Another lucid presentation from Jeff Miron, this time on the inevitable insolvency that will result from current levels of entitlement spending:
The train wreck of entitlements growth
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Category Archives: Health Care Finance
The changing face of medicine
his NY Times article from over this past weekend is among the most important that I have read recently on the dynamics that are materially changing the fractured U.S. health care system.
That’s not to suggest that the direction of medicine described in the article is a good thing. In fact, my late father is rolling over in his grave over what is described in the article. Patients as commodities. Doctors minimizing responsibilities so that they can get to their yoga class. Patients are supposed to trust such treatment? This is progress?
This is the reason why I pay a premium so that I have a doctor who knows me and my medical history if I am hospitalized for illness or injury.
Do most patients realize that they will not have such a resource when they need one?
Health Care Myth Busters
Following on this post from last fall, check out this Scientific American excerpt of the new book, Demand Better! Revive Our Broken Health Care System (Second River Healthcare Press, March 2011) by Sanjaya Kumar, chief medical officer at Quantros, and David B. Nash, dean of the Jefferson School of Population Health at Thomas Jefferson University:
Most of us are confident that the quality of our healthcare is the finest, the most technologically sophisticated and the most scientifically advanced in the world. And for good reason–thousands of clinical research studies are published every year that indicate such findings. Hospitals advertise the latest, most dazzling techniques to peer into the human body and perform amazing lifesaving surgeries with the aid of high-tech devices. There is no question that modern medical practices are remarkable, often effective and occasionally miraculous.
But there is a wrinkle in our confidence. We believe that the vast majority of what physicians do is backed by solid science. Their diagnostic and treatment decisions must reflect the latest and best research. Their clinical judgment must certainly be well beyond any reasonable doubt. To seriously question these assumptions would seem jaundiced and cynical.
But we must question them because these beliefs are based more on faith than on facts for at least three reasons, each of which we will explore in detail in this section. Only a fraction of what physicians do is based on solid evidence from Grade-A randomized, controlled trials; the rest is based instead on weak or no evidence and on subjective judgment. When scientific consensus exists on which clinical practices work effectively, physicians only sporadically follow that evidence correctly.
Medical decision-making itself is fraught with inherent subjectivity, some of it necessary and beneficial to patients, and some of it flawed and potentially dangerous. For these reasons, millions of Americans receive medications and treatments that have no proven clinical benefit, and millions fail to get care that is proven to be effective. Quality and safety suffer, and waste flourishes.
At first blush, this may seem shocking, but it really provides a great incentive for the consumer of health care services and products to be as fully informed as possible about various treatment alternatives.
The human body is an incredibly complex organism. That we can predict and control outcomes relating to such complexity in even a fraction of cases is a remarkable achievement.
The approach we need to take is to embrace that complexity and randomness, educate ourselves as best we can on the risks that certain behaviors and habits have in regard to affecting bad health outcomes, and then lead our lives in a way that deals with those risks in a manner that is acceptable to each individual.
However, the reality is that neither we – nor our doctors – control the outcome of many of our health care decisions. We can make choices based on the best available information. But life is still largely a roll of the dice.
Rethinking Obesity
The stigma attached to obesity has been an accepted practice of American society for a long time.
Heck, even those who should know better often embrace the simplistic thinking that obesity is merely the result of an individual’s lack of willpower.
But research is increasingly revealing that the obesity stigma is misplaced and counterproductive. Michelle Berman, MD noted this awhile back in this post on KevinMD.com:
Did you know that some psychologists and psychiatrists would like to classify obesity as a brain disease?
The reason for this is that there is mounting evidence that food, or certain types of food, can trigger the same addictive effects in the brain as drugs like heroin and cocaine.
There is also substantial evidence that some people lose control over their food consumption and exhibit other behaviors (e.g. tolerance, withdrawal) that may meet diagnostic criteria . . . for substance dependence.
