Believe those who are seeking the truth. Doubt those who find it. Andre Gide


Sunday, February 6, 2011

The health care debate

As some of you probably know, I am a Canadian citizen and have lived most of my life in Canada. I moved to the United States about a year and half ago. I now live in St. Louis and am privileged to be working at the Federal Reserve Bank of St. Louis. The Fed, incidentally, offers what I think is an excellent health benefits package. And so far, I have been mightily impressed with the health care services provided at Barnes Jewish Hospital. I am fortunate.

When I first moved here, I did not know too much about how health coverage worked in the U.S. Heck, I am still not entirely sure what to believe. I have some vague recollection of hearing stories about poor Americans being denied access to critical care, just because they could not afford it. I wonder whether this can possibly be true.

Here is an excerpt from Paul Krugman's piece "A Tale of Two Moralities:"
There’s no middle ground between these [conservative and liberal] views. One side saw health reform, with its subsidized extension of coverage to the uninsured, as fulfilling a moral imperative: wealthy nations, it believed, have an obligation to provide all their citizens with essential care. The other side saw the same reform as a moral outrage, an assault on the right of Americans to spend their money as they choose.
Wealthy nations, liberals believe, have an obligation to provide all their citizens with essential care. The implication, of course, is that the United States does not do so; at least, not prior to Obamacare. But is what Paul Krugman asserts true? (He is also asserting that conservatives, as a matter of their moral philosophy, do not believe that all citizens should be provided with essential care--an outright lie, of course--but a different matter that I do not wish to pursue here).

And here is Kevin Horrigan, a columnist in St. Louis with his article today: "A Commodity or a Right?"
Health care, regardless of its considerable effect on the economy and the national debt, is not just another consumer item. Like food and water, health care is a fundamental right. We don't let people starve or freeze to death in this country (usually), so why do we routinely let them suffer and die for lack of access to health care?
Again, I ask whether this last claim is factually correct? Do people in America routinely suffer and die for lack of access to health care?

Personally, I cannot say for sure one way or the other. My inclination is to doubt these claims (which is not to deny the existence of many other problems associated with healthcare). But the evidence supporting my view is mainly anecdotal.

When I first got to the bank, I became friends with one of the janitorial staff at the gym. We got to talking and I learned that she had at one time needed a lung operation. Evidently, she was poor and uninsured at the time. She is now healthly as a horse. I'll let you fill in the blanks.

Shortly after that, I attended a lecture by Steve Lipstein, CEO and president of Barnes Jewish Hospital (and Chairman of the Board of the St. Louis Fed). The talk, as far as I can remember, was largely devoted to espousing the virtues of the Obamacare legislation. In his talk, he made a remark that made my jaw drop to the table. He told the audience that Barnes-Jewish does not turn anyone way; they do not ask whether people have insurance...they do not even ask if they are American citizens. I would like to believe that this is true at all U.S. hospitals, but perhaps it is not.

So it seems to me, though I stand corrected if wrong, that the U.S. already has universal health care coverage. Of course, when the uninsured go for treatment, someone has to pay for it. That someone, it appears, is the rest of us who regularly make insurance premiums (this is another point made by Lipstein in his talk). In other words, the U.S. already has a system whereby the "rich" subsidize the insurance and health costs of the "poor."

Of course, recognizing this (if it is even true) is not the same thing as claiming that the current system is any good or in no need of reform. I found this article by Randall Hoven quite interesting: "A Conservative Case for Universal Health Coverage."

The impression I am forming is that the healthcare debate has more to do with insurance than it does with healthcare availability. It appears to be a quirk of the American system that health insurance is tied to your employer. So, if you lose your job, and suddenly become sick (afflicted by a pre-existing condition), you may suddenly find yourself uninsurable. You will still have access to healthcare, of course--that is not the issue (even if liberals like Krugman and Horrigan would like us to believe this to be the case). But if you have any assets, you will have to use these assets to pay for your healthcare. This can be a terrible hardship and, evidently, is a major cause of personal bankruptcies in the U.S. Of course, if you are poor, you have no assets and so this does not apply.

So I am wondering: Have I got this just about right? If I have missed the boat on this one, please set me straight.

Update: February 10, 2011
 
One of my readers sent me something that I thought was too good not to bring to the forefront here. The author goes by the name of "o.jeff," in case that means anything to you.

