September 28th, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
No Comments »
A thoughtful and (dare I say it) balanced look at medical malpractice in today’s NYT:
Malpractice System Breeds More Waste in Medicine – NYTimes.com
The debate over medical malpractice can often seem theological. On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive. On the other side are those liberals who see malpractice reform as another Republican conspiracy to shift attention from the real problem. […]
The direct costs of malpractice lawsuits — jury awards, settlements and the like — are such a minuscule part of health spending that they barely merit discussion, economists say. But that doesn’t mean the malpractice system is working.
The fear of lawsuits among doctors does seem to lead to a noticeable amount of wasteful treatment. Amitabh Chandra — a Harvard economist whose research is cited by both the American Medical Association and the trial lawyers’ association — says $60 billion a year, or about 3 percent of overall medical spending, is a reasonable upper-end estimate. If a new policy could eliminate close to that much waste without causing other problems, it would be a no-brainer.
Read more »
*This blog post was originally published at Movin' Meat*
September 21st, 2009 by Emergiblog in Better Health Network, Health Policy, Opinion
No Comments »
Well, I lead a double life but it isn’t out dancing in formal wear!
“There is time for only fleeting thoughts about that dance you’ll attend during off duty hours.”
There isn’t even time for that.
Besides, who attends a dance during on duty hours?
Well, I guess the most important thing is that our hands are “soft, smooth and free from redness” because “your patients like it and your date expects it”.
Oh yeah?
The day they use a hand sanitizer thirty times in a shift and wash their hands another twenty, they can talk to me about soft hands.
********************
My husband won’t watch football with me because I tend to get hyped up and throw things at the TV when I get upset.
That explains why there were Notre Dame pom poms and a Cleveland Browns jersey at the base of the set this weekend.
I also like to talk back at the President when he is speaking on TV. Usually it’s things like “Say WHAT?” or “Give me a break!” “Get. A. Clue!” is usually a good one. This last speech, the one to Congress about health care, was no exception. My first comment came a bit into the speech when I noted a few times that “I haven’t heard a single thing I disagree with yet” and “he’s right on that point”.
I was afraid hubby was going to need smelling salts.
But I’m like, “let’s hear how he is going to pay for this…let’s hear him out”.
And then I heard it.
And then he lost me.
*****
There were two comments that I could not let go. I looked them up in the text of the speech to make sure I had heard them correctly.
“…we’ve estimated that most of this plan can be paid for by finding savings within the existing health care system a system that is currently full of waste and abuse.”
“The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud…”
Hundreds of billions of dollars? Billions? With a capital “B”?
Waste. Abuse. Fraud.
This means that in order to pay to the proposed health care reform, we have to find enough waste, abuse and fraud to cover expenses.
*****
But I have some questions.
What is the definition of “waste”? To the extent that “waste” means inefficient bureaucratic practices that use up monetary resources, I can get on board with that.
Abuse? What kind of abuse? Using the system inefficiently, like calling an ambulance for a stubbed toe? Remember, the President is using the term “abuse” to represent a potential income stream for the new system, so it would have to encompass behaviors that spend money that should not be spent. Money is spent on patient care, so is he talking about patients abusing the system?
And then there’s fraud…
That’s a crime, folks.
Hundreds of billions of dollars in waste and fraud?
The President must think that there are an awful lot of criminals in the health care system.
So what’s my point?
*****
My point is this: funding for the new proposed health care system (see “most of this plan…”, above) is based on finding waste, abuse and fraud.
What happens when all the waste is taken out, all the abusers are stopped, the fraudsters jailed and the system needs more funding? Does that not make it imperative that we keep finding waste and abuse and fraud? Does that not mean that what constitutes waste, abuse and fraud must be constantly expanded to make up for rising costs?
This can’t be good.
I am in total agreement that our system can be streamlined, big time.
And maybe we could find enough money in waste, abuse and fraud to make it pay for itself, but I doubt it.
If we could do that, wouldn’t we have done it already with Medicaid and Medicare? The budgets for both are getting slashed on a regular basis. Drop the waste, abuse and fraud in those programs and then come back and tell me how much better their budgets are.
If we can’t do it in an existing government-provided system, how on earth do you expect us to believe it can be done on a larger scale?
