Michael Wells
by Michael Wells
Thu Jun 25th 2009 at 6:34pm UTC

To Your Health

While most of the focus in the national healthcare debate is over whether to have a public insurance system, the real action is in a couple of other areas. One involves how the local medical community is organized and decides on treatment. The other is whether decisions on treatment will be based on science or on “local practices” and what’s most profitable for the doctors. Both of these will have far more impact on the cost of healthcare than who pays for it.

The social sciences and mental health or addiction treatment are moving to Evidence Based Practices, where a practice is independently evaluated to see whether it has positive outcomes. But doctors and medicine still make decisions on what they learned in school, maybe decades ago, and on what the local practices are when they talk shop at the country club. As a result, people are often overtreated using less effective models.

As discussed below, people are often overtreated and evidence-based practices would provide a mechanism for changing how medicine is practiced, producing better health outcomes and lowering costs. Buzzcut (a frequent commenter on this forum) calls reducing overtreatment “rationing” and argues that it would prevent medical mishaps. Whatever you call it, it’s going to be vital to both controlling medical costs and raising the quality of healthcare in the United States to the level of other industrialized countries.

There are several examples in America of low-cost, high-quality institutions – the Cleveland Clinic, the Mayo Clinic, Kaiser in the Bay Area and Portland, Geisinger in Pennsylvania, Intermountain in Utah. These institutions are organized for efficiency and effectiveness, using different models and serving different populations, but they universally provide excellent care without generating excessive costs. There are also some local communities where doctors and hospitals have organized themselves without an institution – The New Yorker article below talks about Grand Junction, Colorado.

I’ve been a Kaiser member for years and while you do need to learn to work with the bureaucracy, it’s less hassle then coping with Blue Cross. Aside from a co-pay, I never have additional charges nor receive bills or paperwork. All my health records are kept electronically – if during an appointment my doctor orders lab tests, prescribes from the pharmacy, and refers to a specialist, the information is in their records before I leave the exam room (and without the notorious doctor’s handwriting problem.)

The stimulus package dedicated $19 billion to starting to create a national electronic medical records (EMR) system. In the digital age it’s obscene that people get poor treatment because their records are scattered among file cabinets. I recently worked on a collaborative project between a large mental health/substance abuse provider and a FQHC “safety net” primary care clinic. They both have EMR systems, but the softwares aren’t compatible, so they can’t easily share patient information.

This is from the current issue of Time Magazine:

Americans tend to assume that more is better, especially when it comes to the heroic brand of try-everything medicine we’ve watched on ER and House M.D. But overtreatment is a national scandal. It’s bad for our health: with medical errors now estimated to be our eighth leading cause of death, drugs, procedures and hospital stays can be risky (as well as painful, time-consuming and wallet-straining) even when they’re necessary. It’s also bad for the economy: health costs are bankrupting small businesses and even conglomerates like General Motors as well as millions of families. And it’s awful for the country: Medicare is on track to go broke by 2017, and our long-term budget problems are primarily health-cost problems.

They’ve already stuffed $1.1 billion into the stimulus bill to jump-start “comparative effectiveness research” into which treatments work best in which situations. Now they’re pushing to overhaul the entire health-care sector by year’s end, and they’re determined to replace ignorance with evidence, to create a data-driven system, to shift one-sixth of the economy from “that’s what we do here” to “that’s what works.”

And an article in The New Yorker is what started me thinking about this issue. Here are some quotes:

McAllen, Texas is one of the most expensive health-care markets in the country. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee-half as much as in McAllen.

The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies-neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County (McAllen) actually has fewer specialists than the national average. Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.

14 Responses to “To Your Health”

  1. Mike L. Says:

    Quote: “decision is whether we are going to reward the leaders …”
    Michael, what a great statement! At present it is the poor performers who are rewarded with more bed-nights in hospital due to poor post-operative care, more patient procedures (to fix previous deficient patient procedures), more tests to discover what more has gone wrong, more drugs (to counteract the side-effects of incorrectly-prescribed previous drugs), etc.

  2. Buzzcut Says:

    Michael, I’m not the only one calling it rationing. The American people called it rationing in the 1990s when HMOs did it.

    I think that if there is a system to limit “overtreatment”, which will be as heavy handed as anything HMOs did in the ’90s, there will be a second American Revolution. Don’t get between Americans and their doctors.

