Plotting life expectancy against income for 200 countries since 1810, Hans Rosling shows the enormous impact that the increase in wealth has had on the world (H/T Don Boudreaux).
200 Countries, 200 Years, 4 Minutes
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Category Archives: Health Care
America’s experiment with universal coverage
Many folks believe that universal health insurance coverage is a panacea to the fractured U.S. health care finance system. But take a few minutes to read this masterful Robin Fields/Atlantic article on the unexpected consequences of the nearly universal coverage provided for kidney dialysis patients:
IN OCTOBER 1972, after a month of deliberation, Congress launched the nation’s most ambitious experiment in universal health care: a change to the Social Security Act that granted comprehensive coverage under Medicare to virtually anyone diagnosed with kidney failure, regardless of age or income.
It was a supremely hopeful moment. Although the technology to keep kidney patients alive through dialysis had arrived, it was still unattainable for all but a lucky few. At one hospital, a death panel-or “God committee” in the parlance of the time-was deciding who got it and who didn’t. The new program would help about 11,000 Americans for starters, and for a modest initial price tag of $135 million, would cover not only their dialysis and transplants, but all of their medical needs. Some consider it the closest that the United States has come to socialized medicine.
Now, almost four decades later, a program once envisioned as a model for a national health-care system has evolved into a hulking monster. Taxpayers spend more than $20 billion a year to care for those on dialysis-about $77,000 per patient, more, by some accounts, than any other nation. Yet the United States continues to have one of the industrialized world’s highest mortality rates for dialysis care. Even taking into account differences in patient characteristics, studies suggest that if our system performed as well as Italy’s, or France’s, or Japan’s, thousands fewer kidney patients would die each year.
In a country that regularly boasts about its superior medical system, such results might be cause for outrage. But although dialysis is a lifeline for almost 400,000 Americans, few outside this insular world have probed why a program with such compassionate aims produces such troubling outcomes. Even during a fervid national debate over health care, the state of dialysis garnered little public attention.
Yet another example of what Arnold Kling has observed about U.S. health care — why do we think that that we cannot possibly afford high-quality health care if we have to pay for it individually, but we can afford it if we pay for it collectively?
First Aid Tips
Following on periodic posts regarding developments in providing first aid, Dr. Alex Lickerman provides his top ten rules for providing first aid that everyone needs to know:
1. Don’s panic.
2. First do no harm.
3. CPR can be life-sustaining.
4. Time counts.
5. Don’t use hydrogen peroxide on cuts or open wounds.
6. The two most important pieces of info when someone passes out is the pulse rate and the length of time before consciousness returns.
7. High blood pressure is rarely acutely dangerous.
8. If a person can talk or cough, their airway is open.
9. Most seizures are not emergencies.
10. Drowning doesn’t look like what you think it does.
Elaboration on the foregoing rules is here. Good information to pass along to family members and friends.
An unintended consequence of Medicare
A frequent topic on this blog has been the demise of primary care under our third-party payor-dominated health care finance system. Richard M. Hannon, a Blue Cross-Blue Shield executive, provides a particularly lucid explanation in this recent WSJ op-ed on how one of the unintended consequences of Medicare was the negative impact it had on the delivery of primary care to patients:
Medicare introduced a whole new dynamic in the delivery of health care. Gone were the days when physicians were paid based on the value of their services. With payment coming directly from Medicare and the federal government, patients who used to pay the bill themselves no longer cared about the cost of services.
Eventually, that disconnect (and subsequent program expansions) resulted in significant strain on the federal budget. In 1966, the House Ways and Means Committee estimated that by 1990 the Medicare budget would quadruple to $12 billion from $3 billion. In fact, by 1990 it was $107 billion.
To fix the cost problem, Medicare in 1992 began using the "resource based relative value system" (RBRVS), a way of evaluating doctors based on factors such as education, effort and specialized training. But the system didn’t consider factors such as outcomes, quality of service, severity or demand.
Today most insurance companies use the Medicare RBRVS because it is perceived as objective. As a result of RBRVS, specialists-especially those who perform a lot of procedures-do extremely well. Primary-care doctors do not.
The primary-care doctor has become a piece-rate worker focused on the volume of patients seen every day. As Medicare and insurers focused on trimming the costs of the most common procedures, the income and job satisfaction of primary-care doctors eroded.
So these doctors left, sold or changed their practices. New health-care service models, such as the concierge practice and the Patient-Centered Medical Home, drew doctors away from the standard service models that most patients rely on for coverage.
All of these factors have contributed to a fragmented, expensive health system with most of the remaining doctors focused on reactive instead of preventive care.
The solution to the problem is making primary-care physicians the captains of the ship. They must have the time and financial resources necessary to take care of their patients, tailoring care to patients’ specific conditions and needs. And they need the data to track their patients’ results, so they can guide patient progress. They will then be able to slow (and sometimes reverse) their patients’ illnesses, keeping them out of hospital emergency rooms and specialists’ offices. The end result: reduced costs and improved quality of care.