A Simple Health Care Financing System (by o.jeff)

* Each person is required to put 15% of his or her income into a health savings account.

* All health care spending comes from this account.

* If a charge to your health care account is larger than your balance, then your account balance goes negative. This is effectively a federal health care loan.

* When your account balance is negative, 20% of your income is deducted from your income until your account balance is positive again.

* The money in this account is your money. When you die, any positive balance is passed on in your estate. If you have a negative balance, your assets must first pay off any negative balance in your health care account.

* If you have insufficient assets to pay off your negative balance at death, then the balance is "written off."
Additional points:

* This program replaces all government health care programs, including Medicare and Medicaid. The taxes for these programs would be eliminated.

* Most employers would probably stop offering health insurance as a job benefit. This would free every private employer of this burden and the cost it levies on them. This makes U.S. businesses more competitive.

* The payment for health care services would be immediate and swift--like using a credit card at Wal-Mart. However, providers would be required to retain records about the transaction for a period of time to allow audits for fraud.

* All of the people who are presently employed in medical offices and hospitals to fight insurance companies could be repurposed into actually providing health care services. An enormous gain in productivity.

* People would largely be spending their own money, and thus, they will be more careful about how it is spent. (With today's third party payment of medical expenses, there is little reason for a person to try to spend less.)

* Doctors might get tired of answering the question "How much does this cost?" but the question will be coming from their patient, right in front of them, rather than some nameless guy at an insurance company.

* Cost shifting already happens when non-insured/indigent go to a hospital for treatment. This plan simply makes it very transparent. These people will carry a negative balance funded by all of us. The hospitals would not have to cost shift, and so their prices should become more reasonable immediately.

* The health savings account would be for legitimate health care spending only. Fraud would be very strictly punished--both on the side of the provider and consumer.

* Health care products and services typically covered by an employer-sponsored plan would be eligible.

* Dependents would be paid for out of their guardian's accounts.

* 15% would be a minimum. You could deduct more if you want.

* There would be a maximum account balance per dependent. For example, the maximum account balance might be $75,000 plus $25,000 per dependent. (When this limit is reached, no salary deduction would be required.)

* Funds would be deposited in FDIC/NCUA insured bank accounts. You would get to pick the institution. I would likely pick a local credit union.
Other points:

* I think we should probably include in this plan a sales tax on medical care and services to pay for indigent care (those who die with negative balance). This tax should cover whatever our generation is predicted to cost in indigent care. It might be 3-5%.

* Private health insurance would be largely eliminated. However, insurance companies might provide "negative balance" insurance. That is, when you die with a negative balance, the insurance would payoff your balance. This would avoid an asset sale when a spouse dies first, for example.

O.jeff concludes with this:

Singapore has a system similar to this. My novel contribution is the notion of a "negative balance" in the health saving account, which is effectively a government-provided loan for health care (displacing the insurance model we have today).

p.s. Those who have zero lifetime earnings would simply die with a negative balance (and no assets), which would be paid for via the sales tax levied on all medical care.

27 comments:

  1. David,

    Also Canadian (as you know), but been here longer than you (since '04).

    Hospitals must treat patients that turn up in the emergency room. Billing is a different story, but Medicaid exists for the po' folk. And, most counties/states have further assistance for the less well-off. My county, for example, offers free prenatal and postnatal (for a few years) care. Well... property taxes pay for it.

    So, no, you won't "go without" health care. You can even avoid paying for it if you don't have your I.D. and give a fake name etc.

    Insurance is the other story. The reason insurance is tied to employment is due to WW2 wage controls set in place by FDR (my personal hero...lol). Although it appears that health insurance was being offered as a perk prior to WW2 for some jobs, the prevalence really shot up once wages were no longer available for incentives - I'll see if I can dig out some references on that one. As I recall it was hard to find stuff.

    I think Obamacare had very little economic reasoning behind it. It seems to largely be a political story. I remember a couple of pieces of rhetoric going around; one was the size of the health care industry (17% of GDP or some such) and the other the high number of people without insurance (I've heard anywhere from 40 - 50 million). So, yes, I agree with you; it does appear to be an insurance-centric argument.

    ReplyDelete
  2. Prof J: Yep, knew that. :)
    Another example of unintended consequences? The lack of portability of health insurance across jobs in the U.S. appears to be a huge problem. Not sure that one needs over 2000 pages of legislation to fix it, but who knows...

