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Good Article in Today's NY Times
Old 06-06-2007, 09:46 AM   #1
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Good Article in Today's NY Times

NY Times article on healthcare costs (subscription required).

"But if we are really at the start of a once-in-a-generation push to fix health care, we need to be clear about the true problem. The main reason so many people lack health insurance is because of its cost. And a big reason for that cost is the explosion of expensive, medically questionable care, be it knee replacement, preventive angioplasty or lumbar fusion. The route to an affordable health insurance solution runs straight through this thicket....Still, we shouldnít be naÔve: a lot of people would lose if medical care came to be based more on what actually worked. Right now, drug companies and medical device makers can go to the Food and Drug Administration and get approval for an expensive new product so long as they show that itís as effective as its predecessor. They can then turn around and suggest to doctors that the new product is more effective than its predecessor. The doctors often profit, too. And many patients demand the latest, most expensive procedure, regardless of the evidence."

It's nice to see an article that gets to the root of the issue. We can talk all we want about universal healthcare, HSAs, the uninsured, and socialized medicine, but when it comes right down to it's all about the costs and how we spend our healthcare dollars.
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Old 06-06-2007, 10:03 AM   #2
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Specifically on the high cost of health care in the US, I suggest reading Dartmouth Medicine: The State of the Nations Health

Dartmouth Medicine Magazine :: Home

Investigating staggering differences in how much Medicare spends on patients in various parts of the country, the Dartmouth team has discovered that in Manhattan and Miami, chronically ill Medicare patients receive far more aggressive care than very similar patients in places like Salt Lake City, Utah, and Rochester, Minn. Their research reveals that Medicare beneficiaries in high-cost states are likely to spend twice as many days in the hospital as patients in low-cost states and are far more likely to die in an intensive care unit. The
odds are higher that patients in high-spending regions will see 10 or more specialists during their final six months of life. These facts alone aren't terribly surprising. But here's the stunner: Chronically ill patients who receive the most intensive, aggressive, and expensive treatments fare no better than those who receive more conservative care. In fact, their outcomes are often worse.

In high-cost regions, "patients with the same disease have higher mortality rates, very likely because of medical errors associated with increased use of acute-care hospitals," Wennberg and colleagues noted in a 2006 study of patients suffering from chronic diseases like cancer or congestive heart failure. As Fisher puts it, "Hospitals can be dangerous places—especially if you don't need to be there."


Dave Durenberger, a retired former moderate Republican Senator, is chair of the National Institute of Health policy that is looking at health care cost and access issues. Here is their site: National* Institute of* Health Policy

Durenberger says:

No one can give accurate pricing as someone is subsidizing something else. Unless we deal with that, which gets us to the point of universal coverage. We’re all Americans, and if we get to universal coverage, then there’ll be lots of incentives to drive efficiencies.
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Old 06-06-2007, 10:07 AM   #3
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This is a good article. Many medicines are in wide use, based on faulty, scant or possibly fraudulent "research", mostly funded by drug companies. The recent disclosure that diabetes wonder drug Avandia actually greatly increases the risk of MI or stroke, and does little or nothing for blood sugar control that much older and much cheaper drugs don't do as well or better illustrates this well

Then take Vioxx and Celebrex, the great new things for arthritis. Vioxx causes heart attacks and was finally taken off the market, and Celebrex is a similar drug that probably does too. And apparently they don't do anything for arthritis that aspirin doesn't do.

Drug companies play a game of stay ahead of patent expirations. Even when the drug about to go off patent is better or equal to their new drug, it has one tragic flaw- it is about to become very cheap. It shouldn't be overlooked either that any drug that has been in wide use for 10 years or more should on that fact alone be given some preference; after all many important and often fatal or irreversible but rare side effects are only discovered after the drug has been on the market for a while.

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Old 06-06-2007, 10:19 AM   #4
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While I don't favor unnecessary regulation of any sector, we are very loose about approving drugs and devices through the understaffed and often-criticised FDA.

Manufacturers typically seek approval on me-too drugs which allow them to compete with existing drugs but offer no real advantates (touted advantages in detailing these to physicians are typically hyped, worded in potentially misleading ways, and followed up by lunch, pseudo-educational programs, etc.). Post-marketing dangers are sometimes swept under the rug (vioxx and others; maybe avandia). Evidence against effectiveness is either not accepted for publication ("publication bias") or reflexively disregarded due to the stakeholders being vested in the procedure.

One of the reasons I am open-minded to national health care (a more extreme solution than universal coverage which I favor very strongly) has nothing to do with economics, but rather putting in place a set of standards of care which adhere to best evidence, are open to revision, and flexible enough to be overridden when necessary. Arguments about "medicine is not a cookbook" and "you can never replace the art of medicine" ring true to some extent, but too often are a smokescreen for failing to stay abreast of what's really best for the patients.
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Old 06-06-2007, 02:39 PM   #5
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Quote:
Originally Posted by Martha View Post
Specifically on the high cost of health care in the US, I suggest reading Dartmouth Medicine: The State of the Nations Health

Dartmouth Medicine Magazine :: Home
Thanks for the link. The article was written by Maggie Mahar, whose book, Money Driven Medicine, I recently read and highly recommend. She has a good grasp of the issues and writes well. It will be interesting to see how this all plays out over the next few years.
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Old 06-06-2007, 06:05 PM   #6
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It is true that spend so much on health insurance and other re-imbursement models because HEALTHCARE is expensive, as the Dartmouth article suggests. ALL health insurance plans (re-imbursement models) should place more emphasis on outcomes vs. quantity of care, inlcuding the Medicare and Medicaid models.

