One of the most common justifications for consumer-driven medicine is reduced health care costs. The reasoning here is two-fold:

1. Since they’re high-deductible and low premium, consumer-driven health plans require more out-of-pocket spending. Consumers are more cost-conscious when they have to actively shell out for purchases. As a result, they will user fewer health care services—and thus overall health care costs will fall.
2. If consumers are in the driver’s seat, competition in an open market will drive prices down. For-profit providers will want to offer the best deal to get the most business. Consumers will also have better information thanks to the commoditization of medicine, which will translate medical jargon into universally comprehensible knowledge. Smarter consumers translate into less over-payment for services.

This is standard-issue free market orthodoxy at its finest. Unfortunately, this isn’t the whole story. In fact, there’s an even stronger argument to be made that consumer-driven health plans could lead to higher health care costs.

The Wrong Patients Forgo the Wrong Care

Research by the RAND Corporation’s health insurance experiment shows that when you shift costs to the consumer, patients forego both wasteful and effective care. And this is particularly true of the patients who cost us most in the long run—those suffering from chronic diseases.

A 2007 paper from the National Bureau of Economic Research looked at retired California public employees on Medicare, and its findings contradict some of the basic assumption of the consumerist movement.

The study’s authors–from Harvard, MIT, and the University of Oregon– found that chronically patients who are asked to shoulder more of their health care costs deferred, neglected, or opted-out of doctor’s visits and drugs when the price got too high. This short-term cost reduction led to long-term catastrophe, as their hospitalization rates were significantly higher than other patients suffering from chronic diseases. Immediate savings ultimately led to a greater—and otherwise preventable—use of more expensive care. Oops.

This makes a certain amount of sense. Chronic diseases are not always in-your-face. They often simply simmer. But if the disease isn’t managed, ultimately it explodes. Until that happens, it’s easy to ignore the problem, especially in a context of consumerism that places an emphasis on convenience above all else.

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The newest issue of the medical journal Obstetrics and Gynecology contains a compelling study by R. Jeanne Ruiz of the University of Texas and colleagues. The team looked at 468 low-income pregnant Hispanic women to see how much levels of acculturation (measured by proficiency in English) affected premature birth. What they found is not what you might expect: those mothers who are better assimilated are more than four times as likely to give birth to a premature baby.

That’s right: Women who were born outside the U.S., had not completed high school, were not proficient in English, and had lived in the U.S. for fewer than 10 years were more likely to have higher levels of progesterone. (Researchers have found that a form of the hormone progesterone can reduce the rate of premature births).

This is pretty counter-intuitive—poor and poorly assimilated women with low levels of education are in one important respect healthier than their more Americanized peers. What gives?

While the article is primarily concerned with pointing the distinction rather than trying to explain it, the general message is clear: there’s something different about the way unassimilated low-income Hispanic women live their lives. The obvious distinction is diet and nutrition. I think it’s fair to say that the more someone is tied to his or her culture of origin, the more likely he or she is to consume that culture’s traditional diet.

Hispanics are a broad group, so it’s tough to pinpoint exactly what “less American” Hispanics eat that “more American” Latinos don’t. On the whole, however, the Hispanic diet is much heavier in grains, beans, and fresh fruits and vegetables than the typical American meal. And studies have actually shown that Spanish-speaking Hispanics stick closer to this diet than their English-speaking peers who are more like pick up American eating habits.

Guess who eats healthier?

In 2000, the Department of Agriculture studied diet and nutrition among Hispanics in the U.S. Rating diet quality on a “healthy diet index” drawn from government nutrition recommendations and the food pyramid, the authors found that less assimilated Spanish-speaking adults and children scored higher than their English-speaking counterparts (see table below). In other words, less acculturated Latinos eat better—mostly because they consume less fat and more fiber in their diets.

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I love the Internet. I love convenience, and technology. The creation of new inequalities at a time of profound disparities in health care, however, isn’t my cup of tea. So I have mixed feelings about the fact that online medical consultations are gaining steam.

On the one hand, the pluses are obvious. As I’ve written in a previous post, Tom Delbanco from Harvard Medical School estimates that 50 percent of visits to the physician are unnecessary and could probably be dealt with online. Yet a measly eight percent of doctors use e-mail to communicate with patients, let alone set up their webcam to talk shop. That seems foolish.

But, Doubting Thomas that I am, I see some problems with the rise of Internet consultation. Ultimately it seems like another case of wrong-headed priorities. Once again, too much attention is paid to dispensable improvements that don’t address fundamental problems with our health care system. Enough with the bells and whistles already. 

Traditionally, the biggest obstacle to online consultation was the fact that insurance companies didn’t reimburse doctors for web-based work. But recently Aetna and Cigna, two of the nation’s biggest insurers, have agreed to reimburse doctors for online visits. Other big dogs in the insurance world are likely to follow suit soon.

With these changes, the anatomy of the web-doc industry is beginning to come into focus. For online consultation to be reimbursed by insurers, paperwork needs to be filled; for doctors to have a booming Internet practice, they need a strong online presence. To help with both of these matters, new companies have entered the fray, with cookie-cutter names like RelayHealth and Medem (“medicine” + “modem”; genius!).

The L.A. Times describes how these companies work:

To begin using these online services, patients visit a doctor’s website or go directly to one of the Internet companies that handle such services…Doctors are typically encouraged to respond to patients within a day; they receive an e-mail reminder if they haven’t, with a phone call on the second day. Prices can vary from $25 to $125, which patients pay with a credit card at the end of the session.

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Health Beat Blog is getting a new look. Some of you have asked for larger type, so we’ve re-designed the blog to make it more readable, while including a few extra features– including a link to our “Most Read Posts.”

We’re rolling out the new design on Monday, February 4. If something isn’t displaying property, please be sure to refresh your browser. In Internet Explorer, this is the button with green arrows to the right of the address bar (F5) and in Firefox, this is the blue arrow button to the left of the address bar (Ctrl+R).

Earlier this month, I wrote briefly on how the relationship between high cholesterol and heart disease is growing murkier than has been traditionally assumed. Today, by way of Gary Schwitzer’s Health News Blog, I came across a recent BusinessWeek article by John Carey that cracks this story wide open—in part by addressing an incredibly important, but often misunderstood and misused—statistic: the “number needed to treat.”

The succinctly titled piece, “Do Cholesterol Drugs Do Any Good?,” notes that “Americans are bombarded with the message from doctors, companies, and the media that high levels of bad cholesterol are the ticket to an early grave and must be brought down. According to these ubiquitous messages, statins [cholesterol-lