American Medicine: Bad care to the wrong people

Really interesting article.

Yes, you read that right. According to a recent RAND study published in the New England Journal of Medicine, uninsured patients receive only 53.7 percent of the care experts believe they should get—that is, appropriate, evidence-based treatment. But according to the same study, patients with private, fee-for-service insurance are even less likely to receive the proper care. Indeed, among Americans receiving acute care, those who lack insurance stand a slightly better chance of receiving proper treatment than patients covered by Medicaid, Medicare, or any form of private insurance.
How can this be? To answer that question, you need to understand what the insured are actually getting for their health care dollars. One answer: there’s a lot of unnecessary treatment. Dr. Elliot S. Fisher, a Dartmouth Medical School researcher, estimates that 30 percent of all Medicare spending goes for unnecessary operations and procedures. For instance, under Medicare, the per capita cost of treating terminally ill patients in Miami is $50,000 more than the per capita cost of treating equally old terminal patients in Minneapolis, yet the patients in Miami don’t live any longer. The explanation is simply that Miami’s high concentration of specialists and hospitals is overtreating the city’s patients.

Another huge problem with prestigious institutions catering to the fully insured is their general lack of sensible preventative and follow-up care: for example, you might hope that after your high-priced cardiologist performs an unnecessary surgery he will at least follow up by letting you know the benefits of taking aspirin as a way of managing heart disease. Research has shown that for patients with stable angina (occasional chest pain and constriction arising from chronic heart disease), for example, taking a daily low dose of aspirin reduces the chances of adverse cardiovascular events by 33 percent. But Fisher found that in America’s highest-spending hospitals, only 74.8 percent of heart attack victims receive aspirin upon discharge from the hospital, as opposed to 83.5 percent in lower-budget competitors. This may be one reason why survival rates for heart attack victims are actually higher in low-spending hospitals than in high-spending hospitals.
What’s more, these spendthrift hospitals often skip other routine preventative care such as flu vaccines, Pap smears, and mammograms. This general lack of attention to prevention and follow-up care in high-spending hospitals helps to explain why not only heart attack victims but also patients suffering from colon cancer and hip fractures stand a better chance of living longer if they stay away from “elite” hospitals and choose a lower-cost provider instead. Given this reality, it is perhaps not surprising that patient satisfaction also declines as a hospital’s spending per patient rises.
What explains these findings? Remember first what American doctors and hospitals get paid to do. Outside the Veterans Administration and a few staff*‑model HMOs, they don’t get paid to keep and make patients well. They get paid to provide treatments—and that’s a big difference. It means that most American doctors and hospitals have no economic interest in your long-term well-being, while they also have an enormous economic incentive to perform operations and procedures for which Medicare and private insurance pay well. The result is a systematic bias toward the overtreatment of patients—and particularly of those who are well insured—and a simultaneous neglect of prevention and well-being.

They forgot a whole slew of incentives doctors have to provide random unneeded treatments:

  1. Repeat business: No one goes back to a doctor who tells them to sit up straight when they kvetch about back pain. They go to a competitor who tells them they need an operation, because they don’t want to risk a mis-diagnosis .

  2. Keeping their “co-workers” happy: if you tell referred patients that nothing is wrong, other doctors stop referring to you.

  3. Trying out cool new stuff: You don’t get published if you don’t do something new, and, hey, it’d be awesome to try out that sweet looking procedure you saw the other week in JAMA. I’m not kidding on this one, it actually happens. My dad was bragging about this awesome procedure he did the other week, and how he was one of the few doctors who had gotten to.

Paying the bills is damn important, but doctors also have to consider the dangers of losing patients and getting taken out of the loop if they don’t buy into the current system. I’ve no doubt that everyone would be better off if there weren’t so many incentives for doctors to exploit their expert knowledge, but the system’s design precludes experimentation along those lines.

Y’all can thank the Clintons for this. They took a bad situation and made it much, much worse. My Dad – a surgeon – retired early, while still in debt, rather than continue in the medical profession just so he wouldn’t have to put up with this kind of shit.

If we’re gonna start blaming Presidents for the healthcare mess I’ll see you and raise you.

Add in administration costs - an increased amount of paperwork and phone calls. Every week I STILL get a couple of patients who claim they were enrolled into a plan against their will. It wouldn’t be too bad if there were only four or five plans. Instead it’s a dozens of new plans, each with their own procedures, unique forms, and formularies that can change at any time.

The confusion created under Part D for people who have problems remembering their dates of birth cannot be understated. In New York State, the “dual eligibles”, that is those whose income is low enough they qualify for both medicare and medicaid got screwed.

Oh, I can also bitch about insurance companies in general. There’s an interesting figure i’ve seen in Aetna’s financial reports - I forget the name, but it basically refers to the administration costs of the fund:

Premiums - Amount paid to providers - profit taken = “expense ratio”.

I think Aetna’s was around 20%.

This is an interesting report: http://www.citizen.org/documents/AdminWaste.pdf
It quotes 400 billion out of 1600 billion as wasted in administration in 2003.

