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An Inconvenient Truth About Prevention

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*

How Primary Care Providers Can Help Women Hurdle The “Roadblocks” To Their Care

A report just released on HealthReform.gov, the website for the Obama Administration’s healthcare reform effort, is entitled Roadblocks To Healthcare: Why The Current Health Care System Does Not Work For Women, and cites that more than half of American women (52%) delay or avoid care because of cost, compared to 39% of men.

A video synopsis of the report, hosted by Kathleen Sebelius, the Secretary of Health and Human Services, states that women are being left behind when it comes to healthcare and that there are over 21 million uninsured women in the U.S.  Young women have much more difficulty finding affordable health insurance than do men and often pay higher premiums – sometimes one and a half times – those of a young man. These facts all add up to women not getting the care they need to stay healthy.

As a primary care provider (PCP) focusing on women’s health, the findings of the report don’t surprise me, not even a little. From my anecdotal studies of the number of women that I have seen over the years, the majority of women struggle to receive the care they need because they cannot afford it. What typically will happen is that these women delay, often for years, any type of check-up or preventive care because of costs. Instead, they wait until they are sick or are having issues, and then they are forced to find the money and the time to seek medical care.

I also have found another factor beyond price that is creating a barrier to healthcare for women,  and the word is “convenience.”  Many women cannot, or often will not, take the time to seek routine medical care when most doctor’s offices are open, which is nine to five. Frequently these women are working, albeit on jobs that offer them little or no healthcare coverage, and are loathe to take time off of work for a non-emergency medical issues. Women also have the lion’s share of childcare responsibility, and are more likely to put their children’s schedules and family needs well before theirs.

Primary care can be the first place to look for a solution in bringing affordable, convenient care to women so that there are no roadblocks to access. We strive to do just this at our practice. Our Well Women Clinics were spearheaded after much deliberation about cost and convenience.  We started last year and have found them to be a great success. For these clinics, we designated specific days during the month for routine well women check-ups. Hours for these check-ups are early morning through lunch one day and mid-afternoon through evening on another days. We offer the clinics two days each month on different days of the week, ideally making times available for each patient’s schedule, whether she is a current patient with us or a new one.

Although the biggest hurdle for women to getting the care may be cost, as the Obama Administration’s report cites, let us not forget the role that convenience in getting this care plays. Healthcare and wellness does not have a nine-to-five schedule. Likewise, most women’s roles beyond possibly those in a regular “office” job are not on such a regimented schedule; their roles as caretakers and mothers have round-the-clock demands. We need to work with women determine and then remove all of the roadblocks to accessing of care, starting first and foremost with cost, moving to convenience and then considering others that may exist.

Until next week, I remain yours in primary care,

Valerie Tinley, MSN, RNFA,  FNP-BC

Will Rationing Care Become Part Of Reform?

The impetus for government to control healthcare costs should be obvious to us all and intervention now appears unavoidable.  Two issues will soon come to light: the exorbitant costs to fight disease at the end of life, often when the approach of death is barely retarded and the wide disparity in costs between different geographical regions of our country for similarly aged patients.  It is estimated that 27% of Medicare’s annual $327 billion budget – one fourth of its operating budget – goes to care for patients in their final year of life while Medicare averages $20,000 more dollars for patients in Manhattan than in some rural areas of our country.

With this in mind, I share a deep concern with many of my colleagues that part of the healthcare reform debate will turn to the rationing of healthcare. This appears a logical progression from the proposed establishment of guidelines and advisory committees currently allowed for in the Health Reform bill already passed. The question as to who should receive possibly futile care is not clear, rather it is fraught with complexity, often relying as much on evidence-based research as it is on assessments made by the medical practitioner in light of the relationship the doctor has with the patient.

At the heart of the rationing issue are two, often warring, sides of medicine:  art and science. Medicine began as an art thousands of years ago, and moved more towards science when, in Ancient Greece, Hippocrates taught physicians to observe the results of their treatments and make adjustments. However, art should not be removed from medicine, for this is where the doctor-patient relationship comes to play, serving as a cornerstone of effective and humane medicine.  It would be impossible for physicians to uphold the noble traditions of the medical profession, adequately serve society, or preserve the dignity of human life if doctors were to become, purely, scientists.  As long as we are treating people, medicine should never become solely a science.

