Summary: Could we bring our nation’s health care bill down from 17% of GDP to 12%? An intriguing study from Milliman, the independent consulting and actuarial firm, says”yes.” Looking at actuarial date from some of our best and most efficient health care plans, Milliman’s analysts conclude that, in theory, it would be possible to trim our bloated health care system by 25%.
Before you dismiss the idea, consider this: not that long ago, we brought health care inflation down to less than 3% a year for six years running (1994-1999). During that time, the nation’s health care bill remained flat as a percentage of GDP.
And Milliman points out that today, our most efficient , high quality health plans are achieving similar savings by “reducing unnecessary inpatient stays” and “inappropriate imaging The site of service also changes to emphasize lower cost settings—for example, home care instead of nursing-home care, or office-based primary care instead of emergency room care..
The authors of the Milliman report acknowledge that 12% is only a “target for what is possible, not a budget." They are not suggesting that we try to cap health care spending at 12% of GDP.
But the actuarial firm points out that in the not-so-distant past (1991) health cared did consume just 12% of GDP. Now it equals 17% of the economy. Granted, medical technology continues to advance, but have we really made that much progress since the ''Nineties?
I don’t believe that reform is going to bring the nation’s health care bill down to 12% of GDP. But this report serves as a welcome reminder that health care inflation is not inevitable. And we don’t have to cut quality to cut costs. Nor does Milliman’s model–which is based on what is happening at our premiere health care centers– suggest that we must whack physicians’ fees.
If anyone tries to tell you that health care reform legislation cannot possibly save large sums, remember Milliman’s chart (below). Take a look at national health care spending over the past 20 years, and you will discover that the sharp rise at the beginning of this century stands out as the exception, not the norm.
If we had been making rapid advances in medical science during those years, the steep curve might make sense—but we weren’t. Consumption of medical products and services was rising, along with prices– without a comparable improvement in the population’s health.
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Over the past ten years the amount that health care insurers pay out to hospitals, doctors and patients has spiraled, risng by 5% to 11% each year, from roughly $1.3 trillion in 2000 to $2.5 trillion in 2009.. Yet few patients would say that the care they receive today is twice as good as the medical attention they received in 2000.
Quite the opposite. A Greek chorus of doctors, nurses, and hospital patients tell us that, despite pockets of excellence, the overall quality of U.S. healthcare has declined over the past decade. They are the eyewitnesses who know how chaotic our hospitals have become, and how little time doctors have to spend with patients. Both caregivers and patients are less and less satisfied with the process. Yet health care bills continue to rise. In 1990, we spent 12% of GDP on medical services and products. Now we spend 17% –without comparable improvement in the health of the population.
That is why I was intrigued when Jeremy Engdahl-Johnson sent me a report from Milliman, the actuarial firm, titled “Imagining 16% to 12%.” (Since then health care spending has jumped, so the title needs to be revised: “Imagining 17% to 12%.”)
This may well sound pie-in-the-sky– and I’m not suggesting that we’ll do it. Still, if you believe the many observers who suggest that at least one-third of our health care dollars are squandered in ways that provide no benefit to patients, in theory, we should be able to slice spending by 25%.
Milliman calls this “Imagining the Possible.” And, as the graph on the cover of the report shows, the U.S. did spend just 12 % of GDP on healthcare in 1991.
What has changed since then? Some assume that an aging population has been pushing costs higher. But according to Medicare’s Office of the Actuary, from 1993 to 2009, changes in the age and gender mix of the population account for less than 0.5 % of the annual rise in national expenditures.
Instead, the Congressional Budget Office points out, "about half of all growth in health care spending in the past several decades was associated with changes in medical care made possible by advances in technology." Some of these new technologies have provided “enormous clinical benefits” the report acknowledges, but, as we all know, in other cases cutting-edge technologies are over-used on patients who don’t benefit from the treatments.
Moreover–and this is the part of the report that stopped me in my tracks—while medical bills climbed from 1990 to 2009, there was one period, from 1994 to 1999, when annual growth never exceeded 2.8%. (See chart above) And the share of GDP devoted to healthcare during those six years remained virtually unchanged. In other words, it is possible to bring health care inflation down to less than 3% a year.
Over the course of those six years, as the bold black line on the chart below reveals (click to enlarge) insurance premiums actually fell. At the end of the period, they began to rise, but even then they never rose more than about 5% a year—or only 2% more than the growth in reimbursements to doctors, hospitals and patients.