We need a Microsoft of healthcare to release a directx. Government-backed IT implementation. Standard, negotiated formularies. Commitees that determine the formularies and procedures based on medical cost effectiveness, not kickbacks.

Healthcare run as a for profit business concentrates on providing repeatable, expensive, possibly un-necessary treatments to those who can afford it? Who’d have thought that could happen?

Everyone but conservative capitalist war-mongering rich people?

And despite these enormous costs, America consistently scores worse on fundamental public health benchmarks the comprable first world nations who spend less per capita on health care, such as infant mortality and life expectancy.

I recently read about an interesting study that showed the quality of healthcare in Canada is just as good in most cases and even better in some cases than US healthcare – and Canadians are paying roughly half the cost that Americans do. This is a stark contrast to the doom and gloom stories we repeatedly hear about how much better quality the US healthcare system is compared to Canada’s.

http://wkrn.com/nashville/news/us-healthcare-costly-compared-to-canada/89794.htm

A team of Canadian and U.S. researchers conducted a review of studies comparing American to Canadian health care.

The studies examined the end results in patients treated for different types of diseases, from kidney failure to cancer to various surgical procedures.

They found that the Canadian system provided just as good care at a fraction of the cost.

Canada may even have the edge in quality as 14 studies favored the Canadian system, and just five favored the United States.

The remaining 19 studies found no overall difference.

The United States far outstrips Canada on health care spending. U.S. per capita health care costs totaled over $7,000 in 2006, more than double Canadian costs.

Canada also has universal healthcare, while the U.S. still has more than 45 million people without health insurance.

http://www.cbc.ca/health/story/2007/04/18/health-canada-us.html

“In looking at patients in Canada with a specific diagnosis compared to Americans with the same diagnosis, in Canada patients had at least as good an outcome as their American counterparts — and in many situations, a better health outcome,” said one of the 17 authors, Dr. P.J. Devereaux, a cardiologist and clinical epidemiologist at McMaster University in Hamilton.

“And that is important because in the United States, they’re currently spending a little over $7,100 per individual on health care annually, whereas in Canada we’re spending a little over $2,900 per individual annually,” he said in a telephone interview from Brantford, Ont.

Canada is a good example. For cardiology for example: My uncle had a heart attack a couple of years ago. He waited five weeks for a stress test. Go back home, take some aspirin, diovan, whatever. In the USA you’d do a stress test, maybe a nuclear stress test by the end of the week. The exact amount varies but that’s at least a thousand bucks.

The USA is very aggressive when it comes to caths. They put a camera in a tube to see how blocked off the heart is. Playing video games before the procedure helps (NYU/Cornell). If it’s blocked off they put little ballons to clean it up [bold]angioplasty[/bold]

Very cool stuff. Yet they rarely do this in Canada and the mortality is the same or better.

Two other factors not previously mentioned driving up costs:

  1. Payment is conmesurate to the “cost” of providing the service, not with the amount of time spent. New medical equipment, cutting edge stuff, all drives up costs. Back in 2000, a five-year old ultrasound machine cost about $60k (resale value now $2k on ebay).

  2. Repeating Aeon’s point:

if you tell referred patients that nothing is wrong, other doctors stop referring to you.

  1. Ignorant/panicky patients: This is best illustrated with antibiotics. People show up with cold symptoms, feeling miserable and they want you to fix it. What do you mean you can’t do anything? Give me antibiotics! (Antibiotics only help if it’s bacterial. Usually it’s viral, in which case drink water.)

Say a PCP bills for 4 15 minute visits. Average reimbursement for medicare is $43. That’s $176 an hour. Compare that with a thallium stress test. That’s $1000 over six hours. However, the physician doesn’t really have to be there but a fraction of that time.

  1. Device and drug marketing “reps” push the newest, high-margin products.

The interesting thing about most medical studies I’ve seen is they are shy about socioeconomic breakdowns (thought they are recently trying to explore how different ethnicities and genders respond to drugs). Taking the infant mortality between the USA and say, Canada. How many of them were parents taking drugs? How many people receive decent prenatal care who work at McDonalds?

Around this neighborhood, people who work at Sharro’s (fast food) have the DECENT jobs. They actually get health insurance and minimum wage. I’d be very interested to see data specific to New York City, because I don’t believe for a second these people can be getting decent preventive care. There’s people who can’t read nutritional labels to pick the lowest cholesterol, for example.

I think what’s interesting about this study is that it applies to the people who do have the money. Everyone already knows about those 45 million uninsured Americans dragging down the averages. What’s new is that even people who have money and should, intuitively, be getting the best possible care, aren’t.

I have access to the NEJM archives so I’m going to search for that article. No luck so far. It’s pretty spectacular claim. Aren’t people supposed to cite or give a way to find the article?

Two things i wonder:
Isn’t RAND a right-wing think tank? What’s their angle, don’t worry you uninsured, you’re getting even better care. Second thing, the sicker patients tend to be sent/go to the bigger, “better” hospitals.