*This blog post was originally published at Emergiblog*
September 20th, 2009 by Toni Brayer, M.D. in Better Health Network, Opinion
No Comments »
I read a good post from NYT about Health Care Reform and ‘American Values’ and it got me a thinkin’…just what are American Values when it comes to health care? Usually I get a little anxious when I see “American Values” in a sentence, because what usually follows is something about rugged individuality, pulling oneself up by bootstraps, getting the damn government out of our lives and those damn immigrants and welfare mothers who won’t work and want to live off others.
But I have listened to about ten thousand patients over the past 25 years, and I have a good idea of what these Americans want for health care. They are the silent majority…the people who work, study, raise their kids and seldom call into a radio talk show. They don’t have time to go to town hall meetings and shout slogans.
They range from age 17 to 101 and most of them are middle class. They come in all races…Asian, Black, White, Pacific Islander and mixes of all.
Some are wealthy enough to have multiple homes and private planes.
Some are uninsured and watch their health care spending very closely. Most were thrilled to get Medicare and I’ve never heard a complaint from a Medicare patient.
Here is my list of what these Americans think about Health Care:
- They do agree that everyone should be covered for basic health care and would pay higher taxes if they could believe that there would not be fraud and waste. (The recent banking meltdown has destroyed all confidence that government can regulate or be independent from special interests)
- They want choice of physicians and hospitals
- They are sick of insurance companies and all feel like they have been screwed in one way or another. They are shocked at how little insurance companies pay toward the doctor visit and the way those fees are discounted.
- They are technocentric and want tests, imaging, referrals and think “more is better” when it comes to health care. They think tests are cures. Because of the perverse incentives, the “more is better” philosophy benefits doctors and hospitals, but not necessarily patients.
- They fear losing insurance if they have it.
- They are confused about the current reform debate and mostly fear losing whatever coverage they now have, because they know how impossible it is to get by without any coverage at all.
There are no such thing as “American Values” because we are a diverse group of people. But we all have certain things in common. We want to be healthy. We don’t want to be screwed by anyone (big business or the government).
We want to be able to manage our own health care but we don’t want to have to decide between numerous health plans every year with pages of information that cannot be understood. We are tired of not knowing where all the $trillions really are being spent.
We want to know the price of a service up front, and we want a trusted physician to help us decide if that is how our money should be spent. We want smart, committed physicians to know us, and not hurt us.
Sounds American to me.
*This blog post was originally published at EverythingHealth*
September 17th, 2009 by DrRich in Better Health Network, Opinion
No Comments »
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*
September 16th, 2009 by DrRob in Better Health Network, Health Policy
No Comments »
I got something in my e-mail this morning. It’s a press release aimed at helping with prostate cancer awareness month, and is supported by Lance Armstrong’s foundation.
SURVEY SHOWS AT-RISK MEN LACKING IN PROSTATE CANCER KNOWLEDGE
SUNNYVALE, CALIF.,– September 9, 2009 – Prostate cancer remains one of the most commonly diagnosed cancers in the United States. In fact, one in six men will develop prostate cancer. It is also the second-leading cause of cancer death in the United States. But a recent survey suggests that many men at risk for the cancer still aren’t aware of all available treatment options. The survey, conducted late last year, reveals that nearly 50% of men aged 40 and older are not aware of the most common approach to surgery for prostate cancer — robotic-assisted surgery to remove the prostate. “I had to do my own research and then self-admit myself to the [hospital],” says surgery patient Tim Propheter. “…. Most people are just told … ‘Sorry, you have to have surgery, and we’ll set you up for such and such day,’ and they don’t know any better until they run into someone like me,” he says. This lack of information persists despite the fact that prostate cancer treatment has changed dramatically in the last decade. For example, surgery — which remains the gold standard treatment for localized prostate cancer — has become much less invasive. According to the American Urologic Association, the major benefit of prostatectomy, or prostate removal, is a potential “cancer cure” in patients with localized or early stage cancer.
Guess who the press release was from? Guess who sponsored the survey? The following was at the bottom of the email:
About the survey
Data was collected from 1000 self-selected adult healthcare information seekers through an online panel available through Ztelligence.com, using an survey questionnaire. Fifty-four percent of those were male and 46 percent were female. The results reflect only the opinions of the healthcare seekers who chose to participate.
About Intuitive Surgical, Inc.