Since then, the combination of slower economic growth, and accelerated spending on health care has led to a stiff rise in health care outlays as a share of GDP. And as costs rose, so did premiums—up 13% in 2003.
What Happened From 1994 to 1999?
Managed care. Private insurers began to reduce our use of advanced medical technologies. As I have written in the past, sometimes they refused to pay for needed care, while in other cases they were right when refusing to authorize unnecessary tests, futile treatments, or over-priced brand-name drugs that were no more effective than generics.
Nevertheless, by the end of the 1990s, patients, doctors and the media had come to loathe the phrase “managed care”—and understandably so. Too often, insurers made their decisions based on price, rather than medical evidence. The backlash was inevitable.
Insurers reacted. By 2000, they were tired of seeing themselves on the evening news, accused of having killed a mother of three. In some cases, they had simply refused to cover a treatment that would be worse than the disease. (Bone marrow transplants for breast cancer patients come to mind.) Nevertheless, neither the public nor the media were in a position to know when insurers were right and when they were wrong,–and insurers were not focusing on medical evidence when making these decisions. Meanwhile physicians were enormously frustrated by the time they spent on the phone with insurers who were trying to micro-manage their practice..
In the face of widespread (and justifiable) suspicion that insurers were simply trying to save money, insurance companies began to throw in the towel, and say “yes” more often than “no.” They also passed the cost of “yes” on in the form of higher premiums, and so from 2000 to 2010 premiums soared, along with reimbursements for drugs, devices, hospital and physicians’ service.
Spending Levitated after 1999—but We’re No Healthier
Most observers agree that the managed care of the 1990s was a fiasco. It represented a short-sighted, ham-handed effort to control costs. For-profit insurers did not understand that making care more affordable is all about making it safer and more effective. Lift quality, and the savings will follow.
But—and here’s what we need to think about—while health care spending has soared over the past decade, one would be hard-pressed to demonstrate that the population’s health has improved. “Unmanaged Care” (or what Dartmouth’s Jack Wennberg calls “disorganized care”) is no more successful than managed care. It just costs more. Far more. (See Wennberg's seminal new book, Tracking Medicine, Oxford Press,2010)
In earlier decades, when health care costs were climbing, medicine was making stunning progress. From the early 1960s into the 1980s, doors were opening right and left. Doctors were doing things they had never done before.
But over the past ten to twenty years, progress has plateaued. Pharmaceutical companies have been producing “me too” drugs that merely put old antihistamines into new bottles . Ever-more expensive cancer drugs flood the market. But for the average patient, they don’t represent a breakthrough; instead, they simply prolong the process of dying by a matter of weeks.
Some surgical procedures have been refined in subtle ways that represent real advances. But in the areas that make headlines, costs and risks have climbed—without producing comparable benefits. For example, from 2002 to 2007 the number of older patients undergoing complex spinal fusions rose 15-fold, while questions about safety and efficacy multiplied. The explosion in robotic surgery also is raising red flags highlighted in the newest issue of NEJM.
Today, fewer Americans die of heart disease. But as a 2009 article published in the journal, Circulation, points out, most of those gains came in the late 1970s and 1980s. Research reveals that the estimated net risk for cardiovascular disease in the US population fell sharply from the end of the 1970s (1976–1980 ) to the early 1990s (1988–1994) . But when they compare the odds of developing heart disease in the early 1990s to the net risk a decade later (1999 to 2004), little has changed, particularly for women and middle-aged Americans.
Make no mistake: mortalities following heart attacks have dropped in recent decades, but researchers have found that between 1975 and 1995, most of the increase in thirty-day survival following an attack “was the consequence of low-cost treatments such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and thrombolytics” –not the high-tech invasive procedures that made headlines.
Since 1996, “survival gains have stagnated, while spending has continued to increase” explains the same article in Health Affairs . Meanwhile, “regions experiencing the largest spending gains were not those realizing the greatest improvements in survival. Factors yielding the greatest benefits to health were not the factors that drove up costs.”
HealthCare Spending Shouldn’t Grow Faster than GDP
Granted, GDP growth has slowed, which is one reason why health care costs as a percentage of GDP looks so bad. But it’s also one reason why we cannot afford to continue squandering health care dollars. (For once, Alan Greenspan may be right: I suspect we’re looking at a double-dip recession.) The other reason to rein in runaway health care inflation is that over-spending and overtreatment is hurting patients.
