The Agenda

John Goodman on the Fifth Step

John Goodman has written a neat conceptual post on how people who have the same views concerning the maladies plaguing the U.S. health system can disagree so strongly on prescriptions for addressing them:


I’ll use an example I’ve used before: Jeffrey Brenner, the Camden, New Jersey doctor who identifies the sickest, most expensive patients and lowers their overall health care costs by getting the patients to change their lifestyles. Because most of what Brenner does is effectively social work and because there is no current procedural technology code for social work, Brenner is essentially working outside the system. He is saving Medicare and Medicaid millions of dollars; but these bureaucracies are doing nothing to reward him for his efforts.

Pro-ObamaCare writer Atul Gawande wrote about Brenner in a widely read article inThe New Yorker and I found myself agreeing with everything Gawande wrote. Except for one paragraph, in which he asserted that the Obama administration’s goal was to encourage Brenner’s approach all across the country.

Nothing could be further from the truth. The administration is giving Brenner not one thin dime for his exceptional work. In fact Brenner is surviving and paying the rent only because of help from nonprofit foundations. For Brenner to get government help, he must jump through all kinds of hoops and try to qualify as an Accountable Care Organization!

[BTW, this is the only point in Gawande’s article where he becomes sloppy — treating step five as though it were an unimportant afterthought.]

My solution: Give Brenner 25% of all the money he’s saving the federal government. Let him become a millionaire. Then invite every other doctor in the country to copy Brenner’s example, or even improve on it.

I’m sympathetic to Goodman’s approach. 

Recently, Goodman linked to an article in the Los Angeles Times that described another potential driver of constructive health-system reform:

Executives say providing in-house medical care keeps workers healthy and productive. But the clinics also help the bottom line by reducing absenteeism and slashing employers’ medical bills for outside doctors and emergency rooms.

Employers have an incentive to restrain medical costs, but also to keep workers healthy and productive. Medical providers and insurers face a different set of incentives. 


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