The survey was conducted by Intuitive Surgical, Inc. (NASDAQ: ISRG), the manufacturer of the da Vinci Surgical System, the world’s only commercially available system designed to allow physicians to provide a minimally invasive option for complex surgeries. Intuitive Surgical, headquartered in Sunnyvale, California, is the global technology leader in robotic-assisted, minimally invasive surgery (MIS). Intuitive Surgical develops, manufactures and markets robotic technologies designed to improve clinical outcomes and help patients return more quickly to active and productive lives. The company’s mission is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. Intuitive Surgical — Taking surgery beyond the limits of the human hand.™
Imagine that. A survey done by company that sells the da Vinci robotic surgical equipment shows that men have tragically no knowledge of the da Vinci robotic prostate surgery!
So let’s see what the evidence shows:
- Prostate cancer occurs in 186,000 men each year and kills nearly 29,000.
- In a well-known autopsy survey, over 1/3 of men over 80 were found to have cancer present in their prostate without evidence of significant disease. It is not clear how many of these men will progress to overt cancer, but it is very clear that this is the vast minority.
- PSA Testing (the blood test for prostate cancer screening) is by far the largest source of surgical candidates. It is a controversial test, having a high rate of false positives and an unproven record of significant benefit.
From the reference uptodate.com:
The European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a small absolute survival benefit with PSA screening after nine years of follow-up; however, 48 additional patients would need aggressive treatment to prevent one prostate cancer death. Although the report did not address quality of life outcomes, considerable data show the potential harms from aggressive treatments. Further sustaining the uncertainty surrounding screening, a report from the large United States trial, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, published concurrently with the European trial, found no benefit for annual PSA and digital rectal examination (DRE) screening after seven to ten years of follow-up. The crux of this screening dilemma was aptly stated by the urologist Willet Whitmore, who asked “is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible?”
The most important line in this is at the end of the first sentence, stating that 48 patients would need aggressive treatment (including prostatectomy) to prevent one prostate cancer death. So how much does “aggressive treatment to prevent cancer death” cost?
From the Journal of Clinical Oncology:
For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P < .001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P < .001).
note: it was very hard to find numbers here. This is actually from Medicare claims from 1992 and 1993, so it is a huge underestimate from today’s numbers.
Which means that based on the 1992 numbers, you would spend $672,000 to save one life using radiation therapy and $1,084,000 if you used surgery. This does not take into account the consequences of surgery for the men who underwent the surgery.
What about robotic surgery? In a comparison of the cost of open prostatectomy to robot-assisted surgery, the cost is even higher.
Cost was the one area in which the older open surgery was the clear winner: Open radical prostatectomy costs $487 less a case than non-robotic laparoscopy and $1,726 less than robot-assisted prostatectomy.
According to the review, “Shorter operative time and decreased hospital stays associated with the robotic procedure did not make up for the cost of the additional equipment expenditure.” Estimated costs of the robotic system to a provider run about $1.2 million a year, with maintenance costs of $120,000 a year and one-time costs of $1,500 a case.
To summarize:
- Prostate cancer screening is controversial, as it fails to differentiate between the minority of men who would die from the disease from the majority who would simply die with it.
- PSA Testing as greatly increased the number of men diagnosed with early stage cancers.
- Prostate cancer surgery or radiation therapy is recommended for men who have early stage cancers.
- Aggressive prostate cancer treatment has to be done 48 times to save one life.
- The most expensive treatment for prostate cancer is prostatectomy, or removal of the prostate.
- The robotic form of the surgery is a higher-cost procedure by a significant amount.
So, an expensive form of surgery that may not be appropriate is done on a group of men identified on a very unreliable test yielding a very small number of lives saved and a lot of men who then have to deal with the physical consequences of the surgery. Why in the world is this being promoted at all?
Money. Here’s the homepage of one of our local hospitals. They have aggressively marketed da Vinci surgery on television, billboards, and the radio.
Why do you think they would pay as much money as they do for this device? It’s good business? Not so fast. Dr. Paul Levy stated back in 2007 about this very procedure:
Here you have it folks — the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the “state of the art”, so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?
No, hospitals are employing this just to keep pace. The real winner in this is Intuitive Surgical, Inc., who has been a darling of Wall Street, beating estimates in earnings with a Q2 net profit of $62.4 Million.
Why is the cost of healthcare going up while physician reimbursement goes down and hospitals go out of business?
It’s Intuitive.
God Bless America!
*This blog post was originally published at Musings of a Distractible Mind*