Arya Sharma, MD picks up on this line of thinking in this recent KevinMD.com post:
Recently, I attended a scientific symposium on addictions. One of the books I picked up at that conference . . . is A. J. Adams’ “Undrunk: A Skeptic’s Guide to AA”. [. . .] The definition [of alcoholism] reads as follows:
Alcoholism is a primary chronic disease with genetic, psycho-social and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol despite adverse consequences and distortions of thinking, mostly denial.
Let us look at this definition of alcoholism and see what aspects of it (if any) apply to obesity.No doubt, as readers of these pages know, obesity is most definitely a chronic condition, whose development and manifestations are influenced by genetic, psycho-social and environmental factors. In some cases obesity may be more genetic, in others more psycho-social and sometimes purely environmental, but certainly, obesity would fit the bill as far as this statement goes.And yes, obesity is often progressive and fatal. [. . .]This may not seem as obvious as in the case of the alcoholic who dies of liver cirrhosis or totals his car (and himself) whilst DIU, but when you start looking at the many ways in which obesity can kill you, from heart attacks to cancer, there is no doubt that obesity is fatal (often after ruining most of your life first – another similarity to alcoholism).
Clear Thinkers favorite Art De Vany does an excellent job of explaining the physiological underpinnings of overeating in his recent book, The New Evolution Diet: What Our Paleolithic Ancestors Can Teach Us About Weight Loss, Fitness and Aging (Rodale 2010). The following oversimplifies De Vany’s explanation, so definitely read the book if you are interested in this subject.
But the essence of De Vany’s point is that the brain needs glucose – generally supplied by carbohydrates or body fat – in order to live and thrive. Thus, the brain signals that it needs more glucose, which triggers our desire to eat carbohydrate or for the body to use body fat to fulfill that need. The body (specifically the pancreas) generates insulin to absorb the ingested glucose into the bloodstream.
So far, so good. However, DeVany explains that most people who become obese fall into a sort of negative feedback loop in which they become insulin and leptin insensitive (leptin is a hormone that signals to the brain that hunger has been satisfied).
This is bad for a variety of reasons (inflammation on a cellular level, etc), but it is particularly damaging in regard to obesity – the body ends up generating excess insulin, which it stores as fat, and the brain becomes desensitized to leptin, which makes it much more difficult to satiate hunger.
Thus, insulin and leptin insensitivity cause a negative feedback loop in which the consumer becomes conditioned to being continually hungry (the brain is constantly hungry and signaling that it needs glucose), the consumer eats high-calorie, processed (and readily available) carbohydrate to fulfill that hunger, the body produces more insulin that it needs to absorb the glucose, the body stores the excess insulin as fat, the body rarely uses body fat to fuel the brain, and then the process starts all over again, partly because of the consumer’s increasingly insulin and leptin insensitive nature.
In short, willpower really doesn’t have that much to do with it. Physiological impulses do.
Stated simply, it’s hard to lose weight if you are always hungry.
As De Vany explains in his book, the solution to this obesity syndrome is to become insulin and leptin sensitive – and, thus, fat adaptive – through eating lean meats, vegetables and fruits and avoiding calorie-laden processed foods, as well as exercise and recreation that promote maintenance of lean body mass. Toss in some intermittent fasting (12-16 hours of no food, most of which occurs during sleep) a few times a week to help control cellular inflammation and you have the blueprint for a healthy lifestyle.
However, the more important message that DeVany delivers is that the social stigma attached to obesity is inhumane and counterproductive. That stigma drives obese people to “quick fixes” such as fad diets and excessive exercise routines, both of which rarely result in sustained weight loss.
Rather, the key to overcoming the compulsion toward high caloric food is to educate the consumer to understand the physiological underpinnings that drive the consumer’s compulsion and then to address those physiological issues.
In short, less stigma and better education equals less obesity and better health.
Sounds like a good trade to me.
