The title might suggest an article on personal finance, but comes from an article by Tikkanen and Schneider, who examined data from multiple countries to relate social spending, exclusive of health care spending, with population health. Taking a broad view of social spending, they postulated
“…the marginal health benefits of additional spending on each of these three age groups [childhood, adulthood, and old age,] may differ…Although total social spending per capita may be similar in the United States and other high-income countries, our results show that the United States allocates relatively less to the social needs of families with young children and working-age adults and relatively more to supporting older adults—an allocation that may fail to optimize population health overall.”
Ganguli and associates published an article showing among commercially insured adults in the United States, use of primary care services declined 24% from 2008 to 2016. Their study used data from a national commercial insurance company and was based on 142 million primary care visits among 94 million member-years, so it is a “big data” study. 11% had one or more chronic conditions. Problem-based visits declined 30.5% to 112.8 visits per 100 member-years in 2016. Out of pocket costs for these visits went up, while the number of visits for preventive services went up and out of pocket costs went down, reflecting a trend toward high-deductible plans in the commercial market.
An accompanying editorial by Rask focuses on the changes in pricing.
“Effective primary care builds on 4 attributes: first-contact access for each need; longitudinal, person-focused care, comprehensive care for most health needs; and coordination when care is sought elsewhere. Studies have shown that health is better in areas with more PCP’s, that patients who receive care from PCPs are healthier, and that the 4 attributes of primary care are associated with better health…Patient cost sharing and high-deductible health insurance plans to not promote the development of any of this infrastructure.”
An article in today’s newspaper reports…
“In Tennessee, several hospitals have slashed staff to offset a dramatic drop in revenue, even as the demand for nurses and doctors surges. Nationwide, at least 70 hospitals are furloughing workers according to an index from Becker’s Hospital Review.”
As explained in the article, the cessation of elective procedures and a lot of outpatient care visits that fund hospitals at the same time expenses for caring for critically ill patients is going up is causing a cash flow problem superimposed on chronically shaky finances. While there are efforts to inject cash into the system, a lot of the efforts are based on pre-payment, otherwise known as loans, on the Medicare book of business. But most hospitals have had difficulty making a profit on that book, even before the shift to the high-expense virus patients.
Tying some of these threads together is an article by Valentino-DeVries and associates in The New York Times.
“Although people in all income groups are moving less than they did before the crisis, wealthier people are staying home the most, especially during the workweek. Not only that, but in nearly every state, they began doing so days ahead of the poor, giving them a head start on social distancing as the virus spread…The data offers (sic) real-time evidence of a divide laid bare by the coronavirus pandemic—one in which wealthier people not only have more job security and benefits, but also may be better able to avoid becoming sick. The outbreak is so new that the relationship between socioeconomic status and infection rates cannot be determined, but other data, including recent statistics released by public health officials in New York City, suggests (sic) that the coronavirus is hitting low-income neighborhoods the hardest.”
I am already starting to see articles forecasting good changes in society as a result of the pandemic, but history is not really encouraging in this regard. Changes do occur, but not necessarily in a positive direction. Consider that the 1918 Influenza Pandemic was followed by “the Roaring 20’s” in some areas, and a wide-spread, prolonged economic slump in the rural parts of the country. I am not going to prognosticate but I do think we have the opportunity to re-think how and where we spend our money, because “doing things the way we have always done it” is certainly changed for now and for a while to come, and it is reasonable to assume there will be institutional, as well as human, casualties along the way. The question I hope we ask ourselves collectively is “What do we want from the health care system?” This might lead to questions about how we develop and sustain the infrastructure needed to attain the goals identified.
13 April 2020
 Tikkanen RS, Schneider EC. Social Spending to Improve Population Health—Does the United States Spend as Wisely as Other Countries? N Engl J Med 2020;382(1):885-887. doi:10/1056/NEJMp1916585.
 Ganguli I, Shi Z, Orav J, Rao A, Ray KN, Mehrotra A. Declining Use of Primary Care Among Commercially Insured Adults in the United Staets, 2008-2016. Ann Intern Med 2020;172(4):240-247. doi:10.7326/M19-1834.
 Rask K. Pricing Patients Out of Primary Care. Ann Intern Med 2020;172(4):283-284. doi:10.7326/M19-4000.
 Tamburin A. Coronavirus Exposes Cash Crunch at Several Hospitals. The Jackson Sun, Monday, 13 April 2020, p. 1A.
 Valentino-DeVries J, Lu D, Dance GJX. Location Data Says It All: Staying at Home During Coronavirus Is a Luxury. The New York Times, 3 April 2020. Accessed 6 April 2020 at: https://www.nytimes.com/interactive/2020/04/03/us/coronavirus-stay-home-luxury
Asking the Right Questions
Solutions for problems in health care abound, but are we asking the right questions?
Big medicine may be financially necessary, but it poses risks unless care is taken to become a real system, which requires putting the clinical enterprise at the center.
Conflicting Economic Models
Providers are being forced to take on financial risk for the cost of care as shown by recent news articles.
Experimentation may seem risky, but is essential for progress. How do we do it safely in challenging times?
Medical Care as a Commodity
Are big data and machine learning likely to solve the problem of uncertainty in medical practice?
New Payment Methods
A central question for healthcare organizations as they face the future is what is our goal? While taking care of patients might seem the obvious answer, it is the one that is usually not considered.
Putting Patients At The Center Of Healthcare
Putting patients at the center is crucial for healthcare organizations, but how can it be done?
The Limits of the Medical Model