    ReplyDelete
  3. David,

    If you are anything like me (and probably you are but much worse) you have exactly no time for extra reading. But I would like to recommend Sanford Ikeda's "Dynamics of the Mixed Economy." I read this awhile ago and I got a lot of perspective from the public choice (Buchanan, Tullock, etc.) literature and the Austrian political economy literature (mostly Hayek) regarding political intervention in markets.

    The purpose of the book was to develop the theory of growth/recession of state intervention in the economy. Lots of factors, obviously, but a key one was ideology and the lack of knowledge of unintended consequences. I think that explains why 2000+ pages of legislation were the result, when actually only recession of state intervention was needed.

    Right now, the public generally think that an unhampered market is dangerous to them (the robber baron bias). Politicians have an interest in control over the economy and so encourage this belief because it allows them to accrue private benefits. This leads to the situation where, when some stuff happens that people don't like, the free market can be blamed (market failure - the most misused phrase in the English language these days) and politicians get to amass more power unto themselves.

    Furthermore, because of ideology, people are deaf to the economists' story that intervention in the market has caused the problems. Take health insurance. State governments have loaded required coverages (mandates) onto insurance companies to the extent that people are quite priced out of the individual market and thus must rely on employer subsidies to afford insurance. Rather than roll back mandates, we get Obamacare.

    Sorry for the rant... tried to keep it intellectual.

    ReplyDelete
  4. Well I actually work in health care and I can tell you that it is categorically false that hospitals must treat patients that show up in the emergency room. Hospitals refuse care to patients all the time. We got a patient by helicopter one time that flew past six other hospitals with neuro surgeons on call. The patient didnt live and might have if seen twenty minutes earlier.

    The issue with insurance is the number of insured patients who get dropped once they get sick. They pay for coverage and then get it denied or delayed. Private health insurers are incentivized to deny care not pay for it, so the whole business model is flawed from the start.

    Check out this article on rescission.... quite scary
    http://tauntermedia.com/2009/07/28/unconscionable-math/

    As I see it regarding PHIs, it makes no sense to have a middle man pay your bill for you who charges over 25% when you can find one who'll do it for 3-5%.

    As far as uninsured patients go the problem with them is not getting health care just disaster care. Very few doctors will see the uninsured other than in an emergency situation which makes their care waaaay more expensive. Basic single payer for all is the answer with individuals who want to buy additional private coverage being free to do so.

    We do a great job of disaster management but a terrible job with health maintenance.

    I'm not defending Obamacare per se but I do think that PHIs are a BIG part of the problem their incentives and the patients incentives are not aligned in any way.

    ReplyDelete
  5. Greg:

    I was hoping to hear from you...thanks!

    Since you are in the profession, I have to defer to you. In particular, your statement that "Hospitals refuse care to patients all the time." This statement contradicts the one made by Randall Hoven, so I can only presume that he is wrong.

    Can you tell me what are the characteristics of the hospitals that would refuse critical care to an unisured person? This does not happen at Barnes-Jewish. Is BJ the exception to the rule? Or is non-admittance the exception? Please elaborate, if you can.

    Actually, now that I mull over your post a bit, I am a bit puzzled. You say:

    As far as uninsured patients go the problem with them is not getting health care just disaster care. Very few doctors will see the uninsured other than in an emergency situation...

    Now this seems to suggest that uninsured patients generally will receive critical care.

    Oh, and thanks for the link. Yes, there's definitely something broke and in need of fixing.

    ReplyDelete
  6. I wonder, too, if the treatment of non-insured varies by hospital ownership (private v. county-funded, say) or state. Certainly in the states I have lived, and a couple others I'm aware of, it seemed the state/county-owned hospitals did treat uninsured patients.

    ReplyDelete
  7. It is illegal to turn anyone away from emergency care from any accredited hospital in the United States with the exception of a few specific hospitals (AMTALA is the 1986 Act of Congress which mandates this).

    The hospital staff are required to stabilize an individual until they can be discharged according to current medical standards. Now, someone may be turned away from services which are not considered necessary for stabilization, or excuses made why certain hospitals can't take others. However, no physician will turn you away, lest they be sued to high hell.