So who really killed primary care? The idea that a centrally planned system with the right formulas and lots of data could replace the art of practicing medicine; that the human dynamics of market demand and the patient-physician relationship could be ignored. Politicians and mathematicians in ivory towers have placed primary care last in line for respect, resources and prestige-and we all paid an enormous price.
The pervasive effect of the now engrained third-party payor system of health care finance is that many patients do not feel any responsibility for their health care expenses. As Arnold Kling has observed, why do we think that that we cannot possibly afford high-quality health care if we have to pay for it individually, but we can afford it if we pay for it collectively?
The Cancer Sleeper Cell
The state of cancer research is a frequent topic on this blog (for example, here, here and here), so this NY Times excerpt from Columbia oncologist Siddhartha Mukherjee’s new book – Emperor of All Maladies: A Biography of Cancer (Scribner November 16, 2010) – caught my eye. It’s well worth a read:
Why does cancer relapse? . . . when a cancer disappears on a CT scan or becomes otherwise undetectable, we genuinely begin to believe that the disappearance is real, or even permanent, even though statistical reasoning might suggest the opposite. A resurrection implies a previous burial. Cancer’s “relapse” thus implies a belief that the disease was once truly dead.
But what if my patient’s cancer had never actually died, despite its invisibility on all scans and tests? . . .
In fact, this view of cancer – as tenaciously persistent and able to regenerate after apparently disappearing – has come to occupy the very center of cancer biology. Intriguingly, for some cancers, this regenerative power appears to be driven by a specific cell type lurking within the cancer that is capable of dormancy, growth and infinite regeneration – a cancer “stem cell.” [. . .]
But if tumors contain dedicated stem cells, then delivering maximal doses of poisons to kill the bulk of the tumor might achieve one response – a shrinkage of the tumor – but have no effect on relapse. If the rare stem cell lurking within a tumor somehow escapes death, then it will reassert itself and grow again. Cancers will come back like a garden that has been cleared by hacking at its weeds while leaving the roots behind. [. . .]
If such a phoenix-like cell truly exists within cancer, the implication for cancer therapy will be enormous: this cell might be the ultimate determinant of relapse. For decades, scientists have wondered if the efforts to treat certain cancers have stalled because we haven’t yet found the right kind of drug. But the notion that cancers contain stem cells might radically redirect our efforts to develop anticancer drugs. Is it possible that the quest to treat cancer has also stalled because we haven’t even found the right kind of cell?
There is more than one way to skin a cat
At least that’s the case when it comes to getting around dubious drug prohibition policies. Check out this WSJ article:
When the housing market crashed in 2008, David Llewellyn’s construction business went with it. Casting around for a new gig, he decided to commercialize something he’d long done as a hobby: making drugs.
But the 49-year-old Scotsman didn’t go into the illegal drug trade. Instead, he entered the so-called "legal high" business-a burgeoning industry producing new psychoactive powders and pills that are marketed as "not for human consumption."
Mr. Llewellyn, a self-described former crack addict, started out making mephedrone, a stimulant also known as Meow Meow that was already popular with the European clubbing set. Once governments began banning it earlier this year, Mr. Llewellyn and a chemistry-savvy partner started selling something they dubbed Nopaine-a stimulant they concocted by tweaking the molecular structure of the attention-deficit drug Ritalin. [. . .]
Mr. Llewellyn is part of a wave of laboratory-adept European entrepreneurs who see gold in the gray zone between legal and illegal drugs. They pose a stiff challenge for European law-enforcement, which is struggling to keep up with all the new concoctions. Last year, 24 new "psychoactive substances" were identified in Europe, almost double the number reported in 2008, . . .
Particularly interesting is Mr. Llewellyn’s “foolproof” safety testing method for new drugs:
[Mr. Llewellyn] boasts that his safety testing method is foolproof: He and several colleagues sit in a room and take a new product "almost to overdose levels" to see what happens. "We’ll all sit with a pen and a pad, some good music on, and one person who’s straight who’s watching everything," he says.
Rationalizing Misery
The title of this post refers to the thought process of the folks described in this New York Magazine article who are obsessed with following a severe calorie restriction diet.
And as if that isn’t bad enough, this NY Times article reports on the large number of 40-somethings who are consumed with training and competing in triathlons. The article points out that some of the participants got into triathlons because their bodies were already breaking down under the stress of long-distance running!
What is utterly lacking in the lives of all the people described in these two articles is any sense of balance. Rather than eating a sensible and balanced diet, calorie restriction advocates deprive themselves in the hope that it will increase their lives for a few years. Maybe so, but how fulfilling is that extended life if one does not consume enough food to maintain a livable level of lean body mass?
Meanwhile, the triathletes punish themselves training under the delusion that more exercise is always better for their health. They ignore the substantial research that indicates that adequate rest and recovery after exercise is just as important for good health as the exercise itself.
What is it about life in America in 2010 that provokes people to do such things to themselves?
Insulating Delusion
This NY Times story on long-distance runners and medical insurers provides a case study on why productive reform of the U.S. health care finance sector so difficult.
As noted many times on this blog, long-distance running is not healthy. Thus, as the article notes, medical insurers are beginning to balk at insuring long-distance runners.
