"It's unclear to me...
...why we pay Aetna $20 so they can pay Medco $15 so they can pay CVS $10 so CVS can collect a $5 copay from us for something we could have just bought at Wal-Mart for $4 in the first place."
It's not unclear to me, but those are the words of Mark Smith, an MD with an MBA, speaking in this video as one member of a panel -- Imperatives for US Health Care Reform: The Next Four Years -- of Very Serious People and they get a chuckle out of the audience, which is also made up of Very Serious People.
Unfortunately, instead of going on in that direction to detail the expenses and entanglements and outright graft of how we pay for health care in this country, he goes on to talk about how we can lower health care costs by de-skilling medicine -- with the miracles of innovation awaiting us, nurses [whose pay is lower than doctors'] can take on more of what doctors are now doing, techs [whose pay is lower than nurses'] can take on more of what nurses are now doing, and patients [whose pay is zilch] can take on more of what techs are now doing.
To be fair to Doc Smith, the whole panel [and probably the entire conference, I haven't checked it out yet] is all about how to lower health care costs by (1) giving less money to doctors and hospitals, and (2) getting patients to quit demanding so much expensive care.
A brief introduction to some of the players here --
Mark Miller, Senior Advisor, McKinsey & Company, is the moderator, so there really isn't all that much to say about him. McKinsey, you might note, advises insurance companies on ways to bilk us the little people out of our money.
Stirling Bryan, the first panel member to speak, was originally with NICE, an institute in the UK that pontificates on health policy. Bryan's contribution here is on applying cost-benefit analysis to the use of expensive medical technologies.
Arnold Milstein, next speaker, is a member of the Pacific Business Group on Health, a coalition of businesses seeking ways to cut their health insurance costs, and is apparently also affiliated with Mercer, a human resources consulting firm. His topic concerns the importance of businesses being able to offer good healthcare benefits to their employees, because otherwise how could they lure/keep the best and brightest employees? He mentions, only briefly, the the Dorsett family, whose insurance company basically bankrupted them by not paying for complicated medical care that one of the Dorsett kids needed. Of course neither the speaker nor anyone in the audience or on the panel follows up on this little unpleasantness. An interesting note, during the Q&A at the end, when someone in the audience asks [I'm paraphrasing] "Are we eventually going to have to end up with a healthcare system in which employers no longer play a part?" he mutters "Yes."
And finally, Dr Smith speaks. He starts off in a promising manner, pointing out that up to that point nobody has been talking about patients, that they've all been talking about patients as though they were interchangeable with widgets, or with hamsters. Unfortunately, he then goes on to propose his de-skilling innovations. Smith is president and CEO of the California Health Care Foundation and a member of the Google Health Advisory Council -- aha! De-skilling the medical workforce will be made possible by Google's tech innovations!
Aetna is an insurance company [you knew that] and CVS is a pharmacy chain [you knew that too]. Medco is a PBM -- pharmacy benefit manager. PBMs are supposed to help lower health care costs by negotiating lower drug prices between insurance companies and drug manufacturers. What we've ended up with, though, is a bureaucratic morass, with doctors, drug companies, insurance companies, pharmacies, and PBMs all alternately colluding and competing with each other, and we the hapless consumers of health care end up paying untold [and unknowable, because there is zero transparency in this process] amounts of money.
Nationalizing the way we pay for health care -- single payer, HR 676, Medicare For All -- will eliminate at least two layers of this bureaucracy, the insurance companies and the PBMs, and will allow the government -- essentially all 300,000,000 of us little people -- to negotiate directly with doctors, hospitals, and drug companies on prices.