2005-03-01

Medical costs

My opinion: America is spending too much on medical care.
Circa 1950, we spent about three percent of GDP on medical care.
Now, in 2008, it’s about sixteen percent,
and the forecast seems to be for growth without limit.
Talk about irresponsibility!

Are today’s people more disease and illness prone?
(Well, yes.
But most of that is due to problems that people bring on themselves,
through their own behavior,
behavior which once was considered sinful.
E.g.: sloth, gluttony, promiscuity, drug abuse.)

Is the disease threat greater?
(AIDS mainly, a disease spread through specific behavioral practices.)

Then there is the desire to spend more and more on health care,
seemingly just because it is there,
without regard to cost-effectiveness.
When it comes to defense spending,
the media is quick to describe each new generation of weapons systems
as “gold-plated”,
no matter how much more effective it may be then its predecessor.
But when it comes to medical care,
when have you ever heard them describe
a new, vastly more expensive, medical procedure or drug
as “gold-plated”?
In particular,
expenses for drugs have gone up astronomically since the 1950s.
Is this really worth it?

You know, when I was growing up in the 1950s,
parents certainly knew how to say to their children
“Just because they make it doesn’t mean that we need it.”
I certainly do not want to generalize to all of America’s elderly today,
but I have never heard in the media the equivalent of that statement
applied to the latest, greatest, and most expensive medical procedure or drug.
Rather, the cry from the media and the Democrats is:
“More, more, more for medicine and health care.”
Apparently Democrats are totally unable to ask
just why medical costs should be going up so much.






(An excellent journal addressing these issues is
Health Affairs: The Policy Journal of the Health Sphere;
an excellent newspaper series covering them is
The Evidence Gap” at the New York Times.
Also the NY Times has an excellent blog covering the subject:
prescriptions.blog.nytimes.com: “Prescriptions: Making Sense of the Health Care Debate”.)







2008


2008-03-24-WP-Fletcher
Rising Health Costs Cut Into Wages
Higher Fees Squeeze Employers, Workers
By Michael A. Fletcher
Washington Post, 2008-03-24

2008-03-30-WP-Brownlee
Let's Stop Running Scared
By Shannon Brownlee
Washington Post Outlook, 2008-03-30


2008-04-08-WP-Brown-preventive-medicine
In the Balance
By David Brown
Washington Post, 2008-04-08

Some Candidates Disagree, but Studies Show
It’s Often Cheaper To Let People Get Sick


2008-05-05-NYT-Gross-slow-medicine
For the Elderly, Being Heard About Life’s End
By JANE GROSS
New York Times, 2008-05-05


2008-07-18-NYT-centenarians
Rise Seen in Medical Efforts to Treat the Very Old
By ANEMONA HARTOCOLLIS
New York Times, 2008-07-18

[An excerpt; emphasis is added.]

When Hazel Homer was 99, more than one doctor advised that there was little to be done about her failing heart except wait for it to fail a final time. But Mrs. Homer was not interested in waiting to die of what many would call old age.

Now, at 104, her heart is still ticking, thanks to a specialized pacemaker and defibrillator that synchronizes her heartbeat and can administer a slight shock to revive her if her heart falters.

Her operation, a month before her 100th birthday, reflects what some doctors are hailing as a new frontier in medicine: successful surgery for centenarians. But others say that such aggressive treatment for what are euphemistically known as the late elderly can be wasteful and barbaric, warning that the rush to test the limits of technology can give patients false hope and compound their health challenges with surgical complications.

“She’s just a peek into the future,” said Dr. Steven M. Greenberg, a Long Island cardiologist who performed Mrs. Homer’s surgery, for which the average Medicare reimbursement at the time was $35,000.

Data is hard to come by, since people over 75 are scarcely represented in clinical trials, but several geriatricians said that procedures that two decades ago were seldom considered for people in their 90s are now increasingly commonplace. They include hip and knee replacement, cataract surgery, heart valve replacement, bypass operations, pacemaker implantation and treatment for slow-growing cancers that afflict areas like the prostate.

According to the Census Bureau, there were 90,422 centenarians in America in June, up from 50,454 in 2000, and demographers project there could be 1.1 million by 2050. As for 104-year-olds, the Social Security Administration said that 2,114 of them currently receive benefits.

With such rapid growth of centenarians, debate has mounted over how far to go — not to mention how much Medicare money to spend — in providing major medical services to extend already very long lives.

Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care, which has studied the last two years of life, said there is much research suggesting that most aggressive treatment of late-stage chronic diseases does not actually prolong life and can actually decrease its quality. Of Mrs. Homer, Dr. Goodman said, “the odds are that she’s really an amazing exception.”

“The question is not a relatively healthy, smart, sensible 99-year-old
getting a life-prolonging procedure, one that prolongs the quality of life,”
Dr. Goodman added.
“The question becomes the 82-year-old with dementia
who has cancer or congestive heart failure.”


Bruce Nudell, a senior health care analyst at UBS, said that
the defibrillator would likely not have been approved in Europe, adding:
“America always tends to overtreat the sickest people.”

[These comments will no doubt offend some,
but I feel it necessary to make them explicit, even if some are offended.

Please, once you’ve lived to the ripe old age of 100,
is it really necessary to demand great expenses be paid
so that you can live yet longer?
In fact, I would suggest that those over 90 might want to think about
the morality of soaking up precious dollars
to extend their life even further beyond the Biblical three score and ten.

And they call Baby Boomers self-absorbed!]


...

Mrs. Homer ... has a live-in aide at her tiny bungalow ...

[One wonders just who pays for that live-in aide.]


2008-08-11-AP-Murphy-Health-Care-Rise-Ten-Percent
Health care costs seen rising 10 percent in 2009
By Tom Murphy, AP Business Writer
Boston Globe, 2008-08-11

[An excerpt; emphasis is added.]

Overuse and misuse of services and an
“out-of-control medical liability system”
also contribute to increases,
said Robert Zirkelbach of America’s Health Insurance Plans


2008-08-21-NYT-Medicare-fraud
Report Rejects Medicare Boast of Paring Fraud
By CHARLES DUHIGG
New York Times, 2008-08-21


2008-09-10-Samuelson
Health-Care Realism
By Robert J. Samuelson
Washington Post, 2008-09-10

[Paragraph numbers and emphasis are added.]

[1]
Unless you’ve been living in the Himalayas,
you know that huge numbers of Americans -- 46 million last year --
lack health insurance.
By impressive majorities, Americans regard this as a moral stain.
At the Democratic National Convention,
Sen. Ted Kennedy echoed the view of many that
health care is a “right” that demands universal insurance.
This completely understandable view is, I think, utterly wrong.
[I agree.]
Take note, Barack Obama and John McCain.

[2]

The central health-care problem is not improving coverage.
It’s controlling costs.

In 1960, health care accounted for $1 of every $20 spent in the U.S. economy
[i.e., 5 percent of spending];
now that’s $1 of every $6 [16 percent],
and the Congressional Budget Office projects that
it could be $1 of every $4 [25 percent] by 2025.
Ponder that: a quarter of the U.S. economy devoted to health care.
Would we be better off? Probably not.
Countless studies have shown that many tests, surgeries and medical devices
are either ineffective or unneeded.

Greater health-care spending
forfeits any superior moral claim on our wealth
by slowly crowding out other national needs.

For government, higher health costs threaten other programs --
schools, roads, defense, scientific research --
and put upward pressure on taxes.
For workers, increasingly expensive insurance depresses take-home pay
as employers funnel more compensation dollars into coverage.
There’s also a massive and undesirable income transfer
from the young to the old,
accomplished through taxes and the cross-subsidies of private insurance,
because the old are the biggest users of medical care.

[Not only those points, but also,
the more America spends on health-care,
the less competitive it is internationally.
All those health-care costs that employers labor under
get added to the cost of their products,
making American made goods that much less competitive in the global market.
For comparison, how much of the Chinese economy, say, gets spent on health care?
Chinese employers don’t suffer under that back-breaking load.]


[3]
It is widely assumed that health care, like most aspects of American life,
shamefully shortchanges the poor.
This is less true than it seems.
Economist Gary Burtless of the Brookings Institution
recently discovered these astonishing data:

On average, annual health spending per person --
from all private and government sources --
is equal for the poorest and the richest Americans.
In 2003, it was
$4,477 for the poorest fifth and
$4,451 for the richest

(see table).
Health spending per person from all sources in 2003
Richest fifth$4,451
Second-richest4,941
Middle fifth4,388
Second-poorest4,426
Poorest fifth4,477

[4]
Probably in no other area, notes Burtless, is spending so equal --
not in housing, clothes, transportation or anything.
Why? One reason:
Government already insures more than a quarter of the population,
including many poor.
Medicare covers the elderly;
Medicaid, many of the poor and their children;
SCHIP (State Children’s Health Insurance Program), more children.
Another reason is
the skewing of health spending toward the very sick;
10 percent of patients account for two-thirds of spending.

Regardless of income, people get thrust onto a conveyor belt of costly care:
long hospital stays, many tests, therapies and surgeries.

[5]
That includes the uninsured.
In 2008, their care will cost about $86 billion,
estimates a study for the Kaiser Family Foundation.
The uninsured pay about $30 billion themselves; the rest is uncompensated.
Of course, no sane person wants to be without health insurance,
and the uninsured receive less care
and, by some studies, suffer abnormally high death rates.
But other studies suggest only minor disadvantages for the uninsured.
One study compared the insured and uninsured
after the onset of a chronic illness -- say, heart disease or diabetes.
Outcomes differed little.
After about six months,
20.4 percent of the insured and 20.9 percent of the uninsured
judged themselves “better”;
32.2 percent of the insured and 35.2 percent of the uninsured
rated themselves “worse.”
The rest saw no change.

[6]

The trouble with casting medical care as a “right” is that
this ignores how open-ended the “right” should be
and how fulfilling it
might compromise other “rights” and needs.
[I.e., its “opportunity costs.”]

What makes people healthy or unhealthy are
personal habits, good or bad (diet, exercise, alcohol and drug use);
genetic makeup, lucky or unlucky; and
age.
Health care, no matter how lavishly provided,
can only partly compensate for these individual differences.

[Under personal habits, he omits sexual behavior;
also, he omits environmental factors, either at home or at work.]


[7]
There is a basic dilemma that most Americans refuse to acknowledge.
What we all want for ourselves and our families --
access to unlimited care paid for by someone else --
may be ruinous for us as a society.

The crying need now is not to insure all the uninsured.
This would be expensive
(an additional $123 billion a year, estimates the Kaiser study)
and would provide modest health gains at best.
Two-fifths of the uninsured are young (19 to 34) and relatively healthy.

[8]
The McCain and Obama health-care proposals, either impractical or undesirable,
largely ignore the existing challenge of Medicare.
By some studies, 30 percent of its spending may go to unneeded services.
Medicare is so large that by altering how it operates,
government can reshape the entire health-care system.
This would require changes to encourage
more electronic record-keeping,
better case management,
fewer dubious tests and procedures, and
a fairer sharing of costs between the young and the old.
The work would be unglamorous and probably unpopular.
But if the next president can’t do it,
his presidency will fail in one fateful way.

[I would add that a glaring problem is
the increase in demand for health care services
driven by advertising.
Prime examples are
the drug ads that take up three full pages in newspapers these days.
I don’t know when those started;
we certainly didn’t have them in the 1950s and 1960s.
Not only do they drive up demand,
but their very running drives up the cost of the drugs.
Do the drugs sold really do that much good?

I think the biggest boondoggle of the 2000s, besides the Iraq war,
was the Medicare drug benefit.
It certainly benefited the drug companies;
how much it benefits drug consumers is more questionable.
One has to wonder how much of the AARP budget is provided by
companies that profit from the demand for medical services
that it so consistently drives.]



2008-09-24-NYT-Abelson-rising-costs
Health Care Costs Increase Strain, Studies Find
By REED ABELSON
New York Times, 2008-09-24

[This is an example of
the consistent reporting on health care costs in much of the media.
It notes with alarm the ever-rising costs of health care,
and the of course deleterious effects those have
on the budgets of both households and business enterprises,
without, so far as I can see,
making the slightest effort to ask, let alone answer, the question of
Just why those health care costs are rising, rising, rising, year after year.

Some figures, including in some the media,
have mocked George Bush for being “incurious.”
But is it not the most extreme example of incuriosity
that the media can, year after year, story after story,
report on rising health care costs and their negative effect on ordinary people,
without thoroughly investigating and reporting
the reasons for that rise?]




2008-10-16-WP
As Budgets Tighten, More People Decide Medical Care Can Wait
By Ceci Connolly and Kendra Marr
Washington Post, 2008-10-16

Here are some of the people whose medical cost woes are discussed in this article:

Tim Doss, [who drove] a cement truck for an Indiana company
Victoria Freudiger, Plano, Tex.
Marsha Porter-Norton, Durango, Colo.

The article has no dateline, so the reporting was evidently from Washington.
One wonders how these Washington Post reporters uncovered
the stories of ordinary people in such diverse and distant settings:
Indiana, Texas, Colorado.
One (at least I) suspects that
there is some organization (unnamed in this story)
pushing for more spending on medical care
which accumulates and disseminates these stories of financial problems,
while of course all the cases of over- and unnecessary spending on health care
get ignored.
Does this seem to be a systemic bias on the part of the MSM?




2008-10-30-NYT-AP-diabetes
Obesity Blamed for Doubling Rate of Diabetes Cases
By THE ASSOCIATED PRESS, 2008-10-30

[Wash Post has exactly the same AP article here.]

ATLANTA (AP) --

[1]
The nation’s obesity epidemic is exacting a heavy toll:
The rate of new diabetes cases nearly doubled in the United States
in the past 10 years,

the government said Thursday.
The highest rates were in the South,
according to the first state-by-state review of new diagnoses.
The worst was in West Virginia,
where about 13 in 1,000 adults were diagnosed with the disease in 2005-07.
The lowest was in Minnesota, where the rate was 5 in 1,000.