    It is illegal to turn someone away based on citizenship or ability to pay. I could tell you 20 stories a day about people using our emergency medical care as their primary care because they pay NOTHING. The waste is spectacular, people on medicaid will get 'second' and 'third' opinions on their free medical care if they don't like what one physician tells them.

    In regards to these patients just getting emergency care but no access to general care. If you have ever worked with these people, you know it is a joke. They don't care AT ALL (generalized statement) about their long term health. People will walk in with giant tumors which have been there for years and ask 'is this something I should be worried about, it's been hurting for a minute'. A 'minute' meaning A LONG LONG TIME to this population. Insanity.

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  8. EMTALA, not AMTALA, apologies.

    ReplyDelete
  9. David,

    Even if no one is turned away at emergency room I wonder how much it is costing the system from having uninsured people delaying care because they can't afford it and then running to the emergency room because they can no longer wait. I don't have any data or empirical evidence on the costs but I presume it is fairly large. Having a universal health care or coverage minimizes this type of costs significantly. As the previous anonymous said, may be I won't wait till my tumor is the size of a football to go and seek help but well before that because I can.

    ReplyDelete
  10. David - I am a self-employed person with a family, and have been self-insured for the better part of a decade. Today I pay $500/month for the privilege of paying the first $7000 in medical fees for the year. This HSA plan was one of the keys to GW Bush's "consumer-driven health care" plan. Yes, it comes with a tax break, but the costs can be crippling to the self-employed.

    Businesses also pay astronomical sums to provide coverage for their employees, the unplanned result, as Prof J noted, of war-time wage freezes during FDR's reign. We need healthcare reform not just to provide coverage to the under- and uninsured, but to reduce the cost of healthcare so our businesses can compete in the global market.

    Have children? Take a look at the EOB from their latest well-child visit. Why does such a visit cost more than $600? That's what my last well-child visit cost, according to the EOB. Vaccines, the fee to administer the vaccine, the fee for the doctor to spend five minutes with the child. It all adds up!

    David - have you dealt with serious illness since moving to America? That's when the terrible flaws of the American health system become apparent. The time and energy needed to get the health insurance company to pay covered expenses can be a heavy burden for people already dealing with serious illness.

    Healthcare reform is urgently needed. I'm not convinced, however, that the reform we got is the reform we needed.

    ReplyDelete
  11. One more thing. You say this in your post: "In other words, the U.S. already has a system whereby the 'rich' subsidize the insurance and health costs of the 'poor.'"

    Using the ER as one's primary care healthcare facility is exceptionally costly, particularly when the patient has not ability to pay the bill. Hospitals pass this cost on to all of us. I personally don't characterize this as "the rich subsidizing the poor," nor is this "universal healthcare" by any stretch of the imagination. It is instead the very high price we pay for our horribly inefficient healthcare system.

    Have you read any Atul Gawande? He's quite informed on this issue.

    ReplyDelete
  12. Let me be clear. There are hospitals which dont refuse patients, my response was to Jeffs first claim;

    "Hospitals must treat patients that turn up in the emergency room"

    That is categorically false. It varies by state I suppose but in Georgia it is related to the amount of state funds you take. If you take none you dont have to treat the indigent and just because you might take the indigent doesnt mean you have room for them. Patients dont just show up at the door, they are brought usually by ambulance and ambulances (or helicopters) are told that they cant come sometimes.

    Yes usually the indigent is able to find someone to treat them in urgent situations but this is expensive and has high morbidity/mortality. When your only contact with doctors is when you are critically ill, the care becomes expensive and labor intensive.

    I have the utmost respect for my fellow healthcare workers regarding the level of skill, knowledge and dedication but the entire system is not really set up to maintain health, its set up to "patch up". Patching up is more lucrative and exciting. That is starting to change now though.

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  13. Greg,

    I was indeed too glib in my statement. The hospitals I was experienced with were all state/county hospitals.

    It is obvious that medical practices can turn down new patients if they want to.

    I think everyone agrees that the current system is absolutely awful. I think there is also a great deal of disagreement as to which direction we should go to improve the system. There's even, I think, disagreement as to what improvements are needed. Where to start the conversation?

    Main Street Muse - I have had experience with the same illness in both Canada and the U.S. and my experience in the U.S. was tremendously better than in Canada. It was not life-threatening, although it was quality-of-life threatening (permanent physical cripple).