Meanwhile, it’s worth noting that, as the authors of “Imaging the Possible” point out: “If the United States reduced healthcare spending to 12% of GDP instead of the current 16% we would still spend FAR more than any other country on health care.”
Where Would the Savings Come From?
The report’s projections are based on actuarial modeling and are grounded in observed best practices in healthcare management among some of the best health plans in the country.. In other words, the projections come from experience in the "real world." Milliman argues that these savings could be achieved while insuring all Americans. And unlike the managed care insurers of the 1990s, these health plans make decisions about what treatments to try and what drugs to prescribe based, not on cost, but on medical evidence.
In the Milliman model, physicians’ fees are not cut. All of the savings are achieved by reducing utilization of unnecessary services, and changing how and where care is delivered. “Certainly other scenarios for reducing healthcare spending are possible,” the authors write . “Our theme is that the right care is better care and is less expensive. Our purpose in writing this paper is to stimulate debate about how we will achieve these significant savings.”
This is a long-term goal: “a drastic change in spending will not happen quickly, but it could reverse the current pattern of waste while making available huge resources for other uses in business, creating jobs, boosting personal consumption, and allowing more government spending for important initiatives.”
They acknowledge that “to some, the 12% goal may at first be taken as a budget or an attempt to ration healthcare. The advantages and disadvantages of an enforceable national budget for healthcare spending are discussed in the Congressional Budget Office’s recent health insurance reform report. But this is not Milliman’s intent. “We consider 12% a target for what is possible, not a budget. We believe rationalizing care is far superior to rationing it.”
I agree. I find the idea of bringing healthcare spending down to 12% of GDP a provocative long-term target—a goal that could stimulate thinking outside of the box.
“The assumptions and models we used to project potential savings are based on observed, composite results of health benefits programs,” the authors add. “While the shifts in utilization and spending are from actuarial models in Milliman’s Health Cost Guidelines, the results are broadly consistent with numerous published studies, and observed variation in aggregate utilization by HMOs and insurers. Certainly, there are other ways to reach the bottom line goals we set: cutting unit reimbursement, better management of chronic disease, better preventive care, etc. These other approaches could produce different distributions of spending than those presented here.
“This report presents national average figures,” they point out. “Healthcare spending in some locales is already very efficient and there is probably little room for improvement. In other places, the potential reductions in spending are greater than those shown above." The report goes on to focus on places where we could improve care–and save health care dollars.
Long-term Care—Just One Place Where We Can Save.
“We can do a better job of caring for the elderly,” the report observes. “ Long-term care (LTC), including nursing-home and home health, is a major burden, at $282 billion or 12% of healthcare spending, most of which is funded by Medicaid. The opportunity for improvement can be realized by diverting or delaying institutional-based LTC (typically now in a nursing home) and substituting enhanced community-based LTC (in a home or assisted-living facility). Of Medicaid benefits for LTC, 56% of the people and 77% of the dollars are spent in nursing homes.
“ States vary enormously in how they spend for LTC. Oregon, a leader in reducing nursing-home use, spends 55% of its LTC dollars on home services, while Tennessee spends only 1% of its LTC dollars on home services.
“The authors of a recent AARP Public Policy Institute report summarize the potential: ‘On average, Medicaid dollars can support nearly three older people and adults with physical disabilities in home and community-based services (HCBS) for every person in a nursing home. Thus, to the extent that states provide HCBS instead of nursing-home services, this shift in service delivery can be both cost-effective and responsive to the preferences of people with disabilities.” Our model has the majority of LTC recipients receiving care in a home or home-like setting.
Looking Ahead
In the end we can’t bring our health care bill down to 12% of GDP because our most efficient health care centers can’t be franchised, like so many McDonald’s, turning out the same delectable French fries—skinny, but not soggy– across the country. As both the Mayo Clinic and Kaiser Permanente have found, it is very difficult to replicate a medical culture with another group of doctors and patients in a different situation. Places like Mayo in Rochester, Minnesota, and Kaiser in Northern California have deep roots: it took many years to develop these cultures, and now they attract a self-selecting group of care-givers who are comfortable working in teams, on salary, subsuming their egos and individual personalities to one goal: evidence-based, patient centered- care. Or as Mayo’s founders put it: “The patient always comes first.”
Nevertheless, research shows that Mayo’s outposts are significantly more efficient (providing better outcomes at a longer price) than the average medical center. With time, I suspect that both the newer Mayo Clinics and the newer Kaisers will discover ways to equal the mother-ship’s results– in different ways, adapting to the culture where they have landed .