[2]
Nationally,
the rate of new cases climbed from about 5 per 1,000 in the mid-1990s
to 9 per 1,000 in the middle of this decade.

[3]
Roughly 90 percent of cases are Type 2 diabetes, the form linked to obesity.

[4]
The findings dovetail with trends seen in obesity and lack of exercise --
two health measures where Southern states also rank at the bottom.

[5]
“It isn’t surprising the problem is heaviest in the South -- no pun intended,”
agreed Matt Petersen,
who oversees data and statistics for the American Diabetes Association.

[6]
The study, led by Karen Kirtland of the Centers for Disease Control and Prevention, provides an up-to-date picture of where the disease is exploding. The information should be a big help as the government and health insurance companies decide where to focus prevention campaigns, Petersen said.

[7]
Diabetes was the nation’s seventh-leading cause of death in 2006, according to the CDC. More than 23 million Americans have diabetes, and the number is rapidly growing. About 1.6 million new cases were diagnosed among adults last year.

[8]
Type 2 diabetics do not produce or use insulin, a hormone needed to convert sugar into energy. The illness can cause sugar to build up in the body, leading to complications such as heart disease, blindness, kidney failure and poor circulation that leads to foot amputations.

[9]
The study involved a random-digit-dialed survey of more than 260,000 adults. Participants were asked if they had ever been told by a doctor that they have diabetes, and when the diagnosis was made. The comparisons between 1995-97 and 2005-07 covered only the 33 states for which the CDC had complete data for both time periods.

[10]
The researchers had data for 40 states for the years 2005-07.

[11]
West Virginia, South Carolina, Alabama, Georgia, Texas and Tennessee had the highest rates, all at 11 cases per 1,000 or higher. Puerto Rico was about as high as West Virginia. Minnesota, Hawaii and Wyoming had the lowest rates.

[12]
It is not entirely clear why some states were worse than others. Older people, blacks and Hispanics tend to have higher rates of Type 2 diabetes, and the South has large concentrations of all three groups. However, West Virginia is overwhelmingly white.

[13]
The report asked about diagnosed diabetes only. Because an estimated one in four diabetics have not been diagnosed, the findings probably underestimate the problem, said Angela Liese, a diabetes researcher at the University of South Carolina.

[14]
The underestimates may be particularly bad in the rural South and other areas where patients have trouble getting health care, she noted.



2008-11-14-WP-Hannah-Jones
Britain Debates a Child’s Right to Choose Her Own Fate
By Kevin Sullivan
Washington Post, 2008-11-14

LONDON, Nov. 13 –

[1]
Hannah Jones needs a heart transplant. But after nine years of battling leukemia and heart disease, she has had enough of hospitals, operations, drugs and constant pain. So she has opted to skip the surgery and die at home in the company of her family.

[2]
Hannah is 13 years old, and her case has prompted a wrenching public debate in Britain.

[3]
Her story has dominated headlines this week, and people have found themselves staring sadly at her serious young face, unsmiling and freckled, looking back at them from newspaper pages.

[4]
“I’m not a normal 13-year-old,” she told reporters this week, short of breath and speaking in clipped sentences. “I’m a deep thinker. I’ve had to be, with my illness. It’s hard, at 13, to know I’m going to die. But I also know what’s best for me.”

[5]
The case has raised complex questions about children’s legal rights to decide their own medical care, and whether such cases are private tragedies or matters to be decided by governments and courts.

[6]
Hannah’s mother, Kristy, a former intensive care nurse, and her father, Andrew, an auditor, have backed their daughter.

[7]
“Until you have walked 24 hours a day, seven days a week in my shoes, you don’t understand,” Kristy Jones told the Daily Mail. “Doing my job, as a nurse in intensive care, I have seen so many children suffering like Hannah. Of course, I want them to survive as long as possible, but I also understand that death can sometimes be a merciful relief.”

[8]
Hannah was diagnosed with leukemia in 1999, when she was 4. Chemotherapy sent the cancer into remission but caused her to lose hair and skin. Amid all the strain on her young body, she developed a hole in her heart.

[9]
In March 2000, she came home from the hospital weighing less than 30 pounds. She had to be fed by tube and needed an oxygen cylinder to help her breathe.

[10]
Her leukemia remained in remission, and at age 9 she started school for the first time. But last year, when she was nearly 12, she fell ill in class and doctors determined that her heart had become so weak that her only option was a transplant.

[11]
She was fitted with a pacemaker, and doctors showed her films of a transplant operation. They told her that the surgery itself might kill her and that her weakened immune system would make her susceptible to a recurrence of leukemia. They told her she would need a constant regimen of drugs and that she would probably need a second transplant in about 10 years.

[12]
When the doctors finished explaining it all, Hannah looked at them and said, simply, “No, I don’t want a new heart. I want to go home.”

[13]
Facing reporters this week, Hannah said she had no regrets.

[14]
“My parents have always encouraged me to make my own decisions. When it comes to my heart, I’d much rather do things my way than have other people decide for me.

[15]
“It wasn’t an easy choice, but being in hospital reminds me of bad times,” she said. “I’ve spent long enough in hospital. I just want to be at home, even if that means my life might be shorter.”

[16]
At first, doctors at Hereford Hospital, about 120 miles northwest of London, accepted Hannah’s decision. But in March, the hospital called her parents and threatened to send police to forcibly remove Hannah from their care, saying they were not acting in her best interest. Hospital officials threatened to seek a court order forcing her to have the transplant.

[17]
Andrew Jones said he explained the family’s position to the officials.

[18]
“It was very emotional trying to reach the sort of decision you would never wish on your worst enemy,” he said. “My wife and I agreed that whatever Hannah wanted, we would support her.”

[19]
After talking to the Joneses, the hospital decided not to send the police and instead send a child protection officer to meet with the family. The officer spent an hour with Hannah, who convinced her that she knew what she wanted, and that she was acting of her own free will. Hospital officials relented and apologized to Hannah’s parents.

[20]
British law does not state the age at which children can take responsibility for their own medical care. Experts have offered different views, with many suggesting that children’s experience is a much better indicator than age of their ability to make an informed decision about their best interests.

[21]
“It appears that she has deeply thought about the cost of life and the cost of dying with dignity,” Priscilla Alderson, a professor of childhood studies at the University of London’s Institute of Education, told the Guardian newspaper. “She sounds like she is remarkably wise.”

[22]
Others have argued that it is pointless to force anyone to have a heart transplant when there is such a long list of people desperate for one.

[23]
“I try not to think about death, but I do know my time is limited,” Hannah said. “I live each day as it comes. I enjoy life. It’s hard not to feel that life’s unfair, but I am determined to make the best of it.”



2008-11-23-WP-Brownlee-Emanuel
5 Myths About Our Ailing Health-Care System
By Shannon Brownlee and Ezekiel Emanuel
Washington Post Outlook, 2008-11-23

[An excerpt; emphasis is added.]

[T]he average family of four is coughing up
$29,000 a year
for health care

through taxes, lower wages and out-of-pocket medical expenses.



[A]dministrative waste
isn’t what’s driving health-care costs up faster than inflation.
Most of the relentless rise can be attributed to
  • the expansion of hospitals and other health-care sectors and
  • the rapid adoption of expensive new technologies --
    new drugs, devices, tests and procedures.
Unfortunately,
only a fraction of all that new stuff offers dramatically better outcomes.
If we’re worried about costs,
we have to ask whether a $55,000 drug
that prolongs the lives of lung cancer patients for an average of a few weeks
is really worth it.
Unless we find a cure for our addiction to the new but not necessarily improved,
our national medical bill will continue to skyrocket,
regardless of how efficient insurance companies become.







2009


2009-01-01-Will
Dr. Leavitt's Scary Diagnosis
By George F. Will
Washington Post, 2009-01-01

[An excerpt; all emphasis from the original.]

Absent fundamental reforms, over the next two decades,
the average American household’s health-care spending,
including the portion of its taxes that pays for Medicare and Medicaid,
will go from 23 percent to 41 percent of average household income
[original emphasis].



When Medicare was created in 1965,
America’s median age was 28.4; now it is 36.6.
The elderly are more numerous, and medicine is more broadly competent
than was then anticipated.
Leavitt says that
Medicare’s “big three” hospital procedure expenses today are
hip and knee replacements and cardiovascular operations with stents,
which were not on medicine’s menu in 1965.



In the 43 years since America decided that
health care for the elderly would be paid for by people still working,
the ratio of workers to seniors has steadily declined.
And the number of seniors
living long enough to have five or more chronic conditions --
23 percent of Medicare beneficiaries --
has increased.
Many of those conditions could be prevented or managed by
better decisions about eating, exercising and smoking.
The 20 percent of Americans who still smoke
are a much larger percentage of
the 23 percent who consume 67 percent of Medicare spending.
Furthermore,
nearly 30 percent of Medicare spending pays for
care in the final year [original emphasis] of patients’ lives.







2009


2009-01-06-NYT-Pear-2007-spending
Spending Rise for Health Care and Prescription Drugs Slows
By ROBERT PEAR
New York Times, 2009-01-06

Note also this excellent graphic.

[Its beginning.]

National health spending grew in 2007 at the lowest rate in nine years,
mainly because
prescription drug spending increased at the slowest pace since 1963,
the government reported Monday.

But

other types of health spending rose at a brisk pace,
pushing the total to $2.2 trillion,
or 16.2 percent of the gross domestic product,
a record.
Spending averaged $7,421 for each person.

Total health spending rose 6.1 percent,
compared with a 6.7 percent increase in 2006.
[See the graphic.]

The report, published in the journal Health Affairs,
offers the most current and comprehensive data
on the nation’s health care sector....

...


With the exception of prescription drugs,
spending for most other health care goods and services
grew at about the same rate as in 2006, or faster.
And some of those other categories are more significant in the overall picture.
Prescription drugs account for 10 percent of all health spending,
much less than either
hospitals (31 percent of the total) or
doctors (18 percent).

Spending on hospital care rose 7.3 percent in 2007, to $696.5 billion,
compared with an increase of 6.9 percent in 2006,
the government reported.

Spending for doctors’ services rose 5.9 percent in 2007, to $393.8 billion.
That is less than the 6.4 percent increase in 2006, in part because
Congress reduced Medicare payments to doctors for imaging services.

Out-of-pocket spending on health care increased 5.3 percent in 2007,
to $268.6 billion.
Such expenses have been growing more slowly than total health spending,
but faster than household income,
so many consumers have felt a squeeze on their pocketbooks,
federal officials said.



2009-01-11-WP-Brown
We All Want Longer, Healthier Lives.
But It's Going to Cost Us.

By David Brown
Washington Post Outlook, 2009-01-11

[This, to my mind,
is trying to lead opinion into wanting and demanding more, and more expensive, health care.
It is basically salesmanship.
E.g.:]


Medicare estimates that about 500,000 Americans
now qualify for an ICD [implantable cardioverter-defibrillator]
on medical grounds.
Undreamed of when our parents and grandparents were having heart attacks,
these devices are keeping or will keep thousands alive.
So who’s going to give one up
in the interest of slowing the growth of health care spending?
Not I.
And I suspect not you, either.

[Want to reduce heart-attack risk?
Get exercise and control your diet.
This is something (almost) everyone has control over.
Some people say they want more control over their lives:
Well, how about starting with leading a healthier life-style
rather than demanding that
those who do have the self-discipline to maintain a healthy life-style
pay for your lack of self-discipline?]




2009-01-12-Samuelson
Obama's Health-Care Headache
Obama's promised more health-care spending. We need less.
By Robert J. Samuelson
Washington Post Op-Ed, 2009-01-12

[Another excellent Samuelson opinion piece.
An excerpt; emphasis is added.]


[8]
Open-ended insurance reimbursement encourages expensive medicine
by making it easier to recover the costs of clinical advances.
Economist Amy Finkelstein of MIT has estimated that
roughly half the real increase in per capita health spending from 1950 to 1990
reflected the spread of comprehensive health insurance.

In 2006, consumers’ out-of-pocket spending represented
13 percent of total health spending,
down from about half in 1960.
Unfortunately,
this semi-automatic system may now frustrate other national goals
by displacing other spending and spawning ineffective or unneeded care.

[9]
On paper, there are various ways to control health spending:
stricter regulation of prices and the availability of care;
“market mechanisms” to push consumers toward more efficient or skimpier care.
All have foundered, because they cannot be used aggressively.
The reason is politics.
There is no major constituency for controlling spending.
Because most patients don’t pay medical bills directly,
they have little interest in using less care or shopping for lower-priced services.
Providers (doctors, hospitals, drug companies) have no interest in limiting care.
What others call “health costs” are their incomes -- wages, salaries, profits.

[10]
Unless we rectify this political imbalance, efforts to control health spending may fail.
We need mass constituencies that favor cost control.
But our consistent policy has been to

conceal the burden of health spending
by burying it

in untaxed corporate fringe benefits or government budgets.

[11]
We could change this.
We could charge the elderly more for Medicare.
We could tax employer-provided health insurance as ordinary income.
We could create a dedicated federal tax to cover government health costs --
if health spending increased more than revenue,
the tax would automatically rise.
People would quickly feel the costs of our present system.
Of course, that would be unpopular,
because it would compel Americans to face a discomforting issue --
how important is health care compared with other priorities?

[12]
Will Obama be so bold?
In the campaign, he proposed more, not less, health spending.
It’s easier to embrace the rhetoric of change than change itself.



2009-02-14-NYT-Specter-yet-more-for-health-research
Specter, a Fulcrum of the Stimulus Bill,
Pulls Off a Coup for Health Money

By GARDINER HARRIS
New York Times, 2009-02-14

[An excerpt; emphasis is added.]

[E]ven lobbyists are stunned by the coup Mr. Specter pulled off this week.
In return for providing one of only three Republican votes in the Senate
for the Obama administration’s $787 billion economic stimulus package,
he was able to secure
a 34 percent increase in the health agency’s budget —
to $39 billion from $29 billion.


[Talk about overkill!]



