I love graphs, especially interactive graphs.
GE made a graph of the average annual cost of patients with eleven common chronic diseases. Go check it out, marvel at the coolness as you grab the sliders and spin the wheel o’ misfortune. Take home point: hypertension is the single biggest driver of medical cost in all patients age 33 and up. Go figure.
*This blog post was originally published at Movin' Meat*
When DrRich left his medical practice nearly a decade ago, he spent much of the next few years as a consultant to certain companies that make implantable defibrillators.
Most of his work was in research and development, and had next to nothing to do with defibrillators themselves, or any aspect of treating cardiac arrhythmias. Rather, DrRich was interested in developing physiologic sensors that could be deployed in implantable devices, and the algorithms that could use these sensors to predict and detect various developing medical conditions (so as to enable early intervention, and potentially prevent said medical conditions from becoming manifest). DrRich considered this work a) interesting, and b) representative of a business model that could potentially flourish within a healthcare system whose chief concern is reducing costs.
And whenever the captains of industry who signed his checks would ask him something about implantable defibrillators, usually seeking his opinion on a proposed subtle variation in some unbelievably complicated programming feature, DrRich’s reply was likely to be something like this: “Sir (or Madam) – I will be happy to study the question you pose to me, as I am working on your dime. But it greatly saddens me to see all this time, energy and talent wasted on adding yet more irrelevant features to a mature technology, in pursuit of a business model that is fundamentally broken.”
To which they would smile indulgently, hand DrRich the document describing the proposed changes, and schedule a meeting to discuss them.
The indulgent smile was in recognition of the fact that DrRich never made a secret of his disdain for the business model embraced by implantable defibrillator companies. The fact that these captains of industry put up with DrRich’s disapproval was a clear indicator that they considered it to be “quaint,” and apparently not worth taking seriously, and that the value DrRich provided in other arenas at least counterbalanced the annoyance of having him criticize their core business every chance he got.
DrRich’s disdain for the implantable defibrillator business model was based on two factors.
First, their business model relies on the artificially high prices the system will pay for their devices. DrRich has discussed this before. While these high prices are not directly the fault of the companies themselves (rather, they are fundamentally the fault of Medicare processes that distort and destroy natural market forces), these companies have now come to rely entirely on this artificial price structure, and have established all their business practices around this high-margin enterprise. The problem is that this high-price model absolutely precludes any reasonable penetration of this life-saving technology into the vast population of patients who might benefit from it. Also, because the price structure is not only artificial but arbitrary, a few simple changes in Medicare processes could abruptly destroy their business overnight.
Second, nobody is really interested in preventing sudden death. It’s difficult to sell any product when there’s no demand for that product, and there is no demand for sudden death prevention. In contrast, most other medical problems have a built-in constituency Read more »
*This blog post was originally published at The Covert Rationing Blog*
A 90-year old man with a pancreatic mass, almost definitely pancreatic cancer, was admitted to a hospital.
Surgeon Jeffrey Parks does the initial surgery consult on this terminal case, and recommends hospice care.
The next evening, he’s shocked by the “astounding amount of medicine [that] had been practiced” during the day:
Consults had gone out to GI, oncology, and nephrology. The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.
It’s often said that we spend the most money in the world on futile care, often with little benefit to the patient. The preceding account was that phenomenon in action, replicated thousands of times on a daily basis.
A microcosm of what’s wrong with American medicine indeed.
*This blog post was originally published at KevinMD.com*
Everyone is reading Atul Gawande’s article in the New Yorker about health care costs. But I think most people misunderstand Gawande’s major point.
Everyone’s At It
The conventional wisdom on Gawande’s piece is this: our problems are caused by bad incentives in our health care system. They encourage doctors to overprescribe care. McAllen, Texas is the poster child of this problem. If we can change the economic incentives, doctors will behave better. They will follow medical evidence, not their bottom lines, and from this will emerge a rational, affordable system.
This isn’t what Gawande is saying.
