You Can't Get There From Here

Imagine your car has a bit of a snuffle, so you take it in to your friendly neighborhood auto mechanic. He throws the car up on a lift, pokes around under the chassis, then puts it back down.

"I don't see anything wrong from here," he says, "but I need to put it on a diagnostic machine to check the computer."

"Great," you say naively, "do it."

"Can't," he says. "It's against the law for me to own a diagnostic machine."

"Why?" you ask.

"Because then I might run your car on the diagnostic machine and charge you for it even if you really don't need it."

"Oh," you say. "But you might also decide to throw in the diagnostic run for free as part of your overall service."

"Can't." he says. "It's against the law for me 'throw in' anything for free."

"Why?" you ask.

"Because I might try to 'throw in' a bunch of stuff you need for free in order to lure you into buying even more stuff that you don't need."

"I guess," you say.

A week later you go back to your mechanic with the diagnostic report. He tells you that you have a bad valve which needs to be replaced.

"Great," you say, "replace it."

"Can't," he says, "It's against the law for me to do valve replacements here."

"Why?" you ask.

"Because I might try to con every customer into getting a valve job done even if they don't need one."

"But that's someone else's problem," you say. "I actually need one, and now I have to go somewhere else and pay someone else's overhead - - in addition to yours - - in order to get the job done?"

"That's right," he says. "And the state keeps a strict lock on who actually gets to do valve jobs."

"Why?" you ask.

"I'm not really sure," he says. "I think they want to make sure the people who do valve jobs are really good at it."

"I see," you say, "but that means they can charge whatever they want."

"Basically, yes," he says.

"And there isn't anywhere else I can go?"

"Nope," he says.

"So I'm forced to pay higher prices, to multiple people - - each of whom get their profit cut - - plus suffer the inconvenience of trotting all over town, in order to get a procedure done that you're perfectly capable of doing here all on your own, right now?"

"That's right." he says. "And the law says it has to be that way."

"The law should change," you say.

"Good luck with that," he says.

Happily, such is not the state of auto care. You go to the shop, they put your car on the lift, they run the diagnosis machine, they fix the car, you get it back the same day. Not that the service shop doesn't make money, that's a given. But that's OK, it's an expected part of the deal. What's not expected is that you will have to pay for three or four or seven profit margins instead of just one, or have to spend an extra week or two or three and a lot of hours running around to get it done.

But such is the state of healthcare, for two reasons. One, the third-party, fee-for-service reimbursement model that predominates the industry creates an incentive for providers to deliver care that is not really necessary (or at least is only arguably necessary). Second, arcane laws that were designed to offset that incentive (by paternalistically substituting the state's judgment for the patients) force the sort of fractured and siloed care delivery models that nearly everyone complains of. (Those that wrote the law don't complain. They are the only ones that do not.)

The health reform bills did nothing to address the second of these reasons and both expanded and perpetuated the first, and that by leaps and bounds.

Imagine a market landscape where health care providers could spend their time dreaming up ways to make it more convenient and less expensive for patients to get the care they need. As it is now, providers are forbidden from exploring most alternative delivery means, and are rewarded only for dreaming up new ways to get more money from third party payors.

Cheap and convenient one-stop-shopping? It would be great, but you can't get there from here.