2009-02-16-NYT-Pear-comparing-effectiveness
U.S. to Compare Medical Treatments
By ROBERT PEAR
New York Times, 2009-02-16

[Its beginning; emphasis is added.]

WASHINGTON —

The $787 billion economic stimulus bill approved by Congress
will, for the first time,
provide substantial amounts of money for the federal government to
compare the effectiveness of different treatments for the same illness.

Under the legislation, researchers will receive $1.1 billion
to compare drugs, medical devices, surgery
and other ways of treating specific conditions.
...

The program responds to a growing concern that
doctors have little or no solid evidence of the value of many treatments.
Supporters of the research hope it will eventually save money
by discouraging the use of costly, ineffective treatments.



2009-03-03-NYT-Parker-Pope-patients-doctors
A Hurdle for Health Reform: Patients and Their Doctors
By TARA PARKER-POPE
New York Times “The Well”, 2009-03-03

[Emphasis is added.]

[1]
Recently, I went to the drugstore to fill a prescription.
Instead, I left with a costly lesson in health care economics.

[2]
At the checkout, I was surprised when the clerk billed me for $100
instead of my usual small co-payment.
It was only then that I realized
my doctor had traded me up to a costly branded migraine drug,
even though the old drug had worked just fine.
And I had allowed it.

[3]
As a conversation about health care reform intensifies in Washington,
much of the focus is on
the role the government and insurance companies will play
in a revamped health system.
But surprisingly little attention has been paid to
the role that patients and their doctors have played
in shaping the way medical care is delivered.

[4]
Ultimately, for any reform to work,
patients will have to change their behavior.
Of course, everyone should continue to demand the best possible care.
But we will have to accept that
“best” doesn’t always mean
the newest drug or the latest treatment.

The looming question is
whether patients are ready to embrace
the realities of reform.


[5]
“You can make policy changes till you’re blue in the face,
but if patients and doctors don’t change the way they think about medicine,
we’ll never change medicine,”
said Dr. David Newman, an emergency medicine physician
at St. Luke’s-Roosevelt Hospital Center in New York
and the author of
“Hippocrates’ Shadow: Secrets From the House of Medicine”
(Simon & Schuster, 2008).
“If everybody at the ground level believes that
prescriptions and procedures are the things we need
to make us healthy and well,
then it doesn’t matter what kind of policy you draft
or what kind of system you build.
It’s never going to get better.”

[6]
Americans spend $2.5 trillion a year on health care,
or about $8,160 per person,
more than twice as much as many countries in Europe.
But we clearly aren’t getting our money’s worth.
Today, 46 million Americans aren’t covered,
and measures like life expectancy and maternal and childhood health
lag far behind those of many developed nations and even less-developed ones.

[7]
At the heart of reform is a plan to cut costs,
in part by trying to discern which treatments really work.
President Obama’s economic stimulus plan includes $1.1 billion
for studies that will ask basic questions about
the comparative effectiveness of expensive procedures
versus less expensive ones.
For instance, with certain kinds of injuries,
does surgery work better than physical therapy?
Are costly new drugs any more effective than their generic predecessors?

[8]
Dr. Harold Varmus,
the president of Memorial Sloan-Kettering Cancer Center in New York
and a former director of the National Institutes of Health,
said increasing public access to the findings of medical research
would be important for health care reform to succeed.

[9]
“One obvious goal is
getting information out to health care practitioners
about effectiveness experiments,”
said Dr. Varmus, a Nobel Prize-winning cancer biologist
and the author of the new book “The Art and Politics of Science” (Norton).
“This is going to be crucial,
because if the government’s going to spend $1.1. billion from the stimulus bill
on comparative effectiveness research,
you want that stuff to be in the public domain.”

[10]
But when it comes to comparative effectiveness,
the track record of the American public and their doctors is not encouraging.
Even when such comparisons are available, we tend to ignore them.
In 2002, for example,
one of the largest government-financed clinical trials ever found that
generic pills for high blood pressure worked better than
newer drugs that were up to 20 times as expensive.
But most hypertension patients still use
costlier drugs marketed by pharmaceutical companies. [!!]

[11]
Despite numerous studies showing that
most ear infections aren’t helped by antibiotics,
many parents still insist on prescriptions for their children.
Last month, The Archives of Internal Medicine reported that
37 percent of doctors in one survey complained that
patients routinely demanded unnecessary prescriptions.
By some estimates,
unnecessary antibiotic prescriptions add $2 billion a year to health care costs.

[12]
The list goes on.
Whether it’s invasive back surgery, medical scans or expensive drugs,
patients and doctors alike
often refuse to believe that costly treatments aren’t worth it.

[13]
“Doctors believe the industry propaganda that
new drugs are better than old ones,
and that
for every ailment there is a drug,”
said Dr. Marcia Angell,
a senior lecturer in social medicine at Harvard Medical School
and the author of “The Truth About the Drug Companies:
How They Deceive Us and What to Do About It” (Random House, 2004).
“They learn to practice a drug-intensive style of medicine.”

[14]
In a 2004 study in The American Journal of Public Health,
researchers found that
technology played a surprisingly minor role in improving health.
In analyzing mortality data from the 1990s, the researchers concluded that
only about 1 in 16,000 Americans had their lives extended or saved
as a result of recent improvements in health care technology.

The real gains in health, experts say,
have come from
lifestyle changes like
smoking cessation and seat-belt use

or from
public health improvements like
vaccination, a cleaner water supply
and increasing access to primary care.


[15]
“In American culture,
prescriptions and procedures have become surrogates for
real health care and real dialogue,”

Dr. Newman said.
“We need doctors and patients to conceive of medicine and health
in a totally different way
than they have been taught in the last 20 to 30 years.”



2009-03-17-WP-Connolly-comparison-shopping-for-medicine
Comparison Shopping for Medicine
Obama's Stimulus Package Funds Research on Cutting Costs
By Ceci Connolly
Washington Post, 2009-03-17

What’s best for insomnia --
Lunesta, at about $6 a pill, or Zolpidem, at $2?

Should a man with prostate cancer
choose radiation, surgery or “watchful waiting”?

Is it better to operate on a bad knee
or get an injection of the joint fluid known as Visco?

To help doctors and patients decide,
President Obama has dedicated $1.1 billion in the economic stimulus package
for federal agencies to oversee
studies on the merits of competing medical treatments.

The approach, known as comparative effectiveness research,
is aimed at finding the best treatments at the best prices.
Proponents say reducing ineffective or unproven care
is one way to rein in health costs,
which consume nearly 18 percent of the gross domestic product,
straining family budgets, company profits and the federal government.

...

2009-03-18-WP-Vedantam-silenced-drug-study
A Silenced Drug Study Creates An Uproar
By Shankar Vedantam
Washington Post, 2009-03-18

[1]
The study would come to be called “cursed,”
but it started out just as Study 15.

[2]
It was a long-term trial of the antipsychotic drug Seroquel.
The common wisdom in psychiatric circles was that
newer drugs were far better than older drugs,
but Study 15’s results suggested otherwise.

[3]
As a result, newly unearthed documents show,
Study 15 suffered the same fate
as many industry-sponsored trials that yield data drugmakers don’t like:
It got buried.
It took eight years before
a taxpayer-funded study rediscovered what Study 15 had found --
and raised serious concerns about an entire new class of expensive drugs.

...

Just Medicine
By PHILIP K. HOWARD
New York Times Op-Ed, 2009-04-02

WASTE in the health care system costs America upwards of $1 trillion per year.
[Wish he would give a source for that claim.]
Much of this waste is generated or justified
by the fear of legal consequences
that infects almost every health care encounter.
The good news is that it would be relatively easy to create
a new system of reliable justice,
one that could support broader reforms to contain costs.

The legal system terrorizes doctors.
Fear of possible claims leads medical professionals
to squander billions in unnecessary tests and procedures.
“Defensive medicine” is so prevalent that
it has become part of standard protocol —
for example, mandatory pre-operative exams
even where the patient record is current, and even for minor procedures.

...

2009-04-16-NYT-Medicare-readmissions
Back in the Hospital Again
New York Times Editorial, 2009-04-16

An alarming one-fifth of all Medicare patients discharged from the hospital
end up back in the hospital within 30 days,
and fully a third return within 90 days.
If this yo-yoing could be greatly reduced,
Medicare could save billions of dollars.
Many patients would certainly benefit from the better care.

High rates of rehospitalization are partly the fault of the hospitals.
The more fundamental problem is
the fragmented nature of the American medical system:
too often,
health-care providers fail to communicate with one another,
patients fall between the cracks
and no one seems clearly in charge of a patient’s welfare.

[Apparently the New York Times cannot bring itself
to suggest that some of this may be due to either
the patient’s neglect of him/her self, or
their inability to follow the regimen the hospital has called for,
or just the general bad shape that some of these patients are in.
There is, after all, only so much medicine can do,
a fact that many of our opinion-leaders seem extraordinarily reluctant to recognize.
They seem to have a real passion
to commit more and more of our economy to the health industry.
(Perhaps it is unfair to base this suggestion on this particular editorial,
which assets that following its advice will actually save money.)]


...

2009-04-16-Harbaugh-obesity
When I see photos of people like
Dick Cheney, Rush Limbaugh, John Murtha, John Madden, Kwame Kilpatrick,
I think

“Why on earth should the general public be charged,
either through government-paid health care or private health insurance,
with treating any obesity-caused health problems of these people?”


To the extent their health problems, and need for health care,
is caused by their obesity,
this is a personal problem,
one that they have caused through their knowing and deliberate actions,
and should not be a burden on others
who exert the discipline and care to avoid such problems.
It is fundamentally unfair to burden the general public
with the problems caused by their self-indulgence.

We, as a nation, need to reduce the amount we spend on health care;
we must start somewhere
(the promises of “efficiency produced by health care reform”
will no doubt be swamped by one thing or another);
this is a good place to start.



2009-05-07-NYT-Meier-medical-minefield
New Effort Reopens a Medical Minefield
By BARRY MEIER
New York Times, 2009-05-07

[1]
A back-pain researcher, Dr. Richard Deyo recalls the uproar
the last time federal officials tried to suggest
how doctors should practice their profession.

[2]
It was in the mid-1990s, when Dr. Deyo helped develop federal guidelines
urging surgeons not to perform spinal fusions to treat acute pain.
The reason was simple:
There was little evidence that the fusions worked in many patients.

[3]
Spine specialists quickly attacked the report, calling it flawed.
One medical device maker, Medtronic,
sued unsuccessfully to block its release.
Republican lawmakers tried to kill the agency that issued the report.
[Unbelievable.
Why is the GOP so in love with
out-of-control, budget-busting spending on health care?]

It survived, but its funding was drastically cut,
and it decided to stop issuing guidelines.

[By the way, this is something I know something about.
When I was 20, I spent part of my summer vacation working as a laborer
(the pay was excellent, by the way)
and foolishly used working methods
that no doubt put excessive stress on my back.
(Taking out ceilings by swinging a sledge hammer at them with my back bent back.
Does that sound dumb now, but that was a less health-conscious age,
and no one recommended otherwise at the time.)
At any rate, the next winter I experienced excruciating back pain,
which was diagnosed as a herniated (or ruptured) disk.
(I had no Achilles reflex and yes, they took X-rays to verify the rupture.)
The orthopedic surgeon said he could operate on it to fuse the vertebrae,
but why take the risk of that operation failing?
Why not try “conservative treatment” (that was what he called it):
two weeks of bed rest, followed by general efforts to avoid stressing the back
(as well as bedboards, hard mattresses and a back brace).
Sure enough, the pain gradually and continually subsided.
My physical options were lessened (no more backpacking),
but I could certainly tolerate that.
Am I happy he didn’t operate, taking a risk of making things worse.]


[4]
Now, 15 years later,
the Obama administration is entering this same medical minefield.
And once again, opponents are gearing up for a fight.

[5]
The administration plans to spend $1.1 billion over the next few years on studies like the one conducted by Dr. Deyo, to compare the effectiveness of competing treatments for common conditions like back pain, heart disease and prostate cancer. The studies will be publicly released, to help doctors and patients decide which treatment options they want to pursue.

[6]
Supporters include many medical researchers, consumer groups, unions and insurers. They say such studies are essential to curbing the widespread use of ineffective treatments and to helping control health care costs, which totaled $2.2 trillion in 2007, or 16 percent of the nation’s gross domestic product.

[7]
The New England Journal of Medicine published several articles Wednesday supporting the federal effort and rebutting arguments raised by critics.

[8]
But potential opponents — which include medical products companies, some doctors and their political allies — warn that the comparative effectiveness movement could lead to inadequate treatment for some patients and even the rationing of health care.

[9]
“It is not difficult to see how you can get on a slippery slope very easily,” said Tony Coelho, a former Democratic congressman who is head of a new industry-backed Washington group called the Partnership to Improve Patient Care, formed to lobby on the comparative effectiveness effort.

[10]
The group’s backers include major trade organizations that represent producers of drugs, medical devices and biological treatments.

[11]
Critics like Mr. Coelho also point to a British government agency, the National Institute for Health and Clinical Excellence, or NICE, which considers costs in judging a treatment’s effectiveness. Based on NICE’s findings, the British government has denied some patients access to costly drugs like those used to treat cancer.

[12]
Whether cost should be a factor in this country was a hot-button issue during the Congressional debate in February, when the comparative-effectiveness funding was approved as part of the economic stimulus package. A legislative report by Congressional lawmakers who negotiated the final version of the bill said that they did not intend the research money to be used to “mandate coverage, reimbursement or other policies for any public or private payer.”

[13]
Despite that assurance, even supporters of the effort say one goal in identifying effective medical treatments is to stop wasting money on those of little value.

[14]
For now, proponents and critics are warily circling one another, as the first administrative steps of the process unfold.

[15]
A panel of government health experts is holding a series of public hearings at which people can suggest medical conditions for comparative effectiveness reviews. Then, in late June, that federal panel and the Institute of Medicine, a part of the National Academies of Science, will issue reports recommending priorities for comparative research. Past combatants like Dr. Deyo expect the fighting to start as soon as such studies start identifying winners and losers.