    My laterst run-in with overtreatment is the ear-nose-and throat specialist my wife foolishly saw for a swollen lymph node and an itchy ear canal. Her primary said that she has something similar to excema in her ear, and the swollen lymph node was because of an infection due to her itching it with a cue-tip (remember kids, never stick anything in your ear smaller than your elbow). Both will take care of themselves with time.

    But that wasn’t good enough for her, so she got a referral. The specialist wants to do a CAT scan of the lyph node and a biopsy of a small lump in her ear!

    I’m agnostic on the CAT scan (what harm can it do, other than to our bank account) but I put my foot down on the biopsy. No unneccessary surgery. There are simply too many risk with drug resistant bacteria, bad anesthesia, etc.

    You really need to use some common sense when it comes to our medical system. It seems like GPs use a little more common sense than the specialists do.

  3. Buzzcut Says:

    BTW, the solution to our cost crisis is multifold:

    1) eliminate the tax break for employer provided health insurance. ALL employer paid health insurance, not just those above some arbitrary threshold.

    2) Require everyone to have at least a low cost catastrophic health insurance plan. The deductible would be very high (like 10% of your income, at least), as would the co-pay above the deductible (start at 50%, and drop from there with every additional dollar spent). This would eliminate health care inflation at the low end, as individuals decide for themselves what to spend their money on and go out and get deals on routine care. Regulations would need to be eased so companies like Target and Walmart could revolutionize the low end.

    3) Once you hit that deductible, you get treated as you would in a managed care plan. The “experts” would be in control. Because you’re talking about stuff like bypass surgery and other things that have high costs, this would be the area for the experts to save a lot of money.

    I think that we should all be realistic about cost savings. Much of the cost in our health system is from consumer demand. Things cost more simply because Americans are wealthy and can afford to pay more. But making health care markets more like any other market will go a long way towards rationing in a way that is acceptable to the average American.

  4. Michael Wells Says:

    Buzzcut,

    Language is important. When you first mentioned medical rationing I assumed you were against it, because to me the word rationing has a negative connotation. Further, I thought I’d disagree with you on the issue. But rationing or reducing overtreatment or using evidence-based treatment could be the same thing. Another example of automatic liberal/conservative assumptions we have about each other. As George Bernard Shaw said, America and England are “Two countries divided by a common language.” Some of the Red State/Blue State divide is certainly in how we use and understand words.

    While there are certainly differing details, I don’t fundamentally disagree with your ideas for cost solutions. As noted in my post, I don’t think cost containment alone is going to do it though. We need to have agreement on medical best practices and they need to be science-based. We need a national conversation on what’s good health care, so that people don’t demand unneeded treatment (let alone overpriced drugs advertised on television). We need to move medical recordkeeping out of the 19th century. And we need to build in a move towards good health practices — for example, Kaiser pays for me to belong to a gym, because it’s in their best financial interests for me to be healthy.

    A few years ago, my wife came within hours of serious surgery before all the doctors involved got together and decided it wasn’t necessary. I’ve got multiple examples of acquaintances who’ve had surgery related problems. So I’m with you there.

  5. Buzzcut Says:

    We need to have agreement on medical best practices and they need to be science-based.

    Yeah, good luck with that. Medicine, while partly science based, is not science. Nobody is doing a double blind experiment on your symptoms.

    Medicine is evidence based, and the evidence is often murky. Costs are clear, but benefits are often not.

    Most of all, medical mistakes are the 8th most common cause of death. Yikes!

    That Taleb guy like to tell people that it wasn’t until the 1980s that the medical establishment saved more people than they killed. Not sure if its true or not, but as with much that Taleb says, it sounds cool!

  6. Buzzcut Says:

    Micael, tying in to your last comment, you say that excercise should be encouraged, but also say that we need science based guidelines.

    Does excerice lead to lower weight? Does lower weight make you healthy?

    The evidence is murky.

  7. Mike L. Says:

    “evidence-based practices”
    I was part of a drug study which discovered that a placebo works better than any of the recognized drugs for one diagnosis. But who wants to be treated with a placebo?

  8. Michael Wells Says:

    Buzzcut,

    Double blind, control group testing is one kind of science for small sample studies like pharmaceutical drug tests, but not the only kind. Large population public health studies of outcomes of numbers of people who have different treatments like surgeries, drugs, etc. are the kind of science needed for making best practices decisions in medicine. Benefits can be clear for high percentages of patients, but not for individuals. As we know, medicine for individuals is partly science, partly art, partly psychology and partly luck.

    Any number of studies show the health benefits of exercise in terms of strength, balance, cardio-vascular health, lower bad cholesterol, better VO2 (oxygen use), less tendency to diabetes and high blood pressure, etc. As you imply, I agree that there’s way too much emphasis on weight as if it were the main indicator of health. Its not something I pay much attention to, but I’m blessed(?) with a fast metabolism.

  9. Mike L. Says:

    Michael Wells writes: “there’s way too much emphasis on weight as if it were the main indicator of health”

    True, “being alive” is the main indicator of health. But “diet and exercise” are cheap and effective. Google: – diet exercise control group – for plenty of medical studies with control groups.

  10. David Albrecht Says:

    I agree. I think the debate in the US over healthcare is framed far too narrowly. While I believe that either a single-payer (full government control) or fully private system (as is done with auto insurance in the US) would be better than the status quo, I think there are tons of problems that ALL need to be addressed:

    1. Terribly inefficient record-keeping
    2. Doctors’ resistance to new science (the “local practices” mentioned above)
    3. Various practices by insurance companies of questionable ethical character, often enshrined in opaque, hard-to-understand contracts
    4. Less emphasis on treatment, more emphasis on prevention
    5. General ignorance of healthy eating practices

    There is no silver bullet here; everything has to change.

  11. Mike L. Says:

    David Albrecht is correct, but some things are easier and cheaper than others. Let’s start with #5 “Healthy eating practices”.

    If the politicians in Washington are serious about our health, they should all, from the President on down, immediately and conspicuously switch to healthy eating practices. Mrs. Obama seems to be well ahead on this – http://obamafoodorama.blogspot.com/ – so now is the right time for Pres. Obama’s “bully pulpit” on the issue …

  12. Michael Wells Says:

    David & Mile L,

    I agree with the above, except I would add that it’s up to all of us, not just the Obamas and not just the politicians. Yes, Michelle is setting a great example and Barack can make speeches on healthy diet.

    But Obama can’t do everything and even if he could, it wouldn’t be the change the country needs. For far too long America has looked for the free lunch, the way to avoid personal responsibility for our actions. Real change happens at the grassroots, small group, family, individual level. Some of this is happening already with books, healthy eating classes, farmers markets and groceries like Whole Foods.

    The politicians in Washington will get serious about our health when we do.

    And Mike L as I’m sure you know, good diet has far more benefits than just weight loss, just as exercise does. My concern about people’s obsession with weight is that if they can lose weight with pills or fad dieting they think that’s all they need and their health will still deteriorate — although maybe slower. And I would add exercise to your #5 above.

    This leads back to an earlier post about social support. For people to change their diet and exercise habits, it helps if they have family and group support. I lucked out in that I’m married to a woman who’s very food-health conscious and a great cook. I’ve also had the same running partner for over 25 years, there are many mornings I wouldn’t get up and on the streets if I didn’t know Kent would be waiting. Without the two of them I’d subsist on hamburgers and say “one of these days I’m going to start exercising.” One of the lessons of the current economic, political, environmental situations is we’re all in this together — not just all 300 million of us, but as groups of individuals.

  13. Buzzcut Says:

    Large population public health studies of outcomes of numbers of people who have different treatments like surgeries, drugs, etc. are the kind of science needed for making best practices decisions in medicine.

    That’s not science. That’s statistics. The reliance on statistics is why the evidence is so murky.

    I think that the reliance on multiple regressions is where the problem lies. Almost by definition, because you can mess around with what variables you control for, multiple regression allows the regressor to almost come up with any result he or she wishes. It’s not science.

    This is not only a problem with public health. Most social scientists there days are Excel jockeys.

    Statistics, of course, have their place. Generally, that’s in a well designed experiment.

  14. Janet Brown Says:

    The private sector and competitive market forces, not the federal government, are the best means to meeting our country’s rapidly expanding health care needs. I’ve been looking for a way to take action and contact our legislators and sign petitions and found some good policy the U.S. Chamber of Commerce backs (here). I don’t have a lot of money or time, but I figure this will help other people do good.