On the other hand, hindsight is 20-20. We can look back and say that older people who recieved less care did not necessarily fare any worse and in many cases fared better than those who spent more money on their care, but how do we really know which kinds of care were more detrimental and which kinds of care were more benefiical....And how do we really know that if we had less technology that that would be a good thing?

I guess what I'm trying to say is, isn't it better to give the consumers of the care incentives to look for the best courses of treatment for themselves rather than to count on the government to be contol of a set of standards? For example, I think Colorado did an experiment with the Medicaid program where they allowed people to shop for and purchase their own home healthcare aides, and the program ended up saving thousands of dollars, because the recipients actually got to keep some of the savings to use towards additional care if they could find a better solution than a government assigned caregiver.

I find it difficult to believe that the government, of all entities, could be "flexible" enough to allow standards to be overridden when necessary or be "open" to revisions on a whim. The word "flexible" and "government" in the same sentence is almost an oxymoron.
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Old 06-06-2007, 06:44 PM   #7
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Do you have any other ponies in your barn?

Here is an example that should be clear enough of why enforcing standards from above is often helpful. Something with which you are no doubt quite familiar: Medicare supplements. I believe that what you are calling choice I would call obfuscation and smoke screens designed to confuse the consumer/patient.

Insurance companies want to accept the least risk for the most money. Some find excellent ways to do this- see AFLAC.

But Medicare Supplements are structured so that an F is an F, etc. This forces these marketers to compete on price, and whatever reputation for service they have earned.

BTW, keep posting your ideas, 'cause it is a useful shortcut to help me decide what I am against.

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Old 06-06-2007, 06:48 PM   #8
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As I recall Washington State had a cost versus results based model for government funded healthcare. They ranked cost versus outcomes for a very large number of healthcare procedures. Those procedures that cost little and had very good outcomes generally got funded. Those procedures that cost a lot and had little benefit were generally not funded.

Their model stated that they had a limited financial resource and that they were only going to fund cost-effective medicine. They drew a line in the sand on their ranked list as to what would be funded and what would not be funded.

I have no idea as to what they do today but this results oriented medicine perhaps is something that could be considered as an alternative to what we have today.
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Old 06-06-2007, 06:50 PM   #9
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That may have been Oregon.

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Old 06-06-2007, 07:04 PM   #10
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I wonder how much of the cost is related to expensive end of life care and expectations.

I tossed out a few articles a year or two ago about how 80% of the total costs of health care occur in the last year or so of a persons life...which also means they didnt work.

Perhaps a lot of people have expectations after watching ER and House that when they get seriously ill or arrive near the end of their lives, that a crack team of highly dedicated medical experts are all going to camp out around a white board, order a half million in tests, and pull off a diving last minute save of their lives?

If I remember right, a lot of the "universal care" countries limit major procedures if the patient is very old or unlikely to survive the procedure.

On another tack, I had an interesting day yesterday. We're finally sorting through the thicket of health care benefits through my wifes employer, so its time to pick a plan.

Interesting part is they have a bunch...three PPO plans and an HMO offering. Of course all have different drug coverage, office visit co-pays, deductibles, out of pocket costs, percentage of coverage, hospital costs, etc. Its like comparing cell phone plans.

So I dug out a spreadsheet and did a good old fashioned total cost of ownership for each plan...although its specific to our needs the results are a bit interesting.

Given that we usually each go to the doctor twice a year, mostly for a "hi, howya doin, wanted to collect an office visit fee and see your face before I refilled your prescriptions for another six months" sort of deal...and we each use one generic and one fairly spendy brandname prescription...and we somehow manage to need some major test/xray/whatever once a year that runs into the 500-600 range:

The HMO option, which I'm going to presuppose is similar to what universal-healthcare-done-right would look like...owning its own pharmacy, doctors, lab equipment and hospitals and doing a full managed care plan...was the cheapest. Including premiums, drugs, office visits and an odd medium cost lab test/procedure it was going to run us a little under $4000 a year. And hospitalizations for any reason are a flat $500 and no extra cost thereafter.

The closest PPO offering, which has a similar zero deductible, all labs/tests covered, no 80/20 or 60/40 coverages...was $7200. And hospitalizations were expensive...$750 admittance and $150 a day.

The lowest cost PPO offering, which has a huge deductible ($2000), and aside from "well child/adult" office visits has only 80/20 coverage after the deductible is used up was still $5400.

As an aside, I used the same HMO when I was a single ER paying my own healthcare, and they gave me terrific service. Always got appointments quickly, prescribed drugs and administered tests without any trouble at all, and never gave me the impression that costs were more important than my care.

So I think, after that analysis...that the major portion of health care costs have to do in part with the lack of coordinated control of the health care system, and insurance company overhead...neither of which is a problem for the HMO.

The PPO really has two major benefits...I can choose from any doctor/hospital/organization in their provider directory and perhaps in a dire care situation I may have more leverage when the doctor isnt an employee of the organization paying the bills.

Its pretty tough to look at those two benefits...which given I have a choice of 300 doctors at the HMO and they may service me perfectly well in a serious situation arent necessarily benefits...and pay twice as much for that high end PPO option.
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Old 06-06-2007, 07:10 PM   #11
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Its pretty tough to look at those two benefits...which given I have a choice of 300 doctors at the HMO and they may service me perfectly well in a serious situation arent necessarily benefits...and pay twice as much for that high end PPO option.
Don't mean to be offering advice where it's not being requested, so just take as an observation: the challenge with HMOs is variability in customer service. At their best, they are the ideal choice for the consumer. At their worst, they are a nightmare and you have no alternatives (at least until your next open enrollment). If you know from personal experience that the HMO delivered good service and seemingly sensible care, that sounds like a great choice.
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Old 06-06-2007, 07:20 PM   #12
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They did do well by me, often seeing me the same day for an "I got a little owie" office visit, and no trouble on several tests/lab work...in fact they seemed to go a little overboard at times.

My dad has also used them for his medicare gap coverage, and other than changing doctors on him once a year or so, he's been pleased with their results.

Its a bit of a small pickle...we picked out a PCP more or less at random (closest one to our house) and did an out of pocket office visit. And he was terrific, both of us really liked him.

Not sure I like him $3000+ more a year though.

It was just really interesting to apples-to-apples the costs for the same care and see that huge gap between an HMO and a PPO.
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Old 06-06-2007, 07:48 PM   #13
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Do you have any other ponies in your barn?

Here is an example that should be clear enough of why enforcing standards from above is often helpful. Something with which you are no doubt quite familiar: Medicare supplements. I believe that what you are calling choice I would call obfuscation and smoke screens designed to confuse the consumer/patient.

Insurance companies want to accept the least risk for the most money. Some find excellent ways to do this- see AFLAC.

But Medicare Supplements are structured so that an F is an F, etc. This forces these marketers to compete on price, and whatever reputation for service they have earned.

BTW, keep posting your ideas, 'cause it is a useful shortcut to help me decide what I am against.

Ha
I have no problem with a standardized plan design, but as far as a government designed set of standards for care, that's another story. I could see them coming out with a decent set of standards for what is available in 2007, and then when good technology arises, I can see them refusing such care on the basis of their non-negotiable standards.
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Old 06-06-2007, 07:55 PM   #14
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I could see them coming out with a decent set of standards for what is available in 2007, and then when good technology arises, I can see them refusing such care on the basis of their non-negotiable standards.
Good point; similar things have happened.


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Old 06-07-2007, 07:57 AM   #15
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I wonder how much of the cost is related to expensive end of life care and expectations.

I tossed out a few articles a year or two ago about how 80% of the total costs of health care occur in the last year or so of a persons life...which also means they didnt work.
You have noted this before, but in the current climate (see Terry Shivo case), it doesnt appear much change in the future. There was an author on public radio that I heard last week...yeah I know public radio (trying to find the guy's name...prob. has book coming out soon )talking about how the U.S. views death vs. other countries....I believe he noted that the record for someone on life support was over 35 years....I think his jist was quit paying that money and making sure kids and others get taken care....
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Old 06-07-2007, 12:17 PM   #16
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Originally Posted by tomz View Post
NY Times article on healthcare costs (subscription required).

"But if we are really at the start of a once-in-a-generation push to fix health care, we need to be clear about the true problem. The main reason so many people lack health insurance is because of its cost. And a big reason for that cost is the explosion of expensive, medically questionable care, be it knee replacement, preventive angioplasty or lumbar fusion. The route to an affordable health insurance solution runs straight through this thicket....Still, we shouldnít be naÔve: a lot of people would lose if medical care came to be based more on what actually worked. Right now, drug companies and medical device makers can go to the Food and Drug Administration and get approval for an expensive new product so long as they show that itís as effective as its predecessor. They can then turn around and suggest to doctors that the new product is more effective than its predecessor. The doctors often profit, too. And many patients demand the latest, most expensive procedure, regardless of the evidence."

It's nice to see an article that gets to the root of the issue. We can talk all we want about universal healthcare, HSAs, the uninsured, and socialized medicine, but when it comes right down to it's all about the costs and how we spend our healthcare dollars.
I spoke to a doctor friend of mine, his take was the best I've heard. Of course he's not a politician and he's quite opionated.

His take

"...the problem with healthcare is everyone wants it and no one is willing to pay for it."

Are you actually willing to pay full price for the healthcare you receive? If you are not willing to pay full price, the money to subsidize it needs to come from somewhere (TAXES?).
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