[16]
“If this research is done in a rigorous way and doesn’t pull strings, then a lot of pressure will come to bear,” on the process, said Dr. Deyo, a professor at Oregon Health and Science University in Portland.

[17]
Some conservative and libertarian research groups, as well as commentators like Rush Limbaugh, have attacked the comparative effectiveness effort as a step toward socialized medicine. Some medical experts have also raised concerns that the program may slow the drive toward so-called personalized medicine — an approach in which treatments are tailored to a patient’s genetic makeup. But for now, Mr. Coelho’s opposition group and drug and device makers are using more measured rhetoric.

[18]
Mr. Coelho, a former House Democratic whip who resigned in 1989 over a controversial junk-bond investment, says his organization does not oppose the concept of comparative effectiveness. But the group is concerned, he said, that such studies could lead to a type of cookbook medicine that will ignore the needs of specific patients, including members of minority groups.

[19]
His organization includes patient advocacy groups like the National Alliance for Hispanic Health and the National Alliance on Mental Illness, which also receive financing from medical products companies. Those groups argue that their members are underrepresented in formal clinical trials of drugs and treatments, and so there is not evidence enough on which to draw conclusions on what works for them and what does not, they say.

[20]
Mr. Coelho, a driving force behind the Americans with Disabilities Act, points to his own experience with epilepsy, which he has had since he was a teenager, as an example of how patients need to be treated individually.

[21]
Under the comparative effectiveness program, the Department of Health and Human Services and two agencies under it —the National Institutes of Health and the Agency for Healthcare Research and Quality — will finance studies that will look at various treatments and will pay for the development of information-gathering tools, like databases of patients being treated for a certain condition.

[22]
Right now, “there is no place that helps you sort through a specific option and how that compares to another,” said Dr. Carolyn M. Clancy, the director of the Agency for Healthcare Research and Quality.

[23]
The agency, back when it was known as the Agency for Health Care Policy and Research, was the federal body Dr. Deyo worked with in drafting the back-pain guidelines in the mid-90s.

[24]
More recently, officials of the Oregon Evidence-Based Practice Center began producing reports a few years ago comparing the effectiveness of competing drugs, both brand-name and generic, in treating specific conditions. The work was meant to help purchasers like state Medicaid programs lower their costs, said Dr. Mark Helfand, director of the center, which is part of the Oregon Health and Science University.

[25]
Wherever they went, Dr. Helfand said, he and his colleagues met resistance from drug makers and some patient groups that had rallied to the companies’ side, who raised the same arguments that critics of comparative effectiveness are raising today. The Practice Center’s research, which is continuing, is now used by 14 states. Dr. Helfand said groups representing African-American, Hispanic or elderly patients were right to argue that they were underrepresented in clinical trials. But he added that the whole point of comparative effectiveness was to move medical practice beyond the limits of such trials, by looking at a broader range of evidence that includes the actual experience of patients undergoing treatment.

[26]
“Ironically, the motivation for comparative effectiveness is to see what works in practice,” he said, “rather than overgeneralizing from a few unrepresentative studies.”



2009-05-11-NYT-Pear-pie-in-the-sky-promise-of-reducing-cost-rise
Industry Pledges to Control Health Care Costs
By ROBERT PEAR
New York Times, 2009-05-11


2009-05-21-WP-health-care-fraud
Health-Care Fraud to Be Targeted
New Task Force Will Focus on Costly Waste and Abuse
By Carrie Johnson
Washington Post, 2009-05-21


2009-05-28-NYT-drug-abuse-costs=468G
Governments’ Drug-Abuse Costs Hit $468 Billion, Study Says
By ERIK ECKHOLM
New York Times, 2009-05-28

Government spending related to
smoking and the abuse of alcohol and illegal drugs
reached $468 billion in 2005,

accounting for
more than one-tenth
of combined federal, state and local expenditures
for all purposes,

according to a new study.

Most abuse-related spending went toward
direct health care costs for lung disease, cirrhosis and overdoses,
for example,
or for law enforcement expenses including incarceration,
according to the report released Thursday
by the National Center on Addiction and Substance Abuse,
a private group at Columbia University.
Just over 2 percent of the total
went to prevention, treatment and addiction research.
The study is the first to calculate abuse-related spending
by all three levels of government.

...

2009-06-10-Pearlstein
Fixing Health Care Starts With the Doctors
By Steven Pearlstein
Washington Post, 2009-06-10

If we really want to fix
America’s overpriced and under-performing health-care system,
what really matters is
changing the ways doctors practice medicine, individually and collectively.
Everything else --
mandate or no mandate,
the tax treatment of health benefits,
whether there’s a “public plan” to compete against private health insurers --
is just tinkering at the margin.

2009-06-17-Pearlstein
Self-Help for the Health-Care System
By Steven Pearlstein
Washington Post, 2009-06-17

[Pearlstein surveys arguments concerning
the role of doctors in the rise in health care costs.
I don’t know enough to have an opinion on these issues,
except that I would certainly agree with the doctors
on the desirability of putting caps on
the amount that can be awarded in medical liability lawsuits,
ending the current situation of “Jackpot Justice.”]




2009-07-02-NYT-Leipzig-geriatric
The Patients Doctors Don’t Know
By ROSANNE M. LEIPZIG
New York Times, 2009-07-02

2009-07-08-NYT-Leipzig-geriatric-letters
Letters: Getting to Know Our Elderly Patients
New York Times Letters to the Editor, 2009-07-08

[Where your Medicare dollars are going:]

To the Editor:

Re “The Patients Doctors Don’t Know” by Rosanne M. Leipzig (Op-Ed, July 2):

As someone who has been teaching geriatrics for more than 25 years,
I found Dr. Leipzig’s article music to my ears!
What also needed to be said, however, was
just how few board-certified geriatricians there are
both to care for and to teach about frail elders.

I often see octogenarians along with their daughters and aides,
and each person has questions that need to be answered.

Granny has (at least)
six problems and 10 medicines,
all of which must be dealt with.

For all of this Medicare will pay a fee for service
that is not much more than might be paid for treating a sore throat.

Until our services are adequately valued,
there will be way too few of us to care for Granny,
much less to teach students how to do it.

Robert L. Dickman
Boston, July 3, 2009

The writer recently retired as chairman of family medicine
at the Tufts University School of Medicine.

[Yep, the federal deficit may be $1.n trillion dollars a year,
an impossibly high level to sustain,
but you can rest assured that Granny’s six problems and ten medicines
are being covered by the federal budget,
to be paid for by the next few generations.
And just how much was spent on medical care for Granny’s ancestors?
Nothing like what is being spent on Granny, that’s for sure.
So much for fiscal responsibility or generational equity.

I mean, if the government were running a surplus, that would be one thing,
but it surely isn’t, and never again will according to current predictions.
So why are we spending so much on federal health care now?

As for me, I think you can rely on this:
I will never consume ten medications.
That would be spending too much on myself, an act of self-absorption.]


...


2009-09-04-WP-La-Crosse-last-year
The Unwitting Birthplace of the 'Death Panel' Myth
By Alec MacGillis
Washington Post, 2009-09-04

[This is a good article on
letting seniors make intelligent choices
about the extent to which efforts should be made to prolong their life
even after they are no longer sentient.
Here is an excerpt.]


A quarter of Medicare costs -- totaling $100 billion a year --
are incurred in the final year of patients’ lives,
and 40 percent of that in the last month.




[The Gundersen Lutheran hospital of La Crosse, Wis.]
began urging families to plan while people are healthy.
For those who want help writing a directive,
a physician will discuss the powers and limits of medicine
and explain to family members what it means
if they agree to serve as the “health-care agent.”
They will also help people define
the conditions under which they would no longer want treatment.
Hammes said people often define this as
“when I’ve reached a point where I don’t know who I am or who I’m with,
and don’t have any hope of recovery.”

The directives are power-of-attorney forms
that protect physicians and family members against liability,
and the hospital makes clear to its doctors
that they are expected to follow them.
Today,
more than 90 percent of people in town have directives when they die,
double the national average.

The reliance on directives has an impact on the type of care people receive: Gundersen patients spend 13.5 days on average in the hospital
in their final two years of life,
at an average cost of $18,000.
That is in contrast with big-city hospitals such as
the University of California at Los Angeles medical centers
(31 days and $59,000),
the University of Miami Hospital (39 days, $64,000) and
New York University’s Langone Medical Center (54 days, $66,000).

Those disparities are not explained
just by the hospital’s end-of-life philosophy. Under Medicare formulas,
Gundersen and other Upper Midwest hospitals receive lower reimbursements.
The high-spending hospitals argue that
they are also dealing with
a more diverse and costly patient base.

Gundersen and other Upper Midwest providers are also less costly in general,
partly because they follow a model of integrated care
where doctors work closely together to minimize waste.
At Gundersen, doctors receive a salary
instead of being paid for each procedure they perform.

But locals say

[La Crosse] uses less health care in large part because of
how people view the end of life.
Some of this may be rooted in
the down-to-earth sensibility of
[residents’] German and Scandinavian forebears.
(Hammes said his late mother, who had dementia,
was a “pragmatic German”
who thought that
paying to keep herself alive was
a “waste of her money.”
)

[Amen.
Wise, thrifty, responsible people concerned about the future of their society,
unlike the AARP,
and those groups who profit from endless healthcare,
rather than from such more socially useful activities
as manufacturing and infrastructure upkeep.]


...

“We all die, and we want to do so
with the most dignity and most control,”

[Barbara Frank, a retired teacher] said.

...

The discussions do not promote less aggressive care, [Hammes] said:
“We’re not trying to talk them into anything.
We’re trying to understand their values and goals,
and tell them what medical science can and can’t do.”
But many people do settle on less care.
“In our community,” he said,
“people don’t want to die hooked up to machines.”



2009-09-07-WP-Japan
Health Care in Japan: Low-Cost, for Now
Aging Population Could Strain System
By Blaine Harden
Washington Post, 2009-09-07

TOKYO –

[1]
Half a world away from the U.S. health-care debate, Japan has a system that costs half as much and often achieves better medical outcomes than its American counterpart. It does so by banning insurance company profits, limiting doctor fees and accepting shortcomings in care that many well-insured Americans would find intolerable.

[2]
The Japanese visit a doctor nearly 14 times a year, more than four times as often as Americans. They can choose any primary care physician or specialist they want, and surveys show they are almost always seen on the day they want. All that medical care helps keep the Japanese alive longer than any other people on Earth while fostering one of the world’s lowest infant mortality rates.

[3]
Health care in Japan -- a hybrid system funded by job-based insurance premiums and taxes -- is universal and mandatory, and consumes about 8 percent of the nation’s gross domestic product, half as much as in the United States. Unlike in the U.S. system, no one is denied coverage because of a preexisting condition or goes bankrupt because a family member gets sick.

[4]
But many health-care economists say Japan’s low-cost system is probably not sustainable without significant change. Japan already has the world’s oldest population; by 2050, 40 percent will be 65 or older. The disease mix is becoming more expensive to treat, as rates of cancer, stroke and Alzheimer’s disease steadily increase. Demand for medical care will triple in the next 25 years, according to a recent analysis by McKinsey & Co., a consulting firm.

[5]
Japan has a stagnant economy, with a shortage of young people that hobbles prospects for growth and strangles the capacity of the debt-strapped government to increase health-care spending. Without reform, costs are projected to double, reaching current U.S. levels in a decade, according to the Organization for Economic Cooperation and Development (OECD).

[6]
For generations, Japan has achieved its successes by maintaining a vise-like grip on costs. After hard bargaining with medical providers every two years, the government sets a price for treatment and drugs -- and tolerates no fudging.

[7]
As a result, most Japanese doctors make far less money than their U.S. counterparts. Administrative costs are four times lower than they are in the United States, in part because insurance companies do not set rates for treatment or deny claims. By law, they cannot make profits or advertise to attract low-risk, high-profit clients.

[8]
To keep costs down, Japan has made tradeoffs in other areas -- sometimes to the detriment of patients. Some are merely irritating, such as routine hour-long waits before doctor appointments. But others involve worrisome questions about quality control and gaps in treatment for urgent care.

...



2009-09-29-WP-Connolly-Rationing
In Delivering Care, More Isn't Always Better, Experts Say
By Ceci Connolly
Washington Post, 2009-09-29

[The last paragraph:]

As [Arthur Kellerman, an associate dean at Emory School of Medicine in Atlanta
and a physician at that city’s Grady Memorial Hospital] put it:
“In the United States today, we give you

all the care you can afford,
whether or not you need it,

as opposed to
all the care you need,
whether or not you can afford it.”





2009-10-06-WP-Coulehan-Battery-of-Tests-for-What
A Battery Of Tests. For What?
Physician's Ordeal Leads to a Realization
By Jack Coulehan [, M.D.]
Special to The Washington Post, 2009-10-06

For years I’ve heard friends describe experiences of
being caught in a web of excessive and unnecessary medical testing.
Their doctors ordered test Z
to investigate a seemingly incidental finding on test Y,
which had come about because of a borderline abnormality on test X.

I often wondered why test X was done in the first place.
As a primary care physician,
I would have treated them for the likely diagnosis and done diagnostic tests --
especially a series of diagnostic tests --
only if they didn’t respond as expected.

By the time my friends told me these stories,
their original symptoms had disappeared
(with or without specific diagnosis and treatment)
or my friends had sunk under the weight of a new symptom
or anxiety about the lack of an explanation for their problem.
Many of the tales also included
delays in receiving their test results,
frequent referrals to specialists and
poor coordination among health professionals.

...

One thing’s for sure:
I’ve lost the smugness and condescension I often felt
when listening to others’ stories about
being trapped by the system and
manipulated into excessively complex and specialized medical situations.
Unlike most of my patients,
I actually knew what my diagnosis was and what to do about it,
but I learned how difficult it is to remain objective
when you’re feeling very sick.

I understand now how all those people could have been so gullible,
so easily manipulated by the system.