It is a big country. As Dr. Atul Gawande said at a National Quality Colloquium earlier thiw week: "All healhtcare is local." Communities must learn to create systmes that work. Health care reform will take different forms in different places.
Who was President during 1994-1999?
That was the exact same time period I was earning 36% average annual total return on my invested money.
I’ll offer a few thoughts on this.
First, part of the 1990’s backlash against HMO’s was due to people who did not like having to go to a primary care doctor for a referral if they wanted to see a specialist. They wanted to go to the specialist directly. In short, they wanted access to whatever care they wanted whenever they wanted it and they expected someone else (employers or taxpayers) to pay for it.
Second, when the former health minister in Switzerland was asked about why U.S. healthcare costs are so high in the August Healh Affaris article compared to Switzerland’s and other European countries, he said that the primary reason is that we pay more for everything here. According to him, we in the U.S. pay 30% more for drugs and our doctors earn 30%-40% more than Swiss doctors do. Hospital costs are far higher in the U.S. for most procedures than elsewhere. Even if all health services in the U.S. were paid for at Medicare rates, which are considerably higher than Medicaid rates, we would still be spending far more, relative to GDP, than other countries.
Third, while I agree that there is significant potential to reduce utilization of healthcare services in the U.S., people will have to accept being told, NO sometimes. For example, you can’t have that MRI to reassure yourself that your mild headache is not due to brain cancer. You can’t sue your doctor if you had an unfortunate outcome even though all evidence based guidelines were followed. You can’t have a prescription for that new drug you saw advertised on TV if the doctor doesn’t think it would help you. You can’t have every last bit of futile end of life care that you or your family members might want. People need to learn to care about costs even when insurance is paying all or most of the bill. They need to think of someone other than themselves, especially their children. If there is a need for collective thinking, it’s here and not just a willingness to pay ever higher taxes.
To curb utilization, we need improved incentives as well as better price and quality transparency tools. Limited capitation could probably work for primary care, at least as practiced by large physician groups. It is already used quite widely, at least to some extent, in California. Bundled payments for surgical episodes could encourage more efficient and coordinated care. Tiered in network insurance products could help to steer patients away from high cost hospitals and physician groups whose costs are high because of their market power and not their quality. Financial incentives are important and right now, they are largely all wrong.
Maggie, I agree that curbing unnecessary care or harmful “care” is the chief way to get costs down. I also agree with Barry that much of the excess utilization is driven by patients, not doctors. Of course in a fee-for-service system the excess “care” does drive up doctors salaries, so we physicians have no incentive to limit what we do, and considerable encouragement not to do so.
I notice that the authors of the study emphasize that they are not reducing doctors’ fees. This may be true individually; in aggregate, of course, doctors’ incomes will fall, especially for proceduralists.
Maggie – this is a good assessment. If you have a chance – I do still have some good questions (I think) about whether PPACA will really accomplish anything substantive along these lines.
Margalit Gur-Arie
Excess utilization is too broad of a term. In some areas, and for some items, we utilize less than other developed nations and in others we utilize more. Some is driven by patients who don’t know any better and some is driven by hospitals and doctors who should know better.
A good solution will have to selectively cut utilization, but also cut unit costs. We pay more than Europeans for everything, from Aspirin to heart transplants.
As Chris wrote, any way you look at it physicians and hospitals income will have to come down. Hopefully some more than others.
I just don’t know who is qualified to make these decisions. Certainly not insurers who have obvious ulterior motives.
Caspian, Margalit,
Caspian– This evening I responded to your comments on the other thread.
Margalit–
I totally agree. My book (Money-Driven Medicine) is based on the idea that we have two huge problems in this country: Some patients (the unisured and under-insured) are undertreated; others are overtreated.
Who should decide what consitutes undertreatment and over-treatment?
A panel that is made up of physicians and other health care experts. (This is what happens under the ACA)
Will there decisions be perfect? No.
But this is much better than letting for-profit insures make these decisions (based on cost, not medical evidence0.
And it’s also better than encouraging individual physicans to simply “do it my way”– following habit, or what they learned in med school 20 or 30 years ago.
We know that geographic variations in care are tied up with where you went to med school. Most U.S. docs wind up practicing close to where they went to school.
Some med schools encourage much more aggressive (and expensive ) care. Docs in those areas tend to follow that model.