Another factor forgot to add in overuse of procedures - fear of lawsuits and covering your ass.

Rand is basically Washington establishment - good government, process, etc. They were somewhat liberal back in their heyday, at the same time they were sucking down money to do giant piles of military analysis for end of the world nuclear exchanges.

I think the article is here. Googling for “new england journal medicine rand” shows a bunch of ones that might be it too.

Piles and piles of further data.

Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The Commonwealth Fund, May 2007, by K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea: Overview Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report—an update to two earlier editions—includes data from surveys of patients, as well as information from primary care physicians about their medical practices and views of their countries’ health systems. Compared with five other nations—Australia, Canada, Germany, New Zealand, the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives. The U.S. is the only country in the study without universal health insurance coverage, partly accounting for its poor performance on access, equity, and health outcomes. The inclusion of physician survey data also shows the U.S. lagging in adoption of information technology and use of nurses to improve care coordination for the chronically ill.

I don’t doubt the over-riding theme of the thread, but man, two and a half of the five categories in that study were based on universal health care: equity (people w/o insurance don’t go when they’re sick), access (people w/o insurance do go when it’s expensive), and efficiency (based in part on national expenditures and admin costs). Throw any country w/o national health care in there and they fare about the same in those categories, I’d wager.

There may be some truth to this. My aunt died after a lung transplant for inherited emphysema at Houston Methodist. They kept her, a lung transplant patient, in a post-op room with 5 or 6 others, with only a thin sheet between them. When a nurse checked her temperature and ordered a xray, the staff nurse overrode her and insisted she didn’t need it. Pleurisy and pneumonia set in and she died about a week later.

While they washed their hands of the case and did not bill anything to the family, it just seemed like they did several, basic, common sense things wrong, especially for the cost and sophistication of the operation.

Wow, I guess Desslock is right, Canadian healthcare does pretty much suck.

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

Access: Not surprising—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost, but if insured, patients in the U.S. have rapid access to specialized health care services. In other countries, like the U.K and Canada, patients have little to no financial burden, but experience long wait times for such specialized services. The U.S. and Canada rank lowest on the prompt accessibility of appointments with physicians, with patients more likely to report waiting six or more days for an appointment when needing care. Germany scores well on patients’ perceptions of access to care on nights and weekends and on the ability of primary care practices to make arrangements for patients to receive care when the office is closed. Overall, Germany ranks first on access.

Efficiency: On indicators of efficiency, the U.S. ranks last among the six countries, with the U.K. and New Zealand ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of the use of information technology and multidisciplinary teams. Also, of sicker respondents who visited the emergency room, those in Germany and New Zealand are less likely to have done so for a condition that could have been treated by a regular doctor, had one been available.

Equity: The U.S. ranks a clear last on all measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick, not getting a recommended test, treatment or follow-up care, not filling a prescription, or not seeing a dentist when needed because of costs. On each of these indicators, more than two-fifths of lower-income adults in the U.S. said they went without needed care because of costs in the past year.

Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives. The U.S. and U.K. had much higher death rates in 1998 from conditions amenable to medical care—with rates 25 to 50 percent higher than Canada and Australia. Overall, Australia ranks highest on healthy lives, scoring first or second on all of the indicators.

I’m a huge passionate proponent of some type of universal health care in the U.S., but most of the reading on the topic over the last 10 years has not indicated that America has crappy quality of health care - in fact, while there are always anecdotal stories, most non-biased (i.e., not funded by insurance companies or others with financial or political stakes in the results) studies in the past have indicated just the opposite. I do know when we lived in states near the Canadian border the better hospitals constantly had Canadians coming across for more advanced diagnostics and treatments unavailable to them, or not available within a reasonable time frame. On the anecdotal side, when I was working for a multinational company some years back a scientist I knew in our Canada division had his father die of cardiac problems while he was on a 6 month wait list for some cardiac testing which, apparently, would have revealed a very treatable problem.

I suppose the other anecdotal item that makes me ponder a study such as this is so many wealthy people from other countries who come to the U.S. for treatment. When my wife worked at Cleveland Clinic it seemed a pretty regular occurrence for some Saudi prince or British entertainer to fly in for advanced treatment.

I’d like to see the data in a more raw form: when you make conclusions such as higher death rates than Canada or Australia, it makes me wonder what other factors are being accounted for or ignored.

I think you’re focusing on the wrong thing. I don’t know anyone who says that you can’t get high quality medical care in the US. In fact, it’s well known that if you have a very serious condition that requires a specific operation and money, the US is definitely the place to be. However, when you have a condition that does not require surgery, non-fatal conditions and so on that show up on general surveys of “health”, it seems the lack-luster general situation in regards to insurance, getting paid by treatment ordered, strong advertising by drug companies, poor preventative care and other boring, run-of-the-mill stuff adds up to an unnecessarily expensive and unreasonably low level of care.

So if you have money, and in need of a specific operation, then going to the US works just as well, or better, than any other alternative.