June 4th, 2009 by EvanFalchukJD in Better Health Network
No Comments »
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*
May 30th, 2009 by DrRich in Better Health Network, Opinion
No Comments »
Earlier this year, DrRich offered several potential strategies for doctors and patients to consider, should healthcare reformers ultimately decree it illegal for Americans to seek medical care outside the new universal system. This eventuality (i.e., making it a crime to spend your own money on your own healthcare) may not be as far fetched as one might think at first glance, since in societies where social justice is the ultimate goal, such individual prerogatives must be criminalized.
At that time, DrRich offered several creative solutions to this problem, including offshore, state-of-the-art medical centers on old aircraft carriers, and combination Casino/Hospitals on the sovereign soil of Native American reservations. A reader subsequently offered the possibility of simply establishing institutions something like the “Cleveland Clinic Tijuana,” i.e., cutting-edge medical centers just south of the border. (This solution would have the added advantage of encouraging the government to finally close the borders once and for all, employing whatever means it might take, including military patrols, minefields, and missle-armed drone aircraft.)
As entertaining as it might be to imagine such solutions, a readily available, though much more mundane, solution exists today – medical tourism.
Medical tourism, where one travels outside one’s country in order to obtain medical care elsewhere, is a booming business. A number of superb state-of-the-art medical centers expressly aimed at attracting medical tourists have been established in the Middle East, Singapore, India, China and elsewhere in Asia. These institutions cater to citizens of the world whose own healthcare systems cannot (or will not) provide in a timely fashion (or at all) the level of care patients may desire. They offer modern hospitals, numerous amenities, luxurious accommodations, attentive nursing care, top-notch doctors – and they do it all for a tiny fraction of what the same care might cost (if you can even find it) in the U.S. and other “first world” nations.
Obviously medical tourism is not particularly feasible for medical emergencies such as heart attack or stroke, or for chronic illnesses such as diabetes, congestive heart failure, or Parkinson’s disease, which require frequent visits and long-term management. What is feasible is to become a medical tourist for those one-time medical services that can be scheduled and planned, for which there is a long waiting period at home, or which is simply too expensive in one’s own country. Such medical services often include coronary artery bypass surgery, hip replacements, knee replacements, and numerous minimally-invasive and not-so-minimally-invasive surgical procedures. In other words, medical tourism to a large extent is something one does for elective (i.e., non-emergency) surgery.
It ought not be a surprise, therefore, that the first organization of American physicians to issue a formal policy statement regarding medical tourism is the American College of Surgeons.
The reaction of American surgeons to medical tourism ought to be obvious. They hate it. Elective surgical procedures – the very procedures for which Americans become tourists – are the bread and butter of most surgical specialties. And here go their prospective patients, off to Singapore for their lucrative bypass surgeries. American cardiac surgeons, for instance (already underemployed, thanks to American cardiologists throwing stents at every tiny coronary artery indentation they they can justify as a “blockage”), are nearly apoplectic at the idea.
It’s always fun to read formal policy statements which attempt to deliver an entirely self-serving message whose essence is, “We hate this and if you do it we’ll hate you,” but in which it is necessary to deliver the message in a polite, politically correct, non-judgmental, helpful and even friendly manner.
The surgeons in general have made a good effort, as you can see if you’d like to read the policy statement for yourself. It’s pretty much what you would expect – “Go ahead and have your knee replaced in Timbuktu if you want to. It’s your right, so go ahead and devil take the hindmost. Just don’t come crying to me when things go south a month later.” Only, of course, the surgeons employ the obligatory very polite and professional tone.
DrRich is struck by two aspects of the surgeon’s policy statement on medical tourism.
First, the surgeons begin with a litany of dire warnings regarding all the medical considerations one must take into account before trusting one’s health to foreign medical hands:
“Some of the intangible risks include variability in the training of medical and allied health professionals; differences in the standards to which medical institutions are held; potential difficulties associated with treatment far from family and friends; differences in transparency surrounding patient discussions; the approach to interpretation of test results; the accuracy and completeness of medical records; the lack of support networks, should longer-term care be needed; the lack of opportunity for follow-up care by treating physicians and surgeons; and the exposure to endemic diseases prevalent in certain countries. Language and cultural barriers may impair communication with physicians and other caregivers.”
These are all very important considerations. DrRich notes, however, that these very same considerations (even the warning about endemic diseases, once one allows for the MRSA infections which are secretly “endemic” in some American hospitals) must also be taken into account before agreeing to receive care even in an American institution. It may be that these considerations are more an issue in top-notch foreign hospitals than in your average American hospital, but DrRich is not convinced this is the case, and the surgeons do not provide any evidence that it is. That is, DrRich sees this very good advice as being equally applicable whether one is considering becoming a medical tourist, or just a typical American patient.