Yet we know that, in areas where docs practice more aggressive and more expensive care, patient outcomes are not better. Sometimes they are worse.
And, in the U.S. many physicians ignore medical evidence and best-practice guidelines within their own specialites. (Much reserach.)
This is, in part, because evidence-based information is not well-organized and easy to access.
The reform legislation would change this.
Doctors would not be forced to follow evidence-based info (these would be guidelines, not rules) but those who achieved better outcomes (which tend to come when you follow medical evidnence) would receive higher payments.
Thank you for posting a very thorough description of healthcare costs and the US system.
Our Journal has published several articles related to US healthcare system reform and related costs, including a March 2010 commentary with suggestions for reducing costs and a January 2010 research study that revealed that electronic medical records (as currently configured in the US) do not save money.
I have added your blog to our blog roll. Could you add ours to your link list? Thanks.
Pamela J. Powers, MPH
AJM Managing Editor
call me a puzzled believer. I believe there is massive overconsumption and that costs could theoretically be cut by at least 25%. I am also aware that we have never cut costs and that reducing the rate of increase is a very different thing than reducing the total medical bill.
as I understand it, these folks allege that some providers are delivering quality care for at least 25% less. good news. that suggests that they are charging premiums that are 25% below the market — if we assume they’re not another group of health pirates. if they’re charging 25% less, why aren’t people flocking to them, giving them greater market penetration and basically driving the market. when a cellphone firm offers unlimited calling for 25% less, they get a bunch of new customers and drive competing prices down as well. so why hasn’t this happened where these efficient providers are operating?
bottom line– if they’re delivering care for less, where are the lower premiums? and if premiums aren’t lower, why do we care whether their costs are less (and thus their profits higher)
Chris, Jim, Pamela
Chris–
Good to hear form you–sorry it has taken me so long to respond.
I still think that suppliers (i.e. hospitals and doctors) drive health care demand.
They tell patients what they need, and most patients accept the recommendation from a doctor or hospital that they need a test, surgery, to be put in an ICU, etc.
Particuarly when it comes to the big-ticket items (another surgery, another round of chemo, ICU care) these are not things that most patients look forward to or desire. They do it because they feel they must: this is what their doctor or hospital has told them is necessary.
And when patients have access to pallative care, most patients, (and even “difficult” families) tend to respond to information that pallative care specialists give them about risks & benfits. Research shows that when they have the info, they choose less aggrssive care.
That said,I must acknowledge that there is a chicken/egg relationship between supply and demand in heatlhcare.
Doctors often say that they recommend what their patients want and expect; patients say that they do what their doctors reocmmend.
Which comes first?
Nevertheless, in the patient/doctor or patient/ hospital relationship, the doctor or hospital has much more power because medical professionals have so much more knowledge. And, as you know, better than I, sick patients (or the relatives of sick patients) desperately want to believe that their doctor–or their hospital–knows what is best.
For this reason, most patients look up to and respect their own doctor or hospital (even if they are skeptical about “doctors” or “hospitals” in general)
Jim–
In Northern California, people do flock to Kaiser.
In Pennsylvania, people flock to Geinsinger.
In Utah, people flock to Intermountain.
This is because these plans offer excellent care at a lower cost. It is usually not the cheapest plan in the market. But as I have said before, when it comes to health care, famlies who can afford good plans are not looking for bargains. When it comes to clothing, food, even Cable TV, they will will look for bargains–but they don’t want a discount surgeon.
Patients who buy Kaiser in Northern California, or Geisinger in Pennsylvania, could find less expensive care in these areas, but they know that it won’t be as good. When I was writing the book, Pitney Bowes told me that if they didnt’ offer Kaiser in Nothern California, no one would come to work for them.
Can you think of a health care insurer who is that popular in the greater NYC area?
In the NorthEast, there are no Kaisers, no Geisingers, no Intermountains. And, by and large, we pay much higher premiums.
(When Kaiser tried to branch out in Texas, doctors drove it out. Kaiser would have no chance of putting down roots in N.Y/.N.J. CT))
The medical culture in the Northeast is pretty rigid. Docs are accustomed to operating in solo or small practices. They don’t want other docs looking over their shoulders. They don’t think of medicine as a team sport.
Marquee hospitals in the Northeast are accustomed charging what they want to charge (see Boston Globe articles on brand-name hospitals charging 30% more for simply procedures) and doing as many as tests and procedures as they think appropriate (whatever medical research on best practices might say.)