Rationing, however, would be based purely on science, completely devoid of any art and, I believe, serve as a blow against the sanctity of the medical profession.  Setting up rationing guidelines as they pertain to the end of life would circumvent patient’s trust in the doctor-patient relationship and risk the very soul of medicine by negating the importance of the doctor-patient relationship. Evidence-based recommendations can and should be set forth pertaining to protocols for offering treatments as the end of life seems near.  This would likely reduce some of the high and disparate costs in caring for our elders; however, it is important to consider the input of a doctor aware of the needs and desires of his patient.

I come to this argument both as a physician and from personal experience. Several years ago, my 75 year old father was hospitalized four times over five months.  His medical team, led by a kind and experienced surgeon, unburdened by guidelines or anyone else’s recommendations, gave him a chance despite long odds against his survival.  Medically speaking, I am still surprised he made it out of the hospital to live a normal life again.  During the subsequent five years, he has welcomed three grandchildren into our family; I would challenge anyone to assign a monetary value for that life experience.  My professional and personal experience leaves me quite sure that he would have fallen a victim of any rationing guidelines that could ever exist.

In short, as the average life span increases most of us nurture the hope to live longer, cheering as science opens the door to seemingly innumerable advancements. Yet are we, as a society, equipped, whether it be emotionally or fiscally, to handle the decisions that must be made as the end of life draws near? More importantly, should government be allowed to set up strict guidelines without an active debate from physicians and patients?  These guidelines could sacrifice what has long been and should still remain most important to healthcare: the doctor-patient relationship.

Healthcare Reform: Then (1994) And Now (2009)

DrRich has been around long enough to remember the sequence of events that accompanied the collapse of healthcare reform under the Clintons in 1993 – 1994.  (Heck, he has been around long enough to remember Nixon’s plans for healthcare reform, which drowned in Watergate.) When President Clinton was inaugurated, everyone agreed that the American healthcare system was in a state of crisis (e.g., spending levels could not be sustained, there were too many uninsured, there was too much waste and inefficiency, etc., etc.), and that the time for fundamental reform had finally arrived. We had a fresh, dynamic, young President with new ideas and with a solid majority in both houses of Congress, and he was armed with polls showing that the people were in favor of fundamental reform.

Accordingly, when Mrs. Clinton put together her working groups to devise a reform plan, she initially had the enthusiastic participation of numerous interest groups within the healthcare industry – notably including the insurance companies, physician groups, and drug and medical device companies.

But when she finally produced her plan – a disturbingly heavy tome filled with frightening details – everybody was horrified with at least some of the stuff they found there. Most of the big interest groups turned on her – most notably, the insurance industry, which then launched the famous Harry and Louise commercials to scare the people about government healthcare. The people, now duly scared, called their congresspersons, who (despite the Democrat majority) ended up sending Mrs. Clinton’s healthcare reform to a crushing and humiliating defeat. And the Republicans were able to capitalize on the “near miss” of the Clinton’s brazen attempt at socialism, and in 1994 ushered in 12 years of a Republican majority in both houses of Congress.

Obviously, for those Republicans and other observers who abhor Mr. Obama’s plans for healthcare reform, it is relatively easy to see parallels between what happened in the early 1990s, and what appears to be shaping up now. Those parallels, and the subsequent ignominious defeat of the Clinton plan, are the only things keeping these sorry individuals from donning sackcloth, heaping ashes upon their heads, and engaging in public self-flagellation.

So, perhaps, for such outsiders the spectacle of the major private healthcare interests this week throwing in with the Obama administration will be seen as one more sign from the gods that the parallels of 1994 are falling into place.

But they are wrong.

There are at least three important differences between the enthusiastic participation of private interests in Mrs. Clinton’s working groups on healthcare reform, and the action taken this week by representatives of insurers, doctors, drug companies, hospitals, and medical device manufacturers to pledge their undying support for President Obama’s efforts at healthcare reform.

First, in 1993 the private interests were powerful and confident. They participated in the process because they felt they could control it. It turned out they were wrong, of course – the only one who has been able to out-maneuver the Clintons is Mr. Obama – and the plan Mrs. Clinton finally produced (despite all the “input” from diverse private interests) really was a blueprint for a full government takeover of healthcare, all spelled out and wrapped with a bow.  But because the private interests were powerful and confident in those days, once they figured out what the Clintons actually had in mind they were able to scuttle healthcare reform entirely.