The Primary Care Doc Revolt
The demise of primary care as a profitable area of specialization under our third-party payor-dominated health care finance system is a frequent topic on this blog. Dr. Robert Center picks up on that them in this recent KevinMD.com post in which he passes along what he sees happening in the marketplace for primary care services:
I believe primary care docs are rebelling against the system. The system has made primary care physicians suffer emotionally and financially. The system has taken the greatest form of medical care – that consisting of continuity, comprehensiveness, complexity and completeness – and denigrated it.
Now I talk about “the system” in an anthropomorphic sense, but “the system” is virtual. “The system” has no conscious, it is not deliberate, rather it represents the constellation of ignorance that the insurance companies, CMS and policy works have wrought. [. . .]
So what do primary care physicians do? They do what any sensible economic citizen would do, they alter the rules to their benefit. [. . .]
So decreasing numbers of primary care physicians are taking Medicare or Medicaid. So primary care physicians are leaving their jobs to do hospital medicine. So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.
The rebellion is a quiet one. No one has declared this rebellion. This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera. This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable. [. . .]
I believe the rebellion will continue. Every anecdotal sign that I see tells me that the rebellion is gaining speed and power. . . .
One day the wonks on Capitol Hill will realize the problem. AAFP and ACP (amongst others) have tried explaining the problem to the politicians. Until they understand that their constituents are angry because they cannot find a physician, they will not focus on the problem. . . .
As doctors flee from primary care (see earlier posts here, here and here), the vacuum will be filled by nurse practitioners and medical assistants, who are far less trained than primary care docs in key diagnostic procedures.
Make sure those payments on the concierge practice account are current!
Medicine has never been better, but our overall health is worsening
Don’t miss this KevinMD.com/David Gratzer, M.D. post on how – despite the miracles of modern medicine — the poor incentives of the fractured U.S. health care finance system encourage people not to change unhealthy habits:
But if medicine has never been so advanced, the actual health of Americans is far less robust. The Era of Modern Medicine has given way to the Age of Preventable Illness. Americans have embraced a culture of extremes: too much alcohol, tobacco, drugs, and food, and not enough exercise and restraint. American leads the way in medical innovation, winning more Nobel Prizes in Medicine than all other countries combined. We also lead the world in obesity, and have the poor life expectancy statistics to show for it. [ . . .]
ObamaCare seeks to divorce people from the financial consequences of their health decisions — regulating insurance to treat people equally regardless of age or illness (community rating), offering many no-deductible services, mandating the coverage of other services, and sweetening the deal with heavy subsidies.
Let’s be clear: a patient with Schizophrenia shouldn’t be punished because his father and grandfather had the disease. But many illnesses are preventable. Rather than encourage health, ObamaCare seeks to socialize the costs of bad health.
As noted earlier here, perhaps the wisest investment in health care finance that we could make at this stage is simply better education?
The Placebo Effect
Preventing what?
My father was a master diagnostician who had an uncanny knack – honed over many years of personally examining and interviewing patients – of making the correct diagnosis of a patient’s medical problem without the assistance of expensive and often time-consuming tests.
However, my father’s way is not the preferred method of modern preventative care, which often tethers patients to their doctors with a dizzying array of tests.
Dr. H. Gilbert Welch and his colleagues at the Dartmouth School of Medicine aren’t convinced that the modern way is better than my father’s approach. This Abigal Zuger, MD/NY Times review of Dr. Welch’s new book – Over-diagnosed: Making People Sick in the Pursuit of Health (Beacon Press January 18, 2011) — sums up the core issue well:
As the world is currently configured, the authors point out, doctors are never punished for over-diagnosis, no matter how much havoc may be wrought by untrammeled over-testing. It is perceived under-diagnosis that arouses legal and moral wrath.
Is that the way it should be?
An intriguing question, indeed!
A low-cost concierge medicine model
The innovation of concierge medical practice has been a frequent topic here, so this recent NY Times article on the development of a low-cost concierge medical practice model caught my eye:
With 31 physicians in San Francisco and New York, [One Medical Group] offers most of the same services provided by personalized “concierge” medical practices, but at a much lower price: $150 to $200 a year.
