But it’s important to understand the difference between those studies and the Camden one.
“The Camden model targets a population that has a much more varied set of medical needs and social complexity, and with higher health care spending, than the existing successful models,” said Amy Finkelstein, a health economist at M.I.T. and a co-author of the Camden study.
The other approach to fighting wasteful medical spending starts with looking at health care as a system of goods and services: medications and surgical procedures, administrative processes and physical infrastructure. Some of these enhance health and others don’t, while some of it costs more than its benefits warrant. If you can identify wasteful goods and services and deliver effective care at lower prices, you can make the system more efficient for everyone.
This idea is behind many policies that change how Medicare pays for care.
One advantage of the systemic approach is that it’s easier to replicate than programs focused on super-utilizers. If eliminating or replacing a drug, procedure or administrative process means that spending at a hospital goes down, it’s relatively simple to adopt that change at other hospitals. But conceptually simple doesn’t mean easy in practice.
“Directly and systematically reducing wasteful care is hard because the most successful strategies threaten the revenue of dominant health care providers,” said Michael McWilliams, a professor at Harvard Medical School and a general internist with Brigham and Women’s Hospital. “One person’s waste is another’s income.”
This may be why big health systems are resistant to systemic change and prefer patient-focused approaches. Dr. McWilliams and Aaron Schwartz, a resident at Brigham and Women’s Hospital, wrote a commentary in the New England Journal of Medicine arguing in favor of a systems view of cost cutting. A focus only on the relatively few high spenders could miss a lot of waste, it said. Even though the rest of the population may use less care than super-utilizers, collectively they could account for as much or more waste.
Another concern is that when cuts are made to health spending, patients could receive lower-quality care and might have worse experiences. Cutting waste without harming quality is hard but not impossible. Some Medicare programs and private insurer initiatives in recent years have succeeded in doing so, if only a little.
The people-focused approach, on the other hand, is more likely to improve some patients’ experience because it involves additional preventive care. This could manifest itself as less pain or anxiety, and more “satisfaction” with care. But saving money this way requires accurate predictions of who is likelier to use a disproportionately large amount of health care. We don’t yet know how to reliably do this for enough people to make the approach efficient.