Second, and most astoundingly, DrRich notes – not so much with interest, but more with awe – that the surgeons are beseeching their patients to consider just how difficult it might be to launch a malpractice suit against foreign doctors. (DrRich himself does not know how difficult this would be. Given that we are being so strongly urged these days to merge the American legal system with international law, it might not be much of a problem for long.) Indeed, the potential difficulty in suing foreign doctors appears to be the chief differentiator, and the primary argument in favor of good-old-American-surgery. The surgeons, in essence, are saying, “Let us do your surgery, because we’re easier to sue if we screw up.”
This, from the very body of American physicians who are most at risk for malpractice suits, and who traditionally have been most vociferous in favor of malpractice reform.
DrRich can only shake his head in wonderment. If medical tourism is viewed by surgeons as such a dire threat that they are formally embracing medical malpractice suits as their chief weapon against it, then medical tourism must have already caught on far more than most of us realize.
Which means, of course, that when healthcare reform takes place, medical tourism will likely enter a phase of truly explosive growth.
And so, Dear Reader, thanks to this critical clue provided by our friends in the American College of Surgeons, DrRich can confidently offer yet another nugget of investment advice. He formally recommends the medical tourism industry – now in its infancy – as an area ripe for growth.
*This blog post was originally published at The Covert Rationing Blog*
May 18th, 2009 by KevinMD in Better Health Network
No Comments »
Paying physicians via capitation was soundly rejected by patients when it was tried in the HMO era a decade ago.
Massachusetts is trying again. According to a state commission, they recommend “replacing fee-for-service with a system that would use a single payment to cover most of a person’s care for an entire year.”
The last time this was tried, patients rebelled as it was perceived that there was a financial incentive for doctors and insurers to deny care. And they were right. Bluntly put, it’s the only way to control health care spending.
Some are skeptical that Capitation Version 2.0 will work. Hospital CEO Paul Levy feels that doctors and hospitals will be at risk of being caught in the middle: “You also need to let the public know what the new environment will be for their care so doctors and hospitals are not caught in the middle, the way it happened during the last experiment with managed care. If the Commission does half the job in its recommendations and leaves the rest to be fixed in the future, it will leave us will a lot of unintended consequences and will undermine the good that might otherwise come from a new payment scheme.”
Health insurer CEO Charlie Baker echoes my skepticism about whether patients will accept the implications of this new model. In addition to the fear that doctors will be incentivized to withhold care, patients will also worry about a possible “restriction on their ability to see any physician they wanted to see.”
But, the bottom line is that saying “no” is the only way to control costs. Whether patients will accept that fact will determine whether these payment reforms will be successful.
*This blog post was originally published at KevinMD.com - Medical Weblog*
May 14th, 2009 by DrRob in Better Health Network
No Comments »
I met a urologist from another city recently. Since it had been a much discussed issue recently, I asked him what he thought about PSA testing. His answer was immediate.
“I think PSA testing has been proven to save lives, and I have no doubt it should be done routinely.”
When I mentioned the recent recommendation that prostate cancer screening be stopped after a man reaches 70, his faced turned red. “That report is clearly an attempt by the liberal media to set the stage for rationing of healthcare. It was a flawed study and should not be taken as the final say on the matter.” He went on to recount cases of otherwise healthy 80 year-old men who developed high-grade prostate cancer, suffered, and died.
I chose not to debate him on the subject, but did point out that his view was that of one who sees the worst of the worst. I personally can recall less than ten patients who died of prostate cancer in the fifteen years I have practiced. My view is one that sees a non-diseased general public, and not worst-case scenarios. I also didn’t point out that even the American Cancer Society stopped pushing the test and states, and does not think as highly of the evidence as he does: “Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives.” (1).
But I digress. What really struck me in the discussion was the way he pulled out the idea of rationing as the end-all hell for American healthcare. It is regularly used as a scare tactic for those who advocate a “free market approach” to healthcare. They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis. Rationing healthcare seems a universal evil, and any step that is made toward controlling cost is felt by some to be a push of the agenda of the Obama administration toward universal health coverage and ultimately rationing.
So what exactly is so bad about rationing? The word itself refers to an individual being given a set amount of a limited resource, above which none will be available. In healthcare, the idea is that each American is given only a set amount of coverage for care and above that they are left to fend for themselves. Those who are either go over their limit or are felt to have a less legitimate claim on a scarce resource will be denied it. This is especially scary for those who are the high-utilizers (the uninsurable that I have discussed previously), as they will use up their ration cards much faster than others. I certainly understand this fear.