Patients in the Northeast are accusotmed to hospitals and docs “doing more” and charging more. These patients tend to believe that because their health care is so expensive, it must be better.
Patients in Minnesota have different expectations, They don’t pay nearly as much for healthcare (after adjusting for differences in local costs of care, incomes, age, race, sex and severity of illness. The Dartmouth reserach makes these adjustments in many of its studies– contra to what you may have read in the NYT– I’ve read all of Dartmouth’s many studies.)
Meanwhile, outcomes are at least as good–often better-in Minnesota. And Iowa. And Oregon. And the state of Washington. And Colorado. And Arizona. And Northern California, And Upstate New York. And . .
Bottom line,providers in our very expensive neck of the woods are not competing with health care providers in Minnesota.
Pamela–
Thanks very much. I will take a close look at American Journal of Medicine’s website. (I looked at it briefly, and was impressed.)
I think people believe they are getting excellent care at a lower cost, at places like Kaiser, because they are getting less care, or should I say less “efficient” care. Not many health care providers can influence Kaiser’s willingness to work with them.
Dr. Louis Fehrenbacher, an oncologist at Kaiser Permanente, had said in an interview that “We have too many [cancer drug] agents, we don’t know how to mix them together in the right order, but that’s an awfully nice luxury to have because five years ago we didn’t have much.”
So there’s more “trial-and-error” treatment with “mix-and-match” coctails, they have no idea how to mix them together in the right order. That’s not good patient care, that’s Russion Roulette.
And Dr. Sharon Levine, associate executive director of Kaiser Permanente, says that many executives in the managed care industry want the federal government to sponsor head-to-head tests of a broad range of drugs. “We need to get information about the relative clinical effectiveness of drugs so that when we look at price, we can make real evaluations.”
I submitted to the Committee on Camparative Effectiveness Reserach Priorities, who conducted a study to recommend national priorities for comparative effectiveness research conducted or supported with funds from the American Recovery and Reinvestment Act of 2009.
I asked that they compare the effectiveness of various genetic and cell-based assay technologies to show what technologies work. It would be terrific to have a head to head comparision of genetic and cell-based technologies. This would give the federal government the proper testing technique for mixing [cancer drug] agents, instead of continued “trial-and-error,” even with the newer “targeted” agents.
The “idea” fell on deaf ears.
We could certainly reduce costs by providing more intellectual and financial incentives to stay well through the use of integrative and preventive medicine.
People came to hate managed care during the 1990s.
We had Kaiser then. There weren’t easy to get same day appointments then. The nurse on the phone decided if your complaint was worthy.
In the 2000s they raised their rates as others raised theirs higher. Their service also improved. These days if you have a problem you’ll see someone quickly.
We stuck with them because there are almost no co-pays and a family member has a serious medical situation. It wasn’t the service, it was the money.
I believe the best least stressful way to bring down the rate of medical inflation/utilization is to increase people’s financial exposure. When you are paying then you don’t complain because your complaint isn’t bad enough.
I’m not sure the new health bill/plans are going to do that with all their “this is covered and so is this.” When people don’t have anyone to pay (blame) but themselves they accept the answer “no” more easily.
American “healthcare is local” because we have no national providers of care.
As:
* national clinics emerge,
* patients and physicians benefit from the use of two-way interactive video,
* Internet, wireless, mobile and remote technologies bring knowledge and care to people outside convential channels of care, and as
* “medical tourism” begins to win corporate and insurance support,
we will one day discover that healthcare does not have to remain local.
Ron Hammerle
‘Dr. Louis Fehrenbacher, an oncologist at Kaiser Permanente, had said in an interview…’
Well, he said that back in 2004 when after a long period of lack of options for colorectal cancer we finally had progress and we could look forward to more new treatments. It’s true that it’s challenging to design trials that show what may be working in multi-treatment trials, and that knowledge about effective targeting is often not put to use (and that industry is often not interested in testing combinations).
But we have recently seen progress in testing combinations, and also the excitement of the role of KRAS mutations in determining who can be treated with cetuximab.
While there’s much wrong with the way cancer is being researched, it’s not quite Russian roulette
Ron, ginger R, Alex, Gregory
Ron– We have tried education via remote TV–it doesn’t work very well.
Most patients and physicians would tell you that they want to interact face-to-face. Much of what goes into a diagnosis is intuitive knowledge that doctors accumulate through experience– body languge, the look and sound of the patient are important. And, of course, in many cases, the best diagnosis involve touching the patient.
