We're in trouble . . .

. . . now that Professor Michael Porter published his new book about how to cut health care costs. To his credit, Professor Porter espouses a solution based on the principles that he lives and dies by and teaches to students at the Harvard Business School. But, as soon became clear during an interview on WBUR (an NPR affiliate at Boston University), Professor Porter's solution is a classic ivory tower confabulation having no relationship with the realities of health insurance and delivery of health care services.

His solution? Let's change the way we pay health care providers for their services. Instead of paying a fee for service, which we do now, Professor Porter proposes to pay physicians and others based on health care service outcomes. On the surface, this might seem to be reasonable. After all, when you take your car in to be repaired, you get a warranty on the work performed. Bring it back within the warranty period if anything specific to the repair goes wrong, and they'll fix it for free. Closer to the topic, a patient, or whoever is responsible for issuing payment, might determine that it took little Johnny three weeks to get over his cold rather than the "normal" recovery time of seven days. As a result, Johnny's pediatrician would be paid less. If little Johnny has a relapse (how do we know it's the same cold?), the doctor might receive no payment because of the unsatisfactory result of his treatments.

This is about as logical as Broadway Danny Rose saying to his paramour, when she tells him bad guys shot her ex-boyfriend through the eyes, "Oh, my god, he's blind!" "No, you idiot," she retorts, "he's dead!!"

A medical example might make this more apparent. Say you have a hernia repaired. How long does the doctor have to wait before h/she is paid? Well, if it's done laparoscopically, you walk out of the hospital the same day--the so-called outpatient procedure--and recuperate at home for 10 days-two weeks before resuming normal activities. If it's done with an incision, there's a two-day hospital stay, followed by six weeks of recuperation, during which you can't lift anything. Regardless of which kind of repair is done, any surgeon, if you ask (most patients do not), will tell you that the real test of a surgical repair comes 10 years after the repair. If it's still solid after all that time, you can think of yourself as "cured". Does the doctor have to wait 10 years to get paid?

Or, suppose you break a leg. Dr. Porter and a fair number of other folks with, as my father used to say, "more nerve than brains," will tell you that market forces will determine the path to the most cost-efficient solution to the problem. In other words, much as if you were buying a refrigerator or a computer, you will compare prices, brands, customer experiences, and other things that will lead to a wise purchase.

But, wait a minute! YOU HAVE A BROKEN LEG! YOU ARE IN PAIN! PERHAPS YOU CAN SEE THE BONE COMING THROUGH THE SKIN--A COMPOUND FRACTURE!! You are not going to shop around for the best price for treatment. You are about to go into shock. You must get to the nearest hospital STAT! "I don't care! Just end the pain", you tell the emergency room people as they track down the orthopaedic surgeon on call.

In that scenario, who will evaluate the doctor? On what basis will the evaluation be performed? Did you remember to ask the doctor about his warranty policy? It should be clear by now that Professor Porter and that tribe of business-oriented, cookie-cutter solution-loving people he represents--those who know the price of everything but the value of nothing--offer loopy approaches to problems that can't be measured or contained. They are squishy and fluid, not solid and of fixed shape.

So, avoid the trouble this kind of approach brings. Everybody knows the real solutions to the problem: single-payer, universal coverage, cradle-to-grave coverage. Demonstrating that they will do the job and contain the costs is the next real challenge.

Let me know your thoughts.