But are all limitations put on care really a step toward rationing? Are limits put on care a bad thing? The answer to that is simple: DUH! Of course not! Of course there need to be limits on care! Without control over what is paid for, the system will fall apart. Here’s why:
- Limited Resources – Not only are our resources limited, they need shrinking. The overall cost of our system is very high and has to be controlled somehow. Different interests are competing for resources, and by definition whoever doesn’t win, doesn’t get paid. This means that someone needs to prioritize what is a necessity and what is not.
- Lack of personal culpability by patients – with both privately and publicly funded insurance, the actual cost to the patient is defrayed. They are not harmed by unnecessary spending, so they don’t try to control it. Only uninsured patients are painfully aware of the cost of unnecessry tests.
- Lack of personal culpability by doctors – If I order an unnecessary test or expensive drug, I am not harmed by the waste. For example, it is common practice by emergency physicians in our area to get a chest x-ray on children with fever. Most of this is related to defensive medicine which is understandable in the ER, but clinically the test is often not warranted. Yet the emergency physicians are not really affected by this waste, and the hospital and radiologists are actually rewarded by it if the insurance company pays for it (which they do).
- Incentives for other parties – As I just said, hospitals and radiologists have incentives to have wasteful procedures done. The urologist I spoke to has a huge financial stake in the continuation of PSA testing, as it generates enormous business for him. Drug companies want us to order their more expensive drugs than the generic alternatives. This doesn’t mean any of them are wrong, but they sure as heck won’t fight waste if it harms them financially to do so.
When I was a physician starting out, the insurance companies would pay for pretty much any drug I prescribed. At that time there were very expensive branded anti-inflamatory drugs that were aggressively pushed by the drug companies. When the first drug formulary came around, the first thing that happened was that they forced me to use generic drugs of this type. Before, there was no reason not to prescribe a brand, I had samples, and they were a tiny bit more convenient. But when I changed there was really no negative effect on my patients.
One of our local hospitals just built a huge new cardiac center. Statistically, our area is a very high-consumer of coronary artery stents compared to the national average. Yet there are many cases in which an asymptomatic person will get a stent placed simply because they have abnormalities on their cardiac catheterization. Logically this may make sense, but the data do not suggest that these people are helped at all. Do you think that the hospital wants these procedures halted? Do you think the cardiologists do? Yet if they are truly unnecessary, shouldn’t they be stopped? Couldn’t the $200 million they spent on their state-of-the-art facility be used in better ways? Someone has to be looking at this and making sure the money spent is not wasted.
Without cost control a business will fail, and the same goes for our system. Yet any suggestion at the elimination of clinically questionable procedures is met with cries of rationing. Right now we are not at the point of rationing, and the act of trying to control cost by eliminating unnecessary procedures does not necessarily imply that the end goal is rationing. The end goal is to spend money on necessary procedures instead of waste. I sincerely doubt there is a left-wing conspiracy to push us to deny care where it is needed. I doubt that the American Cancer Society is in favor of rationing.
Let’s just spend our money wisely. It’s just common sense; not an evil plot.
*This blog post was originally published at Musings of a Distractible Mind*
May 11th, 2009 by KevinMD in Better Health Network
No Comments »
One question that occasionally comes up is whether doctors should be paid a flat salary or not.
Currently, the majority of physicians are paid fee-for-service, meaning that the more procedures or office visits they do, the better they are reimbursed. This, of course, gives a financial incentive to do more, without regard to quality or patient outcomes.
One proposed solution is simply to pay doctors a flat salary, with bonuses for better patient outcomes.
Well, according to a recent Kaiser/NPR poll, that idea is a no-go for patients. 70 percent of patients think its better that a “doctor gets paid each time they see you,” while only 25 percent think a yearly salary is better.
As an aside, I find it interesting that any public poll result that goes against the progressive health policy agenda is considered a “weak opinion,” but really, this isn’t a surprising result.
Economist Uwe Reinhardt hinted at the cause when he said that most Americans believe “that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it.”
Perhaps the public believes that a salary is similar to the capitation debacle in the 1990s, where doctors were paid a fixed fee, which gave them an incentive to deny care. And any perceived attempt to restrict care will be met with visceral opposition by the American public.
Which again shows how difficult it will be to engage patients with any dialogue that involves cost control.
*This blog post was originally published at KevinMD.com - Medical Weblog*