However, the myth that long-distance running is healthy remains firmly implanted in the American psyche. So, the medical insurers – not wanting to be perceived as refusing to cover injuries resulting from supposedly healthy activity – are trying to figure out ways to cover the runners.
And, of course, Obamacare is going to require that insurers cover consumers who engage in injury-causing activities.
Meanwhile, the runners delude themselves that they are engaging in a healthy activity while advocating that insurers essentially provide them insulation (rather than real insurance) from the cost of dealing with the unhealthy effects of their activity.
Don’t get me wrong. Folks should be able to enjoy long-distance running as either exercise or a recreational activity (those are two different things, but that’s for another post). My anecdotal observation is that most runners don’t actually appear to enjoy the activity — the delusion that the benefits of long-distance running outweigh the costs apparently pushes them through the displeasure.
But if folks elect to take the risk of injury from long-distance running, then they should have to bear the cost of at least the non-catastrophic damages resulting from that risk. And insurers should be free to elect not to cover consumers who engage in such risky behavior. Shifting the cost of that risk to insurers (who pass it along to the rest of us) simply encourages runners to avoid confronting the myth that they are engaging in healthy activity.
As the late Milton Friedman was fond of saying, consumers will consume as much health care as they can so long as someone else is paying for it.
The ER Doc as Primary Care Physician
One of the numerous inefficiencies of the American health care finance system is that hospitals have been forced to pay high compensation to attract doctors into emergency room care.
The primary reason for this has been that many uninsured and underinsured consumers use the ER for non-emergency medical matters that would be better and more efficiently handled by an internist or family practitioner in their private office. This disturbing trend has been growing for many years and likely will be made even worse by Obamacare.
Turns out that the ER doc-as-primary-care-physician is also having some unintended consequences with regard to patients, as related by an internist/hospitalist friend of mine:
So, I get a call from the ER today – new doc fresh out of the ER training program tells me she has a patient there she wants me to admit for a cardiac workup.
Says that the patient has a history of “heart problems” and that the patient said that she was having chest pain “just like before my bypass.”
So, I go down to the ER – I look at the patient’s chart and note that her primary complaint when she arrived there was fever and vomiting. I note that her cardiac evaluation so far was normal. I looked at her EKG – normal. I pulled up her chest x-ray – normal. And no sign of any telltale median sternotomy wires that are standard post-CABG. Hmm…
So, I go in to talk to the patient. She tells me that she has “chest pain,” and epigastric pain, and fever, and chills, and nausea, and vomiting. I examine her and note that there is no CABG scar on her chest. Hmm….
So, I ask her, “Tell me about your bypass.”
“You mean my gastric bypass?”
Turns out she never has had any heart problems.
Turns out she had a cardiac cath 15 months ago before her gastric surgery – stone cold normal.
Turns out the ER doc stopped listening as soon as she heard “chest pain” and “bypass.”
So, I put her in the hospital to treat her viral gastroenteritis with IV fluids and nausea meds. And I will sent her home in the morning, feeling all better.
And I take solace in the fact that ER docs are paid at least 50% more than I am.
Well, not really, about the solace thing, that is . . .
To make matters worse, in previous times, the ER doctor’s superiors would have castigated her for her stupidity and intellectual laziness. However, if that were to occur today, each of the doctors criticizing the ER doc would probably be labeled as a “disruptive physician” and referred to a series of sensitivity counseling sessions.
This is not going to turn out well.
Lies, Damned Lies and Medical Science
It’s hard to beat that title of this interesting David H. Freedman/The Atlantic article (H/T John Goodman) about medical researcher, John Ioannidis, who has made a name for himself establishing that most medical information that physicians commonly rely upon is largely flawed:
. . . can any medical-research studies be trusted?
That question has been central to Ioannidis’s career. He’s what’s known as a meta-researcher, and he’s become one of the world’s foremost experts on the credibility of medical research. He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies-conclusions that doctors keep in mind when they prescribe antibiotics or blood-pressure medication, or when they advise us to consume more fiber or less meat, or when they recommend surgery for heart disease or back pain-is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed.
His work has been widely accepted by the medical community; it has been published in the field’s top journals, where it is heavily cited; and he is a big draw at conferences. Given this exposure, and the fact that his work broadly targets everyone else’s work in medicine, as well as everything that physicians do and all the health advice we get, Ioannidis may be one of the most influential scientists alive. Yet for all his influence, he worries that the field of medical research is so pervasively flawed, and so riddled with conflicts of interest, that it might be chronically resistant to change-or even to publicly admitting that there’s a problem. [. . .]
We could solve much of the wrongness problem, Ioannidis says, if the world simply stopped expecting scientists to be right. That’s because being wrong in science is fine, and even necessary-as long as scientists recognize that they blew it, report their mistake openly instead of disguising it as a success, and then move on to the next thing, until they come up with the very occasional genuine breakthrough. But as long as careers remain contingent on producing a stream of research that’s dressed up to seem more right than it is, scientists will keep delivering exactly that.
“Science is a noble endeavor, but it’s also a low-yield endeavor,” he says. “I’m not sure that more than a very small percentage of medical research is ever likely to lead to major improvements in clinical outcomes and quality of life. We should be very comfortable with that fact.”