Now that I’m one of them, that is.



2009-10-06-WP-Preventable-Deaths
U.S. Losing Ground on Preventable Deaths
Despite High Medical Spending, Results Trail Other Wealthy Countries
By Ceci Connolly
Washington Post, 2009-10-06

[Some excerpts:]

[8]
“Chronic illnesses are a much bigger driver of health-care costs”
than trauma cases such as vehicle crashes and gunshots,
said Robert Shesser, head of emergency medicine at George Washington University.
“Because of our wacky system,

some people are bankrupted or avoiding care
and some are getting too much care --
they’re hogging care.”



[13]
In tracking preventable deaths,
researchers count deaths from illnesses or injuries
that either need not happen at all
or for which there are therapies proven to keep someone alive to a certain age.
Young children dying of measles is preventable in developed countries,
for instance.
Fatal cases of skin cancer, epilepsy, hernia and surgical complications
should not occur before age 70 and are thus deemed preventable.

...

[15]
In contrast,
more complicated cancers, AIDS and most heart disease, while often treatable,
are not considered preventable,
because even with the best of modern medicine,
patients often die before old age.

[16]
In 1997-1998, the United States
ranked 15th in preventable deaths out of 19 industrialized countries.
In 2002-2003, the nation fell to 19th, even as costs continued to rise.
Up to 100,000 lives could be saved if the country’s health-care system
performed as well those in nations such as France, Japan and Australia,
according to the Commonwealth Fund study,
which was based on World Health Organization statistics.

[17]
Measuring preventable deaths
can illuminate strengths and weaknesses in a health-care system, Schoen said.
Nations that dramatically lowered their preventable-death rates
focused on challenges such as
controlling diabetes and reducing hospital-acquired infections,
she said.

[18]
Looking at the results, Pearson concluded:
“The U.S. doesn’t take primary care very seriously.”

[19]
In terms of spending,
the United States devotes about 16 percent of the total economy to health care
more than seven percentage points higher than the average of OECD countries.
The average American consumed $7,290 worth of medical services in 2007,
compared with an average of just under $3,000 in the remaining nations
when adjusted for price differences,
Pearson said.

[20]
More money went to

higher physician salaries,
larger administrative fees and
higher prices for most medical services.

Americans also have
higher utilization rates of prescription medicines,
sophisticated technology such as imaging and
surgical procedures such as
cataract surgery, knee replacements and Caesarean sections,

according to the OECD analysis.

...





2009-11-20-NYT-mammogram-cost-versus-benefit-ratio
Screening Debate Reveals Culture Clash in Medicine
By KEVIN SACK
New York Times, 2009-11-20

[1]
This week,

the science of medicine
bumped up against
the foundations of American medical consumerism:
more is better,
saving a life is worth any sacrifice,
health care is a birthright.


[2]
Two new recommendations, calling for
delaying the start and reducing the frequency
of screening for breast and cervical cancer,
have been met with anger and confusion from some corners,
not to mention a measure of political posturing.

[3]
The backers of science-driven medicine,
with its dual focus on risks and benefits,
[Can one talk about “costs” in this context?
Is talking about cost-benefit ratios in health-care a no-no?]

have cheered the elevation of data in the setting of standards.
But many patients — and organizations of doctors and disease specialists —
find themselves unready to accept
the counterintuitive notion that
more testing can be bad for your health.

[4]
“People are being asked to think differently about risk,”
said Sheila M. Rothman, a professor of public health at Columbia University.
“The public state of mind right now is that they’re frightened that
evidence-based medicine is going to be equated with rationing.
They don’t see it in a scientific perspective.”

[5]
For decades,
the medical establishment, the government and the news media
have preached the mantra of early detection,
spending untold millions of dollars to spread the word.
Now, the hypothesis that screening is vital to health and longevity
is being turned on its head,
with researchers asserting that mammograms and Pap smears
can cause more harm than good for women of certain ages.

[6]
On Monday, the United States Preventive Services Task Force,
a federally appointed advisory panel, recommended that
most women delay the start of routine mammograms
until they are 50, rather than 40,
as the group suggested in 2002.
It also recommended that
women receive the test every two years rather than annually,
and that physicians not train women to perform breast self-examination.

[7]
The task force,
whose recommendations are not binding on insurers or physicians,
concluded after surveying the latest research that

the risks caused by
over-diagnosis, anxiety,
false-positive test results and excess biopsies
outweighed the benefits
of screening for women in their 40s.

It found that
one cancer death is prevented for every 1,904 women ages 40 to 49
who are screened for 10 years, compared with
one death for every 1,339 women from 50 to 74, and
one death for every 377 women from 60 to 69.

[Very interesting.
But what are the ratios of (dollars spent) to (lives saved)
for the two alternative screening protocols?]


[8]
On Friday, the American College of Obstetricians and Gynecologists
plans to announce a similar revision
to its screening guidelines for cervical cancer.
It will advise that women receive their first Pap test at age 21;
the previous standard had been
three years after a woman’s first sexual intercourse
or age 21, whichever came first.
The group also is recommending that
the test be performed every two years instead of annually
for women ages 21 to 30.

[9]
“A review of the evidence to date shows that
screening at less frequent intervals
prevents cervical cancer just as well,
has decreased costs and
avoids unnecessary interventions that could be harmful,”
said Dr. Alan G. Waxman, a professor at the University of New Mexico
who directed the process.

[10]
The challenge of persuading patients and doctors to accept such standards
requires a transformational shift in thinking,
particularly when the disease involved is
as prevalent, as deadly, and as potentially curable as cancer.
How do you convince them that it is in their best interest to play the odds
when they have been conditioned for so long to not gamble on health?
After all, for the one in 1,904 women in their 40s
whose life would be saved by early detection of breast cancer,
taking the risk would in retrospect seem a bad choice.

[12]
“This represents a broader understanding that
the efforts to detect cancer early can be a two-edged sword,”
said Dr. H. Gilbert Welch, a professor of medicine at Dartmouth
who is among the pioneers of research into
the negative effects of early detection.
“Yes, it helps some people, but it harms others.”

[13]
Dr. Welch said this week’s recommendations
could mark a turning point in public acceptance of that notion.
“Now we’re trying to negotiate that balance,” he said.
“There’s no right answer, but I can tell you that
the right answer is not always to
start earlier, look harder and look more frequently.”

[14]
That concept is proving easier to swallow
in the halls of Dartmouth Medical School
than in the halls of Congress.
Coming as they did
at the height of debate over a sweeping health care overhaul,
the recommendations have provided fresh ammunition
for those who warn that
greater government involvement in medical decision-making
would lead to rationing of health care.
It has not mattered that
the breast cancer screening recommendation is only advisory,
and that the federal government, the American Cancer Society, and numerous private insurers
have said they will not adopt it.

[15]
Senator Kay Bailey Hutchison,
a Republican who is running for governor of Texas,
cited the task force’s screening statistics in a floor speech on Thursday.
“One life out of 1,904 to be saved,” Ms. Hutchison said,
“but the choice is not going to be yours.
It’s going to be someone else that has never met you,
that does not know family history.”
She added,
“This is not the American way of looking at our health care coverage.”

[16]
The health care bills in both the House and the Senate
would establish commissions to encourage research into
the effectiveness of medical tests and procedures,
but would not require that the findings
be translated into practice or reimbursement policies.

[17]
As throughout history,
it may take decades for medical culture to catch up to medical science.
Dr. Rothman pointed out that it took 20 years
for the public to accept the discovery in 1882 that
tuberculosis was caused by a bacterium
and not by heredity or behavior.
More than 160 years after
the Hungarian-born physician Ignaz Semmelweis
[yet another DWM, I might point out]
posited that
hand-washing could prevent
the spread of infectious disease,
studies still show that
half of all hospital workers
do not follow basic hygiene protocols.



[18]
“It’s going to take time, there’s no doubt about it,”
said Louise B. Russell,
a research professor at the Rutgers University Institute of Health
who has studied
whether prevention necessarily saves money
(and found it does not always do so).

“It’s going to take time in part because
too many people in this country have had a health insurer say no,
and it’s not for a good reason.
So they’re not used to having a group come out and say we ought to do less,
and it’s because it’s best for you.”



2009-11-20-WP-Pearlstein-mammogram-cost-versus-benefit-ratio
Sebelius’s cave-in on mammograms is a setback for health-care reform
By Steven Pearlstein
Washington Post, 2009-11-20

[1]
Health and Human Services Secretary Kathleen Sebelius
did a marvelous job this week
of undermining the move toward evidence-based medicine
with her hasty and cowardly disavowal
of a recommendation from her department’s own task force
that women under 50 are probably better off
not getting routine annual mammograms.

[2]
This is an old issue
that has not only sharply divided the medical community
for more than 20 years,
but also taps into deep resentments among women who, over the years,
have felt neglected by a male-dominated medical establishment.
[But remember, when Larry Summers dared to suggest that
there might be innate differences between men and women
which could have an effect on their scientific ability,
that was denounced by the all-powerful feminists as “offensive” and “misogynist”,
and got him fired from his job.]

And there’s no doubt that the advisory panel’s recommendation
came at a politically inconvenient time,
just as Congress enters the crucial final phase in a health reform debate
in which opponents have successfully stoked fears of medical rationing.

[3]
But rather than showing
the leadership necessary to lead a grown-up national discussion
on how to eliminate unnecessary or wasteful procedures,
Sebelius simply disowned the task force and ran for political cover.
Just as the hysteria over “death panels”
killed any chance that Medicare recipients and their patients
might be encouraged to engage in
an intelligent conversation about end-of-life care
before it becomes an issue,
the mammogram brouhaha is likely to set back efforts
to dramatically increase research into what really works and what doesn’t,
and use the results to revamp the way medical care is delivered and paid for.

[4]
I should acknowledge that
I have no idea who should and should not get routine mammograms.
But I know enough about statistics to say that
the issue is not settled just because you know of someone in her 40s
whose breast cancer was detected by a mammogram and cured.
As economists and medical researchers are fond of saying,
the plural of anecdote is data.

[5]
To make a valid scientific finding of who should be screened and how often,
you’d have to take into consideration
how big the risk is
that women are likely to develop cancer at any particular age;
how fast tumors are likely to grow and
how likely they are to be cured once they are caught;
what is the likelihood that a tumor detected by mammogram
might be found some other way;
what is the probability
that a suspected tumor turns out not to be pre-cancerous,
or that doing a biopsy on it will actually
increase the chance that it could become dangerous later.
You’d also have to weigh the benefits of routine screening --
deaths avoided and years of life extended --
against the medical problems caused by complications that arise from biopsies,
along with the mental anguish that goes along with
the large number of false positives
that crop up on mammographies of women in their 40s.

[6]
All that, of course, is exactly what the task force did,
based on numerous studies done
in different countries using different methodologies.
In the end, it found that while some lives might be saved each year,
the benefits of annual screening of women in their 40s
were outweighed by the costs --
and that’s without even getting into the financial costs,
which run to several billion dollars a year.

[7]
As is often the case in such matters,
those raising the most fuss were
those with greatest financial interest in mammography
(the radiologists and the makers of mammography machines)
and the disease groups (in this case, the American Cancer Society),
which tend to resist recognizing limits on
how much time, money and attention is devoted to their cause.

[8]
“How many mothers, sisters, aunts, grandmothers, daughters and friends
are we willing to lose to breast cancer
while the debate goes on about the limitations of mammography?”
Otis Brawley, chief medical officer of the American Cancer Society,
asked in an op-ed article in Thursday’s [11-19] Washington Post.
Dr. Brawley cleverly didn’t answer his own question,
but the clear implication of his question was that
the only acceptable number should be zero.
And

it is that very attitude,
applied across the board to every patient and every disease,
which goes a long way in explaining
why ours is
the most expensive, and one of the least effective,
health-care systems
in the industrialized world.


[9]
The political argument from the White House was that
it was necessary to duck this fight over evidence-based medicine
in order to save it.
The better approach would have been
to see this as one of those teachable moments
that could be used to reaffirm the entire rationale for reform.
For while debate continues over
whether some women may be getting too many mammograms,
there is evidence that there are women who, because they lack insurance,
are getting too few -- and dying unnecessarily as a result.
What health reform is about is correcting that imbalance
while devising new mechanisms for
improving health outcomes and getting better control over costs.

[10]
Put in that context,
it would have been perfectly reasonable for Sebelius to have announced that
she was delaying implementation of the task force recommendation for a year
in order to give it more time
to seek a broader consensus among researchers, doctors and patients.
That would have made clear that the administration remained committed to
a health-care system driven by the best medical evidence
but one that is also sensitive to broad public opinion.
This is a tough-love message the country, and the Congress, need to hear.



2009-09-21-Harbaugh-gender-cost-differences

In the debate [1, 2] over mammogram testing,
it is clear that
many women feel that, quite literally,
no expense should be spared
when it comes to protecting female health (e.g.).
That certainly is consistent with what seems to me to be
generally greater interest in women, vice men,
on spending money on health care,
whatever the cost/benefit ratio may be.

A natural question is how much that gender difference,
to the extent that it is true,
yields actual, measurable differences in per-capita spending on health care.
In particular, an interesting comparison would be comparing
the per-capita national average spending on health care by gender.
(There are variants to those figures: raw and weighted by age distribution.)
That figure no doubt is available somewhere,
but it is not exactly highlighted by the media
as they cover the debates over health care.
I wonder why? :-)



2009-11-23-NYT-Kolata-Breast-Cancer-Guidelines-Data
Behind Cancer Guidelines, Quest for Data
By GINA KOLATA
New York Times, 2009-11-23

[There is really nothing about the politics of the mammograph report discussed above,
but rather a discussion of the studies and data that led to that report.]






2009-12-08-WP-Klein
The medical bill you need to see
By Ezra Klein
Washington Post Op-Ed, 2009-12-08

[1]
We’ve had a pretty good discussion this year on the public option and on “death panels.” But for all the hype over health-care reform, we have not done a very good job of talking about the health-care system itself -- in particular, why our system is so expensive. As a result, we’re not doing a very good job of fixing it. There’s still time to change that, but not much.