As for medical tourism, as I have explained in the past, a patient is taking is taking a risk becuase two months later he can’t easily go back to the doctor for a follow-up appointment. If something has gone wrong doctors here may be hesitant about trying to fix a mistake caused by a doctor that they can’t consult with.
Also malpractice laws do not apply abroad–you have no recourse.
Finally, the cost of flying first class to a country like India, with a friend who will serve as your patient’s advocate is very expensive. (If you are sick and in need of medical treatment, you really don’t want to fly coach–certainly not these days.)
Medical tourism is fine for wealthy people who like the idea of combining minor surgery with a vacation. Even then, you are taking some risk becuase follow-up is difficult. . .
gingerR–
You say that your family needed no co-pays because someone suffered from a serious medical condition. .
Then you say that other people should have co-pays . .
This seems contradictory.
The truth is that when there are co-pays people put off needed medical treatment. They don’t go for preventive care. They don’t take their drugs. We have good research on this. In the long run, it leads ot more expensive and more suffering.
This is why the health care bill stipulates no co-pays for preventive services that hte U.S. Preventive Services Task Force says work (They use medical evidence and their ratings are very good.)
Alex–
The reform bill encourages use of preventive care by stipulating no co-pays.
But everyone needs to understand that encouraging “wellness” is very, very difficut.
People don’t do what they ideally should to take care of themselves for many reasons.
Depression is a major factor. People who are poor are much more likely to smoke, drink and self-medicate with drugs. If you have little hope of getting a good job (or just a job0, if you have little hope that your kids will get a good education in inner-city or poor rural schools, if you have little hope that your spouse will stop drinking or using drugs . . . you’re just not motivated to take care of yourself.
If we really want to encourage wellness, first we need a war on poverty–more good jobs, better public schools, good, inexpensive daycare, safe places for people to exercise . . .
Gregory: I just don’t know enough about cancer reserach to comment on your idea.
Maggie
In randomized clinical trials of breast and colorectal cancer, new effective adjuvant treatments show decreasing absolute benefit, while new treatments of metastatic disease show unchanging levels of benefit at rapidly escalating costs.
The current research and treatment model makes no difference in outcomes, but adds a lot of profit to researchers, oncologists and pharmaceuticals. How about targeting “individuals” with “individualized” therapy?
From the Annals of Oncology
http://www.medscape.com/viewarticle/726663?src=emailthis
There is a lot of great theory in the reference to actuarial control, but the facts are that the actuarial estimates for the implementation of health reform will cause insurance costs to sky rocket. I am in the benefits business, and our actuarial projections for each component show substantial incremental cost increases. To quote one of our clients when we projected the costs for dependency coverage, grandfathering loss, of which most organizations will lose grandfather status etc, their comment was “why are we even bothering to stay in business”. That is what health reform, along with all of the other recent welfare state actions have done to our country. We have created disincentives to perform and control costs. A review of the most effective health care programs by a number of major US organizations has shown their trend running at 3%. That is what we should be modeling in wellness, prevention, and disease management.
I’m going to beat this medical tourism horse a little more. Last october I started having abdominal pain. 8 months & $7500 later they tell me I am marginally diabetic & have a couple of diverticular spots. Most of the cost was a cat-scan($2500) & a colonoscopy($3000). It was on my companies nickel, but I can’t help but think that I could have gone to Costa Rica & gotten the whole thing figured out in a week for half the price & gotten a vacation into the bargain.
On Long Term Care, I have an aunt in an Alzheimers ward near Waco. She is 88, tied down, & doesn’t recognize her own children. They informed my cousins that she has breast cancer, & were ready to start radiation & chemotherapy. My relatives replied, “are you nuts?” & noticed that many if not most of the other residents/inmates are being given high blood pressure & cholesterol lowering drugs to prevent stroke & heart attack. Why? So they can linger in agony?
Finally, I invite anyone in the North Texas area to visit Willow Bend Mall. About half of the shops are closed & many of those spots are covered with billboards & signs promoting local hospital facilities. (“Medical City: It’s like a mall for women’s health”) Even the children’s play area is filled with four foot statues of all the Bugs Bunny/Looney Tunes characters dressed up as doctors, complete with Yosemite Sam flying the medivac helicopter. It is less a mall than some retail shopping to get you to look at a giant indoor hospital ad.
I don’t think this can be reformed. I sincerely hope I’m wrong, but I doubt it.
