nurse, are interested in the work itself and are willing to make the time sacrifice in order to do it. Personally, I think we would end up with better doctors if they only had to decide on the time sacrifice and not have to take on both the time sacrifice and massive debt.
And I’m 46 and have never owned a house. Home ownership is out of reach for most people these days, especially in urban areas.
amygdala
@gene108:
It’s 30 if you went straight to med school from college and are in a field with a relatively short residency and no requirement for fellowship training in order to practice. For so-called nontraditional med school grads (like Howard Dean!) and nearly all specialists, it’s more like 35. I know a few MD-PhD neurosurgeons. Not having your first career job until early middle age is strange.
MomSense
@Mnemosyne:
I wish I didn’t own my house because it is on land that is in a state with no jobs.
How do the youngs earning 12.50 an hour settle down? $40,000 in student loan debt earning $12,50 an hour takes a long time to pay down.