[2]
The doomsaying is by now familiar: Left unchecked, health-care reform will bankrupt our nation. It will grow to consume every dollar of gross domestic product. And Congress isn’t contemplating anything nearly radical enough to avert the emergency.

[3]
The reason is not that people haven’t heard grim warnings about the future. It’s because they don’t understand what’s going on in the present. In 2009, the average employer-sponsored health-care plan cost a bit less than $13,500. But virtually no one cut a check for $13,500. Employers generally pay more than 70 percent of their employees’ health-care costs. To employees, that seems like a good deal, particularly given how fast costs are growing. A “benefit,” as it’s called.

[4]
But health-care coverage is not a benefit. It’s a wage deduction. When premium costs go up, wages go down. When premium costs go down, wages go up. Yet workers don’t know that. In fact, the information is hidden from them. That means that cost control seems like all pain and no gain, which makes it virtually impossible for Congress to pass. It’s like asking someone to diet when they don’t realize it will help them lose weight.

[5]
Cost control is not, in fact, all pain and no gain. It’s some pain in return for a fat raise. A 2006 study, for instance, by Harvard’s Katherine Baicker and Amitabh Chandra used malpractice payments to estimate the effect of premium increases on wages. They found that a 10 percent increase in health-care premiums “results in an offsetting decrease in wages of 2.3 percent” and an increase in unemployment of 1.2 percentage points. Compensation is basically a set sum for employers, and they don’t seem to care much whether it goes into wages or into health-care costs.

[6]
Workers saw this in the 1990s. This was the era of the managed-care revolution, which most remember as a horrifying failure. Famously, audiences applauded when Helen Hunt broke out into a profanity-laden rant against HMOs in the movie “As Good as It Gets.” The popular backlash was so intense that by the turn of the century the managed-care experiment was virtually over. The problem with this historic failure? The data showed the experiment to be a tremendous success.

[7]
From 1989 to 1995, median wages actually fell a bit. Then, managed care kicked in. Annual growth in health-care costs fell from more than 10 percent in the early 1990s to less than 5 percent in the late ‘90s. Meanwhile, wages shot through the roof, rising more than 11 percent from 1995 to 2000. Then we ended the managed-care experiment, and health-care costs resumed their normal speed of growth. Predictably, wages slumped back down from 2000 to 2006. “By every observable indicator,” says Harvard’s David Cutler, “managed care was a huge success. It cut spending, cut the growth of spending and didn’t seem to kill anyone. And yet everyone hated it.”

[8]
Of course they hated it. They didn’t see its benefits, only its costs. They knew they were suddenly trapped in networks and being hassled by their insurers. As for their raises, those were nice, but why are you changing the subject?

[9]
When Americans rejected managed care, in other words, they didn’t know they were ending wage increases, too. But since 1990, wages have tracked changes in premiums more closely than they’ve tracked the growth of GDP. Maybe if more workers knew that, they would be more interested in efforts to control health-care costs.

[10]
One of the best reforms that could be made this year would be to give workers that information. So far, however, efforts have been unsuccessful. During the Senate Finance Committee’s negotiations, Ron Wyden (D-Ore.) offered to give employees the option to reject their employer’s offerings in return for a voucher that would help them choose their own insurance on exchanges, which meant they would save money if they chose cheaper plans. Much more modestly, Chuck Grassley (R-Iowa) floated an idea to simply require employers to report their health-care spending on workers’ W-2 forms. Both were stymied by an odd-bedfellows alliance of employers and unions.

[11]
It’s not too late, though. Perhaps the easiest way to dramatize the issue for workers would be to attach health-care costs to each paycheck. If employers listed the cost of health care alongside the bite taken by payroll taxes, it would be much clearer to workers that health-care coverage was coming out of their wages, not out of their employer’s largess. That, at least, could help them see the costs of the system more clearly, which is, unfortunately, something that all the congressional debate isn’t helping anyone do.





2009-12-08-NYT-Grassley-requests-payola-data
Grassley Seeks Details on Medical Financing
By GARDINER HARRIS
New York Times, 2009-12-08

[Payola]

[1]
A top Republican senator, Charles E. Grassley, has sent letters to
the American Medical Association, the American Cancer Society
and 31 other disease and medical advocacy organizations
asking them to provide details about
the amount of money that they and their directors
receive from drug and device makers.


[2]
Such financing amounts are often considered proprietary
by the organizations and their directors,
but critics contend that
the industry’s sway over such groups
leads them to lobby on the industry’s behalf.

...

[6]
The letter is part of Mr. Grassley’s long-running investigation into
the influence of drug and device makers on the practice of medicine.
Mr. Grassley, an Iowa Republican, has also long been interested in
how charities get and spend their tax-deductible contributions.

...

[8]
Earlier this year,
Mr. Grassley sent a similar letter to the National Alliance on Mental Illness.
The group told the senator that
more than two-thirds of its donations came from the pharmaceutical industry.
In response to the disclosure,
Dr. H. Richard Lamb resigned from the group’s board.

[9]
Dr. Lamb joined the board of the organization in 2005,
when he was “shocked to learn that
approximately half of NAMI’s income
comes from the large pharmaceutical companies,”
he wrote in a resignation letter that Mr. Grassley made public.
Alliance officials assured Dr. Lamb that the situation would change.
“However,” Dr. Lamb wrote,
“very little has changed, right up to the present day.”
In an interview, Dr. Lamb said that NAMI’s dependence on the drug industry
made some actions impossible.
For instance, Dr. Lamb said that NAMI should consider warning against
the use of some mental health drugs with life-threatening side effects.
But Dr. Lamb said the organization
could not consider such a move
because it could threaten much of its financing.


...



















2010


2010-01-05-WP-Lane-diagnostic-creep
Health reform skepticism, Part I
by Charles Lane
Washington Post Blog, 2010-01-05

[0]
To the list of reasons
Congress may find it difficult to rein in health-care costs,
add “diagnostic creep.”

[1]
Step One:
Society medicalizes imperfections
that formerly were either not defined as disease
or thought to be too minor and/or too intractable for treatment.
Rambunctiousness becomes attention deficit disorder;
impotence becomes erectile dysfunction;
snoring becomes a symptom of sleep apnea.

[2]
Step Two:
Scientists discover treatments;
government approves them;
companies market them;
physicians prescribe them;
patients demand them.

[3]
Step Three:
Disease definitions expand to encompass more marginal cases and treatments
and testing expand to deal with more nuanced symptoms.
Ritalin gives way to time-released stimulants;
Viagra gives way to Cialis;
sleep apnea comes in three varieties, mild, moderate and severe,
identified through millions of dollars worth of high-tech sleep studies.

[4]
NPR’s Alix Spiegel recently broadcast a fascinating piece
about the campaign by Merck, the pharmaceutical giant,
to expand use of its bone-strengthening drug Fosamax.
The company’s effort involved
urging doctors to treat patients not only for osteoporosis
but also for a milder form of bone loss known as osteopenia,
which is common among middle-aged women.
Encouraged by Merck, doctors began to think of it
not as a natural aspect of aging
but as a possible precursor to osteoporosis and fractures.

[5]
Merck also helped doctors get bone-scan machines in their offices
so that they could test women for osteoporosis and osteopenia.
And the company lobbied Congress to get Medicare to reimburse for the tests.
Alerted by their friends,
women themselves began asking for the tests and the pills.
Result: Medicare claims for screening exams
rose from 77,000 in 1994 to more than 1.5 million in 1999,
according to Spiegel’s report, and Fosamax prescriptions soared.
By November 2007,
Fosamax was one of the 100 most frequently dispensed drugs in the U.S.,
with annual sales of about $1.7 billion.
(A generic version became available in 2008,
so the national Fosamax bill is now likely to decline.)

[6]
Diagnostic creep sounds bad, but it obviously can be very good.
Many children (and adults) have been helped by
increased awareness of ADD
and other previously unrecognized psychiatric conditions;
drugs can indeed resolve their symptoms.
Lord knows Viagra and its imitators have improved many lives.
[Wimps!]
People who don’t snore get better sleep;
they’re at diminished risk for conditions such as high blood pressure;
they produce more at work;
they are more alert behind the wheel.
As Spiegel’s balanced piece notes,
Merck claims Fosamax helped many people prevent bone loss
that could have led to even costlier problems.
Who am I, or anyone else, for that matter,
to draw the line between mere osteopenia and truly dangerous osteoporosis?

[7]
But that’s just the point.
Health-care cost containment is all about line drawing,
about separating the problems that are dangerous enough to warrant coverage
from those that aren’t.
Americans have become accustomed to the opposite of line drawing.
In large part because someone else -- insurance -- picks up a lot of the tab,
they have been habituated to
consuming more and more life-improving treatments.
Indeed, they’ve come to feel entitled to do so.

[8]
The health-care legislation being negotiated proposes
measures to deal with spiraling costs --
including an excise tax on “Cadillac insurance plans”
and a government panel to define what works best medically.
I suppose those will have an impact.
But to the extent they do, it can only be by
pushing back against the public’s sense of entitlement.
Comparative-effectiveness studies can inform the discussion -- up to a point.
We’ve already seen the blowback against one that suggested
many mammograms are unnecessary or counterproductive.
Is the government going to stop covering bone-density tests,
much less tell women with osteopenia that insurance can’t cover their Fosamax?
I’ll believe it when I see it.


2010-01-12-NYT-Leonhardt-Prescriptions
‘Big Government’ Health Care
By DAVID LEONHARDT
New York Times Economix Blog, 2010-01-12

[1]
The federal government released its latest estimates of health spending last week, and they allow for some telling comparisons.
In 2008, the United States spent $2.3 trillion on medical care,
or 16.2 percent of gross domestic product and $7,681 per person.

[2]
Of this $2.3 trillion,
the federal government spent $817 billion, while
state and local governments spent $290 billion.
The tax exclusion for employer-provided health insurance amounted to
about $250 billion in lost federal revenues—
which is effectively, a government subsidy for health care.
Add up all of these sources, and you get
about $1.35 trillion of health spending done by the public sector and
slightly less than $1 trillion done by the private sector.

[3]
In per-person terms,
government agencies spent roughly $4,500 on medical care, while
the private sector spent roughly $3,100.

[4]
Here is what is notable about that $4,500 figure:
It is more than what a lot of other rich countries spend on health care—
including both the public and the private sectors.
All told, Belgium, Canada and Germany each spend
about $4,000 per person on health care.
Australia and Britain spend about $3,400 each.
Japan spends a little less than that.

[5]
These calculations were done with help from
the Commonwealth Fund and the Kaiser Family Foundation.



2010-01-22-NYT-Prescriptions-Herszenhorn-rising-costs
The Health Care System Without Change
By DAVID M. HERSZENHORN
New York Times Prescriptions Blog, 2010-01-22

Here’s what has not changed about the health care system in America.

According to the nonpartisan Congressional Budget Office,
by 2019 there will be
54 million people in the United States without health insurance (PDF).

The chief actuary of the federal Centers for Medicare and Medicaid Services,
says it will be even worse:
57 million people without insurance (PDF).

In 2017, just seven years from now,
the Medicare hospital insurance trust fund will be exhausted.
Empty. Dried up. Done.


Total national expenditures on health care will continue to soar,
according to the chief actuary,
to $4.7 trillion in 2019 from $2.6 trillion today.

The average cost of an employer-sponsored family health insurance policy
will rise to $20,300 in 2019, or about $10,000 more than today,
consuming an ever growing portion of family income
and continuing to put downward pressure on wages (PDF)
.

...



2010-02-04-AP-Feds-to-pay-more-than-half
Report: Feds to pay more than half of health costs
By RICARDO ALONSO-ZALDIVAR
The Associated Press (at washingtonpost.com), 2010-02-04

Federal and state programs will pay slightly more than half the tab
for health care purchased in the United States by 2012,
says a report by Medicare number crunchers released Thursday (02-04).

That's even if President Barack Obama's health care overhaul
wastes away in congressional limbo.
Long in coming, the shift to a health care sector dominated by government
is being speeded up by the deep economic recession
and the aging of the Baby Boomers,
millions of whom will soon start signing up for Medicare.

...



2010-03-10-NYT-Ablin-PSA-prostrate-overscreening
The Great Prostate Mistake
By RICHARD J. ABLIN
New York Times Op-Ed, 2010-03-10



2010-03-10-NYT-Leonhardt
Health Care’s Obstacle: No Will to Cut
By DAVID LEONHARDT
New York Times, 2010-03-10

[1]
For anyone who cares about medical costs — which is to say anyone who cares about the take-home pay of American families or about the budget deficit — President Obama’s health reform plan is a terribly mixed bag.

[2]
It does so much less than the ideal plan would do. It would not come close to eliminating Medicare’s long-term budget deficit. It would reduce that deficit only if a future Congress did not tinker with the various taxes and spending cuts scheduled to be phased in over the next decade.

[3]
On the other hand, the plan would make progress in all sorts of areas. Insurance exchanges would create more competition. A Medicare oversight board would gain authority over reimbursement rates. Hospitals that committed certain medical errors — harmful, costly errors — would face financial penalties.

[4]
So which matters more: what the plan does, or what it fails to do? It’s a tough call, and the answer depends on what you see as the alternative to the current plan.

[5]
If the past year of health care debate has offered a single lesson, it’s that the politics of cutting costs are miserable. We pay for most of our health care indirectly, through taxes or paycheck deductions, which lulls us into thinking that the care is somehow free. As the Stanford economist Victor Fuchs notes, many Americans say they want to control costs — but oppose just about any policy to do so. It should be no surprise that politicians do the same.

...



2010-04-07-Leonhardt-power-of-no
In Medicine, the Power of No
By DAVID LEONHARDT
New York Times, 2010-04-07

How can we learn to say no?