    Having experienced both systems, and having friends who maintain private insurance so they have the option of coming to the U.S., I can assure you my personal experience is that the U.S. has much better medical care than Canada.

    What seems to be the case, though, is that people who want to talk normatively about health care and health insurance cannot afford to ignore the positive economics of scarce resources.

    ReplyDelete
  14. Anonymous @1:22PM

    I agree with you completely here. But nowhere in my post did I suggest reforms were not needed. A part of the point I was trying to make was that some people want to demonize another group of people for not supporting what they call univeral health care coverage. Instead, they should stick to highlighting the purported efficiency gains of any proposed program.

    Main Street Muse: Well, if it's a terribly inefficient system--and I believe that it is--then somebody must be paying for these inefficiences. And it ain't the poor; at least, they do not pay in money terms. Thank you for your thoughtful post and the reference to Atul Gawande!

    ReplyDelete
  15. My health care plan may be appealing to you David:

    Simple Health Care Financing System
    ===================================
    * Each person is required to put 15% of his or her income into a health savings account.
    * All health care spending comes from this account.
    * If a charge to your health care account is larger than your balance, then your account balance goes negative. This is effectively a federal health care loan.
    * When your account balance is negative, 20% of your income is deducted from your income until your account balance is positive again.
    * The money in this account is your money. When you die, any positive balance is passed on in your estate. If you have a negative balance, your assets must first pay off any negative balance in your health care account.
    * If you have insufficient assets to pay off your negative balance at death, then the balance is "written off."

    Additional points:
    * This program replaces all government health care programs, including Medicare and Medicaid. The taxes for these programs would be eliminated.
    * Most employers would probably stop offering health insurance as a job benefit. This would free every private employer of this burden and the cost it levies on them. This makes U.S. businesses more competitive.
    * The payment for health care services would be immediate and swift--like using a credit card at Wal-Mart. However, providers would be required to retain records about the transaction for a period of time to allow audits for fraud.
    * All of the people who are presently employed in medical offices and hospitals to fight insurance companies could be repurposed into actually providing health care services. An enormous gain in productivity.
    * People would largely be spending their own money, and thus, they will be more careful about how it is spent. (With today's third party payment of medical expenses, there is little reason for a person to try to spend less.)
    * Doctors might get tired of answering the question "How much does this cost?" but the question will be coming from their patient, right in front of them, rather than some nameless guy at an insurance company.
    * Cost shifting already happens when non-insured/indigent go to a hospital for treatment. This plan simply makes it very transparent. These people will carry a negative balance funded by all of us. The hospitals would not have to cost shift, and so their prices should become more reasonable immediately.
    * The health savings account would be for legitimate health care spending only. Fraud would be very strictly punished--both on the side of the provider and consumer.
    * Health care products and services typically covered by an employer-sponsored plan would be eligible.
    * Dependents would be paid for out of their guardian's accounts.
    * 15% would be a minimum. You could deduct more if you want.
    * There would be a maximum account balance per dependent. For example, the maximum account balance might be $75,000 plus $25,000 per dependent. (When this limit is reached, no salary deduction would be required.)
    * Funds would be deposited in FDIC/NCUA insured bank accounts. You would get to pick the institution. I would likely pick a local credit union.

    Other points:
    * I think we should probably include in this plan a sales tax on medical care and services to pay for indigent care (those who die with negative balance). This tax should cover whatever our generation is predicted to cost in indigent care. It might be 3-5%.
    * Private health insurance would be largely eliminated. However, insurance companies might provide "negative balance" insurance. That is, when you die with a negative balance, the insurance would payoff your balance. This would avoid an asset sale when a spouse dies first, for example.

    ReplyDelete
  16. I am a little surprised. For one, why would you believe Mr. Epstein or take what he says at face value? Frankly. Your own university--Simon Fraser University--gave an honourary doctorate to an activist who specializes in misleading the public.

    Now the other surprise. You apparently forget that you were an economist.....

    Steve Lipstein's assertion that the hospital turns nobody away should have generated a couple of obvious questions:

    If nobody is turned away, how does the hospital prevent a flood of non-paying customers overwhelming the facilities?

    What are the participation constraints that keep most non-paying customers out? Why is there, apparently, a stable separating equilibrium?

    Or why doesn't everybody source their medical care for free?