I have been watching this thread unfold. Let me comment:
1.) There is no doubt that the growth of costs for US health care is unsustainable, and it remains critical for both the future of health care and the future of the economy that the growth be slowed, stopped, and reversed. Unfortunately, health care inflation remains a runaway train and neither the private nor the public sector has been successful in stopping or slowing it, although public sector care has had slightly better results over time, with only the managed care initiative of the 1990’s allowing the private sector to briefly perform better than the public sector.
2.) There is only one realistic way to reduce health care costs in the long run: provide less care. There are two ways to do that, one a proposal by conservatives and Paul Ryan and the other a proposal of many health care economists. The conservative plan is to provide less care by making less money for care available by limiting the value of insurance for the poor, the working class, and the middle class, and the elderly, forcing them to consume less health care since they will not be able to pay for it. That would leave medical care of a less limited nature available only to those with the financial resources to pay for it out of pocket, either directly or through “Cadillac” insurance plans with high premiums. The alternative is to reduce the use and availability of unproductive, unnecessary, and even dangerous health care, of which there is a great abundance in the US – estimates run as high as $900 billion a year.
3.) The proposal to ration health care by ability to pay makes no provision for any effort to evaluate the utility of various health care services. Consequently, it would result in worse health care and poorer results because of poor decision making in what to forego and what to embrace. Conversely, the alternative of eliminating spending for ineffective and even dangerous care would result in better health care, as it has in many other developed countries already employing that approach.
4.) Therefore, it is incumbent on any rational person thinking or writing about health care or involved in health care planning or politics to engage in an aggressive effort not only to endorse the approach of more rational health care spending in saving money and in saving our health care system and our economy, but to educate the public and politicians about this. Explanations that this approach is not politically feasible because it will be opposed by stakeholders who benefit from the current poor allocation of resources are not only unproductive but are flat out immoral, since they condemn our country and its people to a path leading to loss of access to health care for the majority of Americans. It is the modern equivalent to arguing that it was impossible to get Americans to smoke less because Americans liked smoking and because there was a lot of money being made by people engaged in the tobacco industry, some of which found its way into the pockets of politicians who were then willing to defend tobacco despite its obvious harm. In the end, some people did oppose tobacco, and today Americans smoke much less, and smoke less than people in many developed and developing countries. The naysayers were wrong then, and are wrong now.
5.) As long as we are mentioning tobacco, it is important to realize that the idea that better health habits will save large amounts of money and save the health care system is simply wrong. Good health habits save money for private insurers in this country, since they cover people under 65. However, those people then pass into the Medicare system, where they eventually experience health care breakdown and high health care costs. Studies performed in national health care systems with good comprehensive data have shown that people with good health habits cost at least as much and probably more, over the entire course of their lives, as smokers, the obese, and the sedentary. Good health habits merely delay the inevitable, both in mortality and in financial cost. Good health habits are good because they allow people to live longer and more healthy lives, but are not a way to save money for the entire US health care system.
6.) Finally, the idea of broad brush approaches to cutting payments is not a good approach. Radiologists (and I am a radiologist) should make less not because their fees should be cut (although I believe some targeted shift of payments from specialists to primary care should be considered,) but because the huge number of unnecessary radiologic procedures, many of which do no good or actually cause harm, should be eliminated. The same is true of orthopedists, neurosurgeons, cardiologists, cardiac surgeons, and other highly paid specialists who all make large amounts of money on procedures and treatments that good evidence shows do not work well, at least in large numbers of cases. Hospitals and other health care systems also need to wean themselves of dependence on income from ineffective and dangerous care.
If we want to have good health care for most Americans in the future and to save the economy we need to stop having arguments revolving around ineffective approaches to health care reform and the supposed invincibility of the opponents of rational health care and start talking about, writing about, and aggressively promoting approaches to health care reform that are effective and scientifically valid.
Addendum: Just one more note. When we talk about the failure of the managed care movement of the 90’s, it is important to note that the public opposition that eventually derailed the effort did not appear spontaneously. Although there were many abuses and mistakes associated with managed care, there was also a very large group that fought to make managed care fail, and aggressively promoted the story of managed care problems to the media, politicians, and the public. This was composed of insurance companies competing with HMO’s for market share, and of physicians and hospitals invested in seeing managed care fail in order to defend their own financial self-interest. The maiming of managed care and the widespread return to business as usual made a lot of people rich, and they and their lobbyists and public relations specialists had spent a lot of time and money seeing that that happened.