2010-06-06-NYT-Metrics-Health-Spending-vs.-Results
Health Spending vs. Results
by HANNAH FAIRFIELD
New York Times, 2010-06-06





















2011


2011-10-17-Samuelson
Why our children’s future no longer looks so bright
by Robert J. Samuelson
Washington Post Opinion, 2011-10-17

“A decade of health care cost growth
has wiped out real income gains for an average U.S. family,”

report two Rand Corp. researchers in the journal Health Affairs.
From 1999 to 2009,
total compensation of a typical four-member family with employer-paid health insurance
rose by $23,000.
About 95 percent of this (almost $22,000) went to inflation and health care,

including employer costs, family premiums, out-of-pocket payments and taxes.
For most families, higher costs didn’t deliver parallel benefits.
The reason:
Health spending is concentrated;
the sickest 5 percent account for half the total.

...

Generational gains tempered individual setbacks.
We may now lose this comforting cushion.
Our leaders might try to avoid that by boosting economic growth,
controlling health spending and trimming benefits for the elderly.
But we aren’t sure how to do the first
and lack the political will to do the second and third.
The future is never entirely predictable,
but downward mobility is not just a scary sound bite.
It’s a real possibility.






































2012

2012-05-21-WP-Aizenman-data-trove-may-shed-light-on-health-care-uncertainties
Data trove may shed light on health-care uncertainties
By N.C. Aizenman
Washington Post, 2012-05-21

How much do hospitals and doctors actually charge insurers for their services?
How much and which of those services are privately-insured patients using?
And, most significantly,
what drives changes in health-care use, costs, and total spending?

They are among the most vexing questions in American health care.
And a recently amassed trove of data from insurance companies
could soon shed new light on them.

Compiled by the non-profit, non-partisan Health Care Cost Institute,
the database will allow researchers to slice and dice
more than 3 billion medical claims for more than 33 million individuals
in search of answers.

...



2012-08-24-WP-matt-miller-the-real-medicare-villain
The real Medicare villain
By Matt Miller
Washington Post Op-Ed, 2012-08-24

[This is really an excellent column.
Mr. Miller has been publishing excellent work.]


[1]
Republicans cry that President Obama
is raiding Medicare to fund a socialist health-care nightmare.
Democrats blast the GOP for
sticking grandma with vouchers
to wreck a program they’ve secretly loathed for decades.
Far be it from me to put the kibosh on all this drama,
but when it comes to the policy stakes,
such breathless charges are beside the point.

[2]
The real Medicare villain is not Barack Obama,
and it’s not even “evil” Paul Ryan.
The real villain is America’s medical-industrial complex
and once you grasp this, everything changes.

[3]
The beginning of wisdom on Medicare’s future starts with
two things both parties say
but which can’t simultaneously be true.


[4]
The first is that
we spend much more on health care than any other advanced nation
yet get no better results.

The second claim —
implicit in the attacks on Obama’s $716 billion in “cuts”
or on Romney/Ryan’s heartless vouchers —
is that,
if we do much to slow the growth of health-care spending,
we’d hurt seniors’ access and quality of care.


[5]
As I’ve argued before, no matter how often and how loudly
interest groups and politicians scream this second claim,
it can’t be true if the first claim is a fact.
And U.S. health care’s inefficiency is indisputable.

...



2012-11-28-WP-Miller-propose-Romney-chair-commission-on-health-care-costs
Mitt on the menu
by Matt Miller
Washington Post Blog, 2012-11-28

I don’t know whether Emily Post has any tips
for breaking the ice over lunch with your just-vanquished foe.
But I have just the thing if President Obama was serious about
asking Mitt Romney to “work together to move this country forward.”

Romney was once a world-class management consultant
with a legendary appetite for “the data.”
His private-equity success was due partly to
his knack for identifying and purging inefficiencies
from bloated, underperforming enterprises.
It’s time, therefore, to set him loose (analytically speaking)
on the mother of all domestic challenges:
America’s radically inefficient health-care system.

Outsize U.S. health costs have killed wage growth, wrecked public budgets
and diverted trillions in resources from other purposes.
They also warp every aspect of public debate —
for example, in today’s “fiscal cliff” standoff,
the fact that both parties are scared to shave Medicare’s growth
ignores the fact that, compared with every other rich country on Earth,
we already spend vastly more on each senior
than is needed for high-quality care.

As can never be said often enough,
we spend 17 percent of our gross domestic product on health care
while most nations
in the Organization for Economic Cooperation and Development
spend around 11 percent with similar outcomes
(and mighty Singapore spends just 4 percent).
The political problem, of course, is that
every dollar of health-care “waste” is someone’s dollar of income.
To reframe the debate, we need an authoritative analysis that
identifies exactly what’s driving our costs so much higher than everyone else’s
as well as a set of lessons we can learn from
the nations that do more (including insure everyone) with much less.

Hence Mitt’s new mission, if he’ll accept it.
Obama should convene a presidential commission on national health costs,
to be chaired by Romney
and filled with leaders from every part of the sector
(plus other relevant experts).
The president would propose a new national goal:
Instead of letting health-care spending rise toward
20 percent or more of GDP in a decade,
America should aim to reduce health spending by, say, 3 percent of GDP
while maintaining or improving quality and outcomes.

Romney’s commission would have three deliverables. It would
explain in detail the sources of difference between our outsize spending,
the OECD nations’ average and Singapore’s;
identify the major lessons and best practices
on how others achieve more cost-effective systems of care; and
identify options and scenarios that could move us toward
these international benchmarks.
The potential impact on every sector of the provider community
would be laid out.

One more thing:
While acknowledging the perspective each commissioner brings
given his or her professional role,
Obama and Romney together would ask them
to step beyond parochial concerns to address these questions
in the context of the broader national interest.
Seriously.

This can be tweaked, but you get the idea.
Done right — and by experience and temperament,
Mitt Romney is arguably better positioned than anyone in the country
to lead such an effort —
the Romney Report could transform the debate.




























2013

2013-01-08-Samuelson-health-care-spending-remains-a-fearsome-foe
Taming the health-care monster?
by Robert J. Samuelson
Washington Post Op-Ed, 2013-01-08

Are we finally controlling health spending?
Few issues loom larger in the economic outlook.
For years, spiraling health costs —
mainly for Medicare and Medicaid, which serve the elderly and the poor —
have consumed a growing share of the federal budget.
Meanwhile,
rapid increases in premiums for employer-provided insurance
have squeezed take-home pay.
So it’s good news that, for the third straight year,
health spending rose modestly in 2011.
To some analysts, this signals a new era of cost-containment.
Well, maybe — and maybe not.

...

Hospitals, doctors and medical suppliers are frightened.
They recognize that the free flow of money into health care won’t continue.
Government will limit reimbursements and spending;
the ACA already cuts hospital reimbursement rates
and requires deeper discounts from drug companies for Medicaid.
Anticipating a stingy future, providers are starting to restrain costs.
That’s the theory.

...

Of course, all this may be wishful thinking.
Slower health spending may be a blip.
The CMS study says the main cause is the weak economy.
People lost insurance and, as a result, use less medical care.
They go to doctors’ offices less often, delay elective operations
and skimp on drugs.
From 2007 to 2010, private insurance coverage dropped by 11.2 million;
although Medicaid enrollment rose by 7.5 million,
the number of uninsured still increased by 7 million.
Even the insured may skip care in tough times
to avoid deductibles and co-payments.

A stronger economy may accelerate health spending.
In past recessions, spending and insurance coverage weakened.
Once the economy recovered, spending rebounded.
This could happen now.

Two other trends also suggest higher spending.
First, Obamacare’s main provisions take effect in 2014;
an estimated 30 million or more uninsured Americans may get coverage.
Susan Dentzer, editor in chief of Health Affairs, notes that
the uninsured use about two-thirds of the health services
that the insured use (costs are often shifted to others);
as the newly insured use more health services,
spending could rise significantly.
The second trend:
Aging baby boomers are entering their sickest years and Medicare eligibility.

Indisputably, health care remains an economic monster.
In 2011, its spending totaled $2.7 trillion,
or $8,680 for every man, woman and child in America.
What happens next is anyone’s guess.
But don’t bet that the monster has been tamed.



2013-01-14-WP-Lane-shining-a-light-on-medicare-payments
Shining a light on Medicare payments
by Charles Lane
Washington Post Op-Ed, 2013-01-14

[What Mr. Lane points out here is both highly significant and highly surprising.
I, and I am sure, many other people have wondered
just why per-capita, inflation-adjusted, Medicare benefits
have gone up so much.
I certainly thought the basic facts about
what Medicare is spending money on
would be known to those who specialize in covering such topics,
if not to me.
But Mr. Lane's article says that is not the case.
The emphasis is added, and also some comments.]


Now costing more than $500 billion per year,
Medicare is central to the United States’ fiscal predicament.
For this complicated problem,
there are many complicated proposed solutions.

But what if we try something simple, like journalism?

In essence, that is the argument that Dow Jones,
publisher of the Wall Street Journal,
is pressing in a federal court in Jacksonville, Fla.
Dow Jones is asking District Judge Marcia Morales Howard
to lift a 1979 court order that
exempted from the Freedom of Information Act
all provider-specific data on Medicare payments.

Arguments ended in August, and a ruling could come at any time.

Thanks to the 33-year-old injunction,
the press and the public cannot examine
the treatments individual physicians billed to Medicare
or — most important — how much Medicare paid for them.

Yet this is a matter of obvious public concern,
given that Medicare made $28.8 billion in improper payments in 2011,
according to a Government Accountability Office report last February.

Media coverage could be a powerful weapon against waste, fraud and abuse,
Dow Jones argues — plausibly, given the Journal’s recent work.

In 2009, Dow Jones and the nonprofit Center for Public Integrity
sued the Department of Health and Human Services
for access to its database of physician fee-for-service claims.
HHS resisted but ultimately agreed
to supply a small portion of its information
in return for a fee
and a promise not to reveal individual physicians’ names.

Even with those limitations,
the Journal produced articles in 2010 and 2011 documenting
many millions of dollars’ worth of
excessive spinal­fusion surgery,
questionable prostate-cancer treatments and
dubious billing for home health-care services.

More irregularities might turn up if all journalists
could comb through Medicare’s records using data-mining techniques.
And imagine how many irregularities would be deterred
if providers knew that they might be named and shamed.

Doctors, of course, see a threat to privacy —
theirs, not patients’,
since patients would not be identified no matter how a lawsuit turns out.
“Privately employed individuals have a substantial interest in
the privacy of their personal financial information,
including their income,”
the American Medical Association argued in its brief to the court.

[This really is a gray area.
Physicians may be in some sense privately-employed,
but when they are billing Medicare
they are expecting the public, i.e., the government,
to pay them.
In a sense, Medicare is then their employer.]


The doctors warn of “deleterious effects on the physician-patient relationship.”
One physician affidavit avers that
“it would undermine my ability to care for my patients
if they think that I might be prescribing” a particular therapy
“for the money rather than for their well-being.”
Public disclosure of Medicare billing
would increase such purported misconceptions,
because non-experts can’t interpret the data accurately,
the doctors claim.

How paternalistic can you get?
Information about doctors’ incentives
might in fact empower health-care consumers,
as it generally does in other markets.
Surely patients who got some of the 276 spinal fusions performed by a single Midwestern surgeon in 2008
would have wanted to know, as the Journal reported,
that the doctor received
more than $400,000 in payments from spine-device makers.

Privacy was the doctors’ argument in 1979,
when they first sought, and won,
a permanent injunction to stop a Carter administration plan
to disclose Medicare reimbursement data.

Though issued by a single Florida district court,
the injunction applied nationwide and can be lifted only if
the court that imposed it finds, in essence,
that times have changed.

[Interesting that it is Florida court,
where such a high percentage of the population receives Medicare benefits.]


They have:
Medicare cost a mere $37.4 billion in 1980.
For that reason alone, the nation’s interest in cost control today
far outweighs doctors’ interest in billing secrecy.
Sens. Charles Grassley (R-Iowa) and Ron Wyden (D-Ore.) agree
and have introduced legislation to overturn the injunction,
though their bill is moving slower than the Dow Jones lawsuit.

[Why is that?
Congress surely has an interest in controlling excessive Medicare spending.
But Congress seems highly reluctant to do much in that direction.
There often is a cry for transparency in many things which affect out lives.
Why is there not much of an outcry for transparency on
where the Medicare dollars go?]


In a way,
it’s too bad that Dow Jones framed its case
as a matter of fighting fraud.
It is indeed that.
But the vast majority of providers are honest.

Still, doctors’ resistance to disclosure illuminates
the mentality bred by a system of
open-ended public financing on the one hand and
private provision of fee-for-service care on the other.

The latter creates powerful incentives to exploit the former,
yet it is often legal to do so.
Congress can only partially counteract this design flaw
by limiting reimbursement rates and other expedients.
And while Medicare makes sense, sort of,
to those who must deal with it on a daily basis,
who knows how the public would react
if people could see, in detail,
how the system really works?


Fuller disclosure about Medicare could help curb abuses.
Even more important,
it might inform a debate about
why Medicare spending keeps rising
even when everyone does follow the rules.

[Mr. Lane really deserves commendation for raising this issue.
I wonder why all the liberals in the media have not.
Can it be that they really have no interest whatsoever in controlling spending
in the areas in which they, and their relatives and friends, make a profit?
Controlling defense spending and farm subsidies
seems the extent of their interest in cutting spending.
But, as I implied above, many of them and their circle
either work in or profit from spending on education and health care.
Seems to be a conflict of interest within the left wing classes,
between their responsibility (one would think) to control spending
and their desire to achieve a profit.
In the famous slogan of Washington leftists, they
"Do well by doing good."
But at the expense of the federal budget, the federal deficit, the federal debt,
and thus future generations, including their own children.]



2013-01-16-Samuelson-in-health-were-not-no-1
In health, we’re not No. 1
By Robert J. Samuelson
Washington Post Op-Ed, 2013-01-16



2013-07-20-WP-Whoriskey-how-a-secretive-panel-uses-data-that-distorts-doctors-pay
How a secretive panel uses data that distort doctors’ pay
By Peter Whoriskey and Dan Keating
Washington Post, 2013-07-20

[This is an extremely important article on an extremely important subject:
why health care costs so much more now than it used to.]