    ReplyDelete
  17. Anonymous @4:48AM

    Have to admit, it sounds not too bad to me. The one thing it leaves out is what sort of entitlement should be in place for those with zero income (and zero lifetime wealth).

    I am tempted to ask you whether I might post your proposal as a separate blog entry (with your name, if you wish). I am no expert in the area, however, so I cannot tell how original this idea is or how much sense it actually makes.

    I do appreciate the contribution though!

    westlope:

    I am surprised at you (not...lol). Now why wouldn't I take Dr. Epstein at his word? He is a well-respected member of our community.

    Those are good questions you ask. But I am not qualified to answer them. Perhaps you are? Let's hear what you have to say.

    ReplyDelete
  18. Re: Simple Health Care Financing System

    Please feel free to use this any way you see fit. I go by "o.jeff" in economics discussions. Singapore has a system similar to this. My novel contribution is the notion of a "negative balance" in the health saving account, which is effectively a government-provided loan for health care (displacing the insurance model we have today).

    p.s. Those who have zero lifetime earnings would simply die with a negative balance (and no assets), which would be paid for via the sales tax levied on all medical care.

    ReplyDelete
  19. I really like Warren Moslers proposal here;

    http://moslereconomics.com/2009/03/02/mosler-health-care-proposal/

    ReplyDelete
  20. I think any discussion of healthcare in America needs to start with how we price it today. David - do you know how much the Federal Reserve pays for your insurance? What percentage of that is your responsibility? Do you know that figure off the top of your head or is research required? Most people are completely ignorant of the cost of their health insurance - because it's paid for by a third party, their employer.

    Then for the pricing of the actual goods and services we receive in healthcare - consumers simply cannot shop around for the "best price." Healthcare is not like a car purchase, where we can choose leather or fabric, new or used, cheap or luxury.

    When faced with something like an appendectomy or cancer, consumers cannot "choose" whether or not to treat it. It must be treated or they die. And sometimes when they are treated, they still die. They cannot even choose the antibiotic they use - it is prescribed to them by their physician and determined in part by whatever infection they are fighting.

    How is the price of medical goods and services determined? Insurance companies negotiate with providers, an elaborate dance that requires multiple levels of expertise - medical, legal, contractual. And there are multiple parties involved who must bring all those levels of expertise to the table: physicians, insurance companies, GPOs, hospitals, pharmaceutical companies, medical device companies, PBMs, etc.

    After they negotiate, is the price they set "fair market value"? Who knows? These negotiations are not subject to traditional market pressures and, in my view, lead to pricing that seem arbitrary at best.

    In my earlier example of the well-child visit, it seems utterly absurd that a well-child visit with three vaccines should cost in excess of $600. We were in the doctor's office (not the waiting room) for about a half an hour at the most. I can save money by refusing to vaccinate, but then my child can get kicked out of school unless I claim a religious exemption.

    I would love to see an economist look at the pricing of healthcare and offer a model on how pricing can be better determined. The way we price it contributes (IMO) to the constantly escalating cost of healthcare in America.

    ReplyDelete
  21. David,

    It could be that Dr. Epstein is better at finding $100 bills on the ground than most.... Regardless of the nuanced, objective truth, would you expect him to say anything different?

    I would imagine that what constitutes Emergency Care is tightly defined and the kinds of nuance issues plaguing emergency rooms in Canada face are not a problem.

    If destitute people are not queuing for charity emergency care, then there must be another allocation mechanism at play here. Perhaps overwhelmed Canadian facilities can learn from their American counter-parts?

    Sorry to disappoint with simply more questions and no material answers.

    ReplyDelete
  22. I can see that there will be a lot of issues with obamacare. The best plan I have heard of so far is outlined in Deane Waldman, MD MBA's latest book titled, "Uproot U.S. Healthcare: To Reform Healthcare." He even has a great tactic for handling malpractice.

    ReplyDelete
  23. This is massive information for me. The government can and should play an important role in the supervision of a reformed system. Many people assume that the center of the disagreement on whether or not to extend coverage to more people.

    ReplyDelete
  24. Health economists say that consolidation could reduce the overall costs of health by encouraging doctors to keep patients healthy rather than encouraging them to perform unnecessary procedures. Some reform proposals promote payment of consolidation.

    ReplyDelete
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