Gawande went to McAllen expecting to see a microcosm of the American health care system. As expected, he found excessive, even abusive spending, and a culture that encouraged both. But he also found that in nearby El Paso, Texas, medicine wasn’t practiced this way, nor in most other places in the country. And so he came up with a surprising insight. Yes, McAllen is a reflection of what can happen based on the incentives in the system. But if every incentive works this way, why is McAllen such an outlier?
Gawande concluded it had to do with the “culture” of medicine in each community. Most doctors go into medicine to help patients. In Gawande’s visit to McAllen, he heard stories that money had become more important than quality care. What Gawande realized was how important this question of “culture” was to how McAllen became McAllen. It made him think of places that had a completely different culture, like the Mayo Clinic.
The doctors of the Mayo Clinic decided, some decades ago, to put medicine first:
The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and the nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. . . . Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially feasible.
Gawande couldn’t believe how much time doctors at the Mayo clinic spent with each patient, and how readily they could interact with colleagues on difficult problems. While it is true, the Mayo Clinic has financial arrangements that make this easier, it is the culture of patient care that dominates, not questions of pay:
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” [Denis] Cortes [CEO of the Mayo Clinic] told me
And this is where Gawande is being misunderstood.
The “cost conundrum” that Gawande talks about is not about how to cut costs, or how to change who pays for health care and how much. It’s deeper than that. Gawande’s point is that we have been fixated for so long on the question of money in health care that we are starting to forget about medicine. By focusing on ever more clever ways to pay doctors, we have systematically undervalued everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
We discount what he calls the “astonishing” accomplishments of the Mayo Clinic on this score. And instead of designing health care reform around ways to help more hospitals become like the Mayo Clinic, we choose instead to think about money, to focus our attention on how to cut costs in places like McAllen.
Politically, it makes sense – it’s convenient to have a poster child like McAllen to explain why one reform plan or another should become law. But the pity is that in this important time of reform we’re not talking about trying to put the needs of the patients first – to put medicine back in the center of health care. The pity is that in spite of the fact that everyone’s reading Gawande’s article, his most important insight is being misunderstood.
If we continue to be focused on money over medicine, we will lose the “war over the culture of medicine – the war over whether our country’s anchor model with be Mayo or McAllen.”
*This blog post was originally published at See First Blog*
Preventable disease is a terrible burden, made all the more tragic by the fact that it can be avoided.
Policymakers in Washington take this a step further, claiming that we can save huge amounts of money by systematic programs to prevent disease and encourage wellness. The document explaining the Republicans’ new “Patient Choice Act” says that wellness and disease prevention can save trillions of dollars (.pdf). President Obama seems to agree, saying these programs like these can create “serious savings” that represent “huge amounts of money in the long term.”
There’s one problem: study after study says it’s not true.
Earlier this year, the prestigious journal Health Affairs published a study on this topic. The author reviewed the results of nearly 600 studies (abstract at link, full article requires subscription) on the cost-effectiveness of various prevention programs. The findings are overwhelming – less than 20% of these programs saved money, while more than 80% actually added more to medical costs than they saved. How can this be?
It isn’t that complicated when you think about it. Take high blood pressure. If every American with high blood pressure took blood pressure medication, we would have lower rates of heart disease and stroke, and of course, eliminate the costs associated with those avoided conditions. But as the study points out:
the accumulated costs of treating hypertension are nonetheless greater than the savings, because many people, not all of whom would ever suffer heart disease or stroke, must take medication for many years.
Studies have shown similar results for other chronic diseases, like diabetes and asthma. There is also important data showing that even screening programs for cervical, breast and colon cancer cost more than they save.
Does this mean we shouldn’t do these things? Of course not. For each life that is touched by avoiding a chronic disease, finding a tumor early on, staying out of the hospital, there is enormous value. But the value is not financial. It’s something we do because it’s right, and it’s inherently good. There are no formulas to measure this.
Health care is very expensive, and the burden of that cost affects us all. But to talk seriously about this problem we need to confront an inconvenient truth: there is more to health care than just dollars and cents.
*This blog post was originally published at See First Blog*
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