When Harinath Sheela was busiest at his gastroenterology clinic, it seemed he could bend the limits of time.

Twelve colonoscopies and four other procedures was a typical day for him, according to Florida records for 2012. If the American Medical Association’s assumptions about procedure times are correct, that much work would take about 26 hours. Sheela’s typical day was nine or 10.

“I have experience,” the Yale-trained, Orlando-based doctor said. “I’m not that slow; I’m not fast. I’m thorough.”

This seemingly miraculous proficiency, which yields good pay for doctors who perform colonoscopies, reveals one of the fundamental flaws in the pricing of U.S. health care, a Washington Post investigation has found.

Unknown to most, a single committee of the AMA,
the chief lobbying group for physicians,
meets confidentially every year to come up with values
for most of the services a doctor performs.

Those values are required under federal law
to be based on the time and intensity of the procedures.
The values, in turn,
determine what Medicare and most private insurers pay doctors.

But the AMA’s estimates of the time involved in many procedures are exaggerated,
sometimes by as much as 100 percent,
according to an analysis of doctors’ time,
as well as interviews and reviews of medical journals.

If the time estimates are to be believed, some doctors would have to be averaging more than 24 hours a day to perform all of the procedures that they are reporting. This volume of work does not mean these doctors are doing anything wrong. They are just getting paid at the rates set by the government, under the guidance of the AMA.

...

2013-07-24-WP-Whoriskey-bill-aims-to-reshape-medical-pricing
Bill aims to reshape medical pricing
By Peter Whoriskey
Washington Post, 2013-07-24

A bipartisan group of legislators has drafted a bill that would reshape the way the nation pays doctors, responding to criticism that the nation’s method of valuing medical procedures misprices payments.

The pricing system, used by Medicare and most private insurers, depends upon assessments made by the American Medical Association, the chief lobbying group for physicians. In confidential meetings held every year, the AMA assigns values to thousands of services doctors provide.

But some of those values are based on exaggerated assumptions for how long a procedure takes and helps unnecessarily raise the doctors’ fees for those services, a Washington Post investigation found. The Post reported its findings this past weekend.

The values are based “on a one-sided negotiation — doctors negotiating with themselves,” said Rep. Jim McDermott (D-Wash.), a critic of the process who has introduced a separate bill on the issue. “There’s a lot of you scratch my back, I’ll scratch yours.”

The legislation, partly based on proposals from Congress’s Medicare watchdog, would require Medicare officials to collect data such as how much time doctors spend doing procedures. It would reduce the doctor payment for overvalued services. A House subcommittee approved a draft of the bill Tuesday.

The bipartisan group’s focus on mispriced services is part of a much larger bill that also seeks to rescind the complex annual adjustments made to Medicare payments for physicians. Instead, the lawmakers proposed adding regular annual increases to doctor payments and add further incentives based on performance.

A complex set of formulas based on inflation, economic growth and other factors determines the physician payment rate. But each year since 2003, Congress has overridden those formulas, which this year called for a 25 percent cut.

“The old method was a cost-control mechanism that didn’t work," said Miriam Laugesen, a professor at Columbia University’s school of public health who has studied the intricacies of physician pay. “Congress kept choosing to step in. This is a significant break from the past.”

The draft bill would replace the formulas with annual increases of 0.5 percent for the next 10 years and provides further financial incentives for doctors to adhere to best practices. It is, in other words, a version of pay for performance.

The AMA has long sought to undo the current method because the annual changes instituted by Congress are unpredictable and create uncertainty for doctors.

The old method of calculating the payment rate “threatened Medicare annually, sometimes monthly, with large pay cuts that have hobbled physicians’ ability to run their practices and, more importantly, distracted them from their top priority of caring for patients,” said Rep. Fred Upton (R-Mich.), one of the bill’s sponsors. The others were: Rep. Joe Pitts (R-Pa.), Michael C. Burgess (R-Tex.), Frank Pallone Jr. (D-N.J.), Henry A. Waxman (D-Calif.) and John D. Dingell (D-Mich.).

AMA President Ardis D. Hoven issued a statement saying the legislation “represents continued progress, though work remains to be done.”

The AMA has also been contacting legislators trying to defend its valuations after The Post’s investigation found that many of the values placed on procedures are based on flawed assumptions regarding how long those procedures take.

By federal law, the values are supposed to be based on the time and intensity of the procedures. The values, in turn, determine what Medicare and most private insurers pay doctors.

But The Post found that the AMA’s estimates of the time involved in many procedures are exaggerated, sometimes by as much as 100 percent, and that if the time estimates are to be believed, some doctors would have to be averaging more than 24 hours a day to perform all the procedures they are reporting.

Many of the doctors achieving this seemingly miraculous proficiency were gastroenterologists.

In their response to members of Congress and the public, the AMA offered statistics indicating that gastroenterologists perform only six to eight procedures per day on average.

The AMA figure, however, appears to be a daily average. As the data reviewed by The Post show, many doctors primarily schedule their procedures for certain weekdays. It is on those days, not reflected in a daily average, that doctors rack up the high volumes that make the AMA time estimates improbable.

The legislators are clearly concerned about the problem of how doctor services are priced.

“A lack of accurate and meaningful data on costs has hampered the ability of Medicare to review the accuracy of payments for services and identify which services are improperly valued,” according to a fact sheet issued Monday by the House Energy and Commerce Committee.

But McDermott, a physician and longtime critic of the AMA process for setting values, would like to go further in overhauling the system than the current bill.

He has introduced separate legislation that would create a federal advisory committee that would weigh in on the values that determine physician pay — essentially giving the government an alternative to the recommendations of the AMA.

“I’m not anti-doctor,” said McDermott, who once was a practicing psychiatrist. “But there has to be some reality here.”

2013-07-25-WP-Editorial-do-doctors-have-too-much-sway-over-medicare-payouts
Do doctors have too much sway over Medicare payouts?
Washington Post Editorial Board, 2013-07-25

[1]
REPORTERS PETER Whoriskey and Dan Keating have opened Post readers’ eyes to the fact that
Medicare pays for physician services — a $69.6 billion item in 2012 —
according to an arcane and little-known price list,
over which doctors themselves exercise considerable and less-than-totally-transparent ­influence.

[Kudos to them and to the Post for reporting this,
but one should still ask:
Why did it take so long to publicize this important information?]


[2]
Known as the Relative Value Update,
the process consists of
a 31-member committee of the American Medical Association (AMA)
recommending what Medicare should pay for some 10,000 procedures —
with the fees based in part on how long it takes to complete each one.
This time-and-motion study often fails to take full account of changing technology
and other factors affecting physician productivity,
so anomalies result:
For example,
Medicare pays for a 15-minute colonoscopy as if it took 75 minutes.

[3]
Bizarre as this system may seem,
it was considered a reform when first adopted two decades ago;
previously, Medicare paid even vaguer “usual, customary and reasonable” rates.
The health-care market is unlike most others;
it’s inherently difficult to set prices through competition
when consumers are at a huge information disadvantage, relative to providers,
and when insurance, such as Medicare,
shields them from the full costs of their purchases.
The Relative Value Update was an attempt at a second-best solution.

[4]
As its name suggests,
the purpose of the Relative Value Update Committee (RUC)
is not to help decide how much Medicare spends but rather
to distribute funds according to ostensibly objective criteria.
Nor does the committee exercise untrammeled control;
in about 30 percent of recent cases,
Medicare officials refused its suggestions.
The AMA says it will review colonoscopy charges in an April meeting,
and Medicare is scrubbing its price list.

[5]
Even allowing for all of that,
it’s hard to defend a system that, according to the Post story,
pays gastroenterologists as if 41 percent of them
are performing more than 12 hours’ worth of procedures a day.
The RUC has historically favored specialists relative to primary-care physicians,
perpetuating a broader bias in U.S. health care.
Nor is it clear why Congress should privilege the AMA —
which is not only an expert organization but also an interest-group lobby —
with the first say on relative value estimates.

[6]
The Post story provides yet another reason for Congress and the courts
to allow full public access to Medicare’s physician payment database,
which the AMA has historically resisted.
Meanwhile, the House is considering a bipartisan bill
that would require Medicare to collect data on doctors’ time usage
and adjust payments accordingly.
Rep. Jim McDermott (D-Wash.) proposes creating a separate federal advisory committee
as a counterweight to the RUC.

[7]
Even these promising measures would not change
the fundamental issue with relative-value pricing:
It reflects physician inputs — not patient outcomes.
This shortcoming is not unique to Medicare.
In fact, the entire health-care system still operates on a fee-for-service payment model
despite well-documented concerns about its consequences for cost and quality.



2013-07-25-CPI-Schulte-obamacare-oversight-among-health-watchdog-cuts
ObamaCare oversight among health watchdog cuts
by Fred Schulte
Center for Public Integrity, 2013-07-25

Budget squeeze, staff departures force HHS inspector general
to trim investigative targets


...

The cuts are “deeply regrettable,” said Malcolm Sparrow,
a professor at Harvard University’s John F. Kennedy School of Government and health fraud expert.
“We’d save a huge number of taxpayer dollars
by doubling the size of these operations.”


Sparrow said fraud artists are adept at quickly figuring out
how to exploit new health care initiatives
and that officials have an obligation to “stay ahead” of them.
“Otherwise three years from now we’ll be saying,
‘how could we not have predicted this mess?’ ”


Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association,
said that OIG audits not only stem financial losses,
but also can protect patients from harm.
Money spent on these efforts “pays for itself many times over,”
he said in an email.

OIG officials contend their investigations typically return $8 for every dollar invested.
They reported fiscal 2012 expected recoveries of about $6.9 billion
and more than 1,100 criminal and civil investigations of individuals or health care businesses.

...

“OIG will not be able to keep pace with the ACA (Affordable Care Act) expansion,
maintain/expand our highly successful Medicare Fraud Strike Forces,
or keep pace with the expanding Medicare and Medicaid enrollment
and the expected need for growth to combat on-going health care fraud,”
an agency document states.











2014

2014-03-12-WP-Will-drop-in-childhood-obesity-may-be-due-to-better-choices
Better health through good choices
By George F. Will
Washington Post Op-Ed, 2014-03-12

...

A significant portion of America’s health-care bill —
caused by violence, vehicular accidents, coronary artery disease,
lung cancer, AIDS, Type 2 diabetes brought on by obesity,
among other problems —
results from behavior widely known to be risky.
So as we wallow waist deep in the muddy debate about health care,
we should remember that the relationship between
increased investment in medicine and
improvements in health
is complex and tenuous.

As [Leon] Kass has said,
in an era of organ transplants and the cracking of the genetic code,
it seems boring to suggest that
the most important path to health is a vanilla virtue:
prudence.
Nevertheless,
[human beings] are animals that go through their days
making choices.
And they often make bad ones.

Such choices often require ameliorative [i.e., improvement-causing] medicine.
Which illustrates this point:
Although preventive medicine is real,
society’s level of health does not depend primarily on medicine,
which too often must be resorted to
when our behavior has forfeited our health.




2014-04-18-NYT-treatment-cost-could-influence-doctors-advice
Cost of Treatment May Influence Doctors
By ANDREW POLLACK
New York Times, 2014-04-18

Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patient care.

The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.

“We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room,” said Dr. Lowell E. Schnipper, the chairman of a task force on value in cancer care at the American Society of Clinical Oncology.

In practical terms, new guidelines being developed by the medical groups could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment — at the end of life, for example — is too expensive. In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing.

Traditionally, guidelines have heavily influenced the practice of medicine, and the latest ones are expected to make doctors more conscious of the economic consequences of their decisions — even though there is no obligation to follow them. Medical society guidelines are also used by insurance companies to help determine reimbursement policies.

The society of oncologists, alarmed by the escalating prices of cancer medicines, is developing a scorecard to evaluate drugs based on their cost and value, as well as their efficacy and side effects. It is expected to be ready by this fall.

And the American College of Cardiology and the American Heart Association recently announced that they would begin to use cost data to rate the value of treatments in their joint clinical practice guidelines and performance standards.

Some doctors see a potential conflict in trying to be both providers of patient care and financial overseers.

“There should be forces in society who should be concerned about the budget, about how many M.R.I.s we do, but they shouldn’t be functioning simultaneously as doctors,” said Dr. Martin A. Samuels, the chairman of the neurology department at Brigham and Women’s Hospital in Boston. He said doctors risked losing the trust of patients if they told patients, “I’m not going to do what I think is best for you because I think it’s bad for the health care budget in Massachusetts.”

...

Still, some analysts say that
there is a role for doctors to play in cost analysis because
not many others are doing so.

“In some ways,
it represents a failure of wider society to take up the issue,”

said Dr. Daniel P. Sulmasy,
professor of medicine and ethics at the University of Chicago.

Generally,
Medicare is not supposed to consider cost effectiveness in coverage decisions,
and other government attempts to do so
are susceptible to criticism as rationing.
Insurers do perform cost analyses,
but they also risk ire from patients and doctors.

...

The cardiology societies ... plan to rate the value of treatments
based on the cost per quality-adjusted life-year, or QALY —
a method used in Britain and by many health economists.

The societies say that
treatments costing less than about $50,000 a QALY would be rated as high value,
while those costing more than $150,000 a QALY would be low value.

“We couldn’t go on just ignoring costs,” Dr. Heidenreich said.








2014-09-08-WP-the-chart-that-shows-not-just-how-but-why-other-countries-spend-less-on-health-care-than-we-do
The chart that shows not just how, but why other countries spend less on health care than we do
By Jared Bernstein
Washington Post, 2014-09-08












2015

2015-12-15-NYT-interactive-the-best-places-for-better-cheaper-health-care-arent-what-experts-thought
The Experts Were Wrong About the Best Places for Better and Cheaper Health Care
By KEVIN QUEALY and MARGOT SANGER-KATZ
New York Times Interactive, 2015-12-15

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