In contrast, today the private interests have come to the table not out of strength, but out of weakness. They come not as partners in negotiation, but as vanquished foes. They come to Obama as the Carthaginians came to the Romans after the second Punic war, suing for peace, begging for terms, offering massive tribute (in this case, $2 trillion) in exchange for being permitted to eke out a meager survival, at the edge of the desert. (DrRich wonders whether the insurance companies and their friends remember the third Punic war.  Surely they must know that somewhere in Congress is another Cato the Elder, ending every speech with the words, “The insurance industry must be destroyed,” and that at some point their remaining, puny base of operation will be completely sacked, and their mission statements sown with salt.)

Second, whereas Mrs. Clinton was a major policy wonk who reveled in providing a fully-fleshed-out and exquisitely detailed set of plans for healthcare reform – thus giving her foes sufficient ammunition not only to defeat her reform plan, but also to banish the Democratic Party to the wilderness for three election cycles – Mr. Obama is not. His reform plan will be bare-bones – merely an outline, more-or-less a statement of principles. There will be nothing to attack, since there will be no details, and little will be spelled out. (Implementing the plan will be left to unelected bureaucrats and regulators, who are always happy to produce prodigious amounts of undecipherable and self-contradictory detail.) This time, at least prior to its actual implementation, critics of the reform plan will be left trying to attack a phantom.

And third, this time there is no Plan B.

In 1994, once the private interests had scuttled the Clinton healthcare plan, they immediately offered an alternative. They came to us and they said: “Citizens!  We have just now dodged a bullet! Thanks to us insurance companies, doctors, drug companies and other patriots, the frightening socialist machinations of the Clintons have been defeated, and the Evil Ones have been reduced to embracing our agenda of tax reform and welfare reform as if it were their own.  But where does this leave our healthcare system? We stand now between Scylla and Charybdis, between the spectre of socialized healthcare on one hand, and the continued profligacy of traditional fee-for-service on the other, and we cannot survive either.

“But here,” they continued, “is a third way. A painless way, an American way, based on the principles of managed care, open markets, and free enterprise. Let healthcare become a business, like any other business, and let the natural efficiencies of the marketplace find ways to cut costs and improve quality, and with minimal government intervention.”

And thus we were launched into an era of managed care run by HMOs and other similar creatures of the insurance industry. And over the past 15 years, while managed care has utterly failed to produce any of the things it promised, it has not been for a lack of trying. They indeed have tried numerous things to control spending, from the reasonable-sounding to the absurd to the frankly murderous, and despite all their strenuous efforts the healthcare system remains a morass of confusion, waste, and inefficiency, and its costs are many times what they were in 1994.

To say it another way, the private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do.

And that’s why they have now fully abandoned their old allies, the Republicans (who are off somewhere – one knows not where – muttering to each other about the efficiencies of the marketplace, and wondering why nobody is listening to them). The last thing the insurance industry wants to hear today is that the burden of figuring out how to control healthcare costs belongs to them. They’ve tried everything they know and have failed, and they are desperately seeking terms for surrender.

So there is no Plan B this time. As of this week, the private interests have formally and publicly admitted they don’t have a clue. They’re throwing in with President Obama, despite the fact that they have no leverage with him whatsoever, not because they believe in his reform plans (which have not even been described in their most skeletal form), but because there is no place else for them to go.

And so, the last obstruction to healthcare reform has been removed. The path – the only path – is clear. If we fail to get comprehensive healthcare reform now, it can only be for one reason. It can only be because Mr. Obama and the Democrats, looking down that wide open road, will be unable to avoid seeing where it leads, and will decide that they do not want to be the administration or the party that finally has to begin saying the “R” word in public.

To turn away from healthcare reform now, when the way seems so clear, would be a crushing blow to them, and would likely not be politically survivable. But to go on will likely force them to begin speaking a truth – that rationing is unavoidable – whose name is more taboo than ever was the name of Yahweh. And every high priest of the ruling class knows that even hinting about healthcare rationing is political suicide.

But still, there it is. There is no Plan B.

Talk about Sylla and Charybdis.

*This blog post was originally published at The Covert Rationing Blog*

Physician Payment Reform By Capitation, Will It Work This Time?

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*

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