One Medical Group doctors see at most 16 patients a day; the nationwide average for primary-care physicians is 25. They welcome e-mail communication with patients, for no extra charge. Same-day appointments are routine. And unlike most concierge practices, One Medical accepts a variety of insurance plans, including Medicare. [. . .]
. . . One Medical is the first to try to carry out such a model on a large scale. It now has several thousand patients and a growth rate of 50 percent a year, fueled largely by word of mouth. Dr. Lee said he planned to open a third office in Manhattan next month and expand to a third large city next year.
It will be interesting to see if this model still works on a larger scale, particularly if less healthy patients use a highly disproportionate amount of doctor time and resources.
However, as this latest disclosure regarding Obamacare reinforces, truly beneficial health care finance reform is more likely to come through innovations such as One Medical Group, not through government-managed overhauls.
The wisest health care finance investment
Three articles caught my eye recently regarding America’s health care dilemma.
This LA Times article reports on the declining quality of the end-of-life period of many Americans:
Life expectancy soared over the last part of the 20th century as treatments for major diseases improved and infectious diseases were quelled by vaccines and better treatment. The most recent data, however, hint that life expectancy is no longer growing. According to a new study, we may spend more years sick than we did even a decade ago. [. . .]
According to the analysis, the average age of morbidity – which is defined as the period of life spent with serious illness and lack of functional mobility – has increased in the last two decades. For example, a 20-year-old man in 1998 could be expected to live an additional 45 years without at least one of these diseases: heart disease, cancer or diabetes. That number fell to 43.8 in 2006. For women, the expected years of life without a serious disease fell from 49.2 years to 48 years over the last decade. [. . .]
"There is substantial evidence that we have done little to date to eliminate or delay disease or the physiological changes that are linked to age," the authors wrote.
Meanwhile, a part of that problem is the result of the fact that many Americans have no idea what – or how much – they are eating:
Nearly 90% of respondents to a Consumer Reports telephone survey thought they were eating right — saying that their diet was either somewhat (52.6%), very (31.5%), or extremely healthy (5.6%).
But when they were asked about what they actually eat, far fewer seemed to be in following a healthy diet.
For instance, of the 1,234 people surveyed, only 30% said they eat five servings of fruit and vegetables every day, just 13% step on the scale every morning, and a meager 8% monitor their daily calorie intake. [. . .]
bout a third of those who said they were a healthy weight actually had a body mass index (BMI) in the overweight or obese range (30% and 3%, respectively).
"It’s likely that Americans are thinking about health more, and that’s a good thing," said Keith Ayoob, EdD, RD, of Albert Einstein College of Medicine. "Still, nine out of 10 think they’re doing pretty well, and to that, I’d say let’s talk again."
So, asks this Dana P. Goldman/Darius N. Lakdawalla article, what would be the best investment to generate significant improvement in the health of Americans?:
The first step is to invest–not in the healthcare system, but in education. We should take the $120 billion it might cost for universal coverage, and use it, instead, to provider earlier education and to improve the quality of education. Better-educated people live longer, are less likely to be disabled, and engage in healthier behavior.
For nearly 40 years, distinguished health economists led by Michael Grossman have observed that more-educated people have much more powerful incentives to protect their own ‘investments’ in education by practicing healthier habits and reducing their risks of death. They also are better at self-managing chronic diseases. And, unlike universal coverage, more education has other valuable benefits to a person and to society. Less crime, less divorce, and higher earnings–can universal health insurance promise that?
The second place to invest is prevention. Primary prevention has the capacity to slow or reduce the rising prevalence of chronic disease, and simultaneously attenuate the downstream spending that is associated with it. Equally importantly, however, prevention leads to a life with less disability and more years of an active lifestyle. It simply makes a lot of sense to avoid disease in the first place, rather than try to treat it later.