Author Archives: The Century Foundation

We Need to Begin A Conversation About “Cost Effectiveness”

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As any policy-maker knows, catering to public opinion, ensuring the public interest, and managing costs can seem an impossible task–especially when what the public thinks it wants is at loggerheads with what it needs. But in the case of health care, there may be an opportunity to do all three at once according to a proposal in the September/October Health Affairs.

The proposal argues for cost-effectiveness analysis (CEA) “to set priorities for Medicare coverage of new or costly interventions” through a citizens’ council made up of “a cross-section of users” who can provide leadership with “well-considered social-value judgments.” This citizens’ council model is borrowed from the UK, where a group of 30 men and women advise the National Institute for Health and Clinical Excellence (NICE) on behalf of the public.

The British experience shows that there are likely to be practical complications with implementing a citizens’ council, but it’s still an idea that’s on the right track. We need to turn “cost-effectiveness” from a bad word into a public interest issue in the US.

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Patients Managing Chronic Diseases: Not Your Average Consumer

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In his new book, Health Care Reform Now!, Kaiser Permanente President George Halverson points out that when you look at the 10 percent of patients running up 70 percent of the U.S. health care bill, you find that most are suffering from one of five chronic diseases: diabetes, congestive heart failure, coronary artery disease, asthma and depression.

These diseases can be expensive because if they are not monitored properly, they can quickly lead to avoidable hospitalizations—and, in the case of diabetes, avoidable amputations.  One of the most pressing questions health care reformers face today is this: How can we better manage these very expensive diseases—and how can the patient participate in self-management?

Recently, Maggie handed me a Bulletin on Aging and Health from the National Bureau of Economic Research, which includes a synopsis of a paper (penned by James P. Smith of the RAND Corporation) which focuses on one of these chronic diseases—diabetes. Smith’s goal is to explore the relationship among diabetes, socioeconomic status, and the patient’s ability to self-manage treatment.

Of particular interest is Smith’s emphasis on education—which, he concludes, is a major factor in determining first, whether a patient is likely to suffer from diabetes, and secondly whether he or she can successfully self-manage. It’s this second point that I want to address, in part because it provides a good example of how a consumer-based approach to medicine distorts the complexities of health care. 

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Disease Mongering By Way of Restless Legs

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Yesterday during lunch I saw an ad for Mirapex, a “prescription medicine used in
the treatment of moderate to severe primary restless legs syndrome (RLS).” The
fact that there was such thing as a restless leg syndrome seemed odd to me, so
I did some sleuthing. (Maggie, who has in fact discussed RLS over at the Health Care Blog, has some great
thoughts on the issue as well.)

 RLS is a “medical condition that is described as an urge to
move the legs”—simple enough. The Mirapex website offers a list of question
designed to help you diagnose yourself:

  • Do you feel a strong desire to move your legs from time to time, often when they make you uncomfortable?
  • Do those sensations in your legs occur or get stronger when you are inactive?
  • Does moving around or stretching help ease those uncomfortable sensations in your legs?
  • Do those uncomfortable sensations feel their worst at night?

Boehringer
Ingelheim Pharmaceuticals, the manufacturer of Mirapex, is considerate enough
to translate these symptoms into layman’s terms:

People often use words like
"burning," "creeping," "crawling,"
"aching," "tingling," and/or "tugging" to try and
describe their symptoms. Many people with restless legs syndrome have
difficulty explaining the odd sensations they feel, even when talking to their
doctor.

So far it seems that I may have RLS if my (1) legs get uncomfortable after
sitting for a while and (2) I have trouble articulating this sensation. By
these criteria, most anyone who has uttered the phrase “my leg feels weird”
qualifies as an RLS sufferer.

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The Dangers of a “Zagat Guide” to Physicians

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Yesterday WellPoint announced
that as of early 2008, a “new online tool” “will allow consumers to
share their physician experiences with others” a la Zagat surveys.
Zagat in fact is partnering with WellPoint on this initiative, and the
format of ratings will be similar to other Zagat products, where
customer anecdotes accompany ratings of different criteria on a 30
point scale. The rated criteria for doctors will be trust,
communication, availability, and environment. Measurements of quality
of care and health outcomes are not included in this rating system, an
omission that Jane Sarasohn-Kahn points out over at HealthPopuli.

Jane is kinder toward this announcement than I am. Neglecting crucial
information about quality misses the point about medicine—that it is
devoted to improving health. As Jerry Flanagan of the Foundation for
Taxpayer and Consumer Rights told USA Today yesterday,
“the fact that a doctor might have a friendly administrator at the
front desk is meaningless if they have a high medical-error rate.” It’s
a bit like having car ratings only address color scheme and seat
comfort: these are nice facts to know, but at the end of the day you
want a car that you can rely on, a consistent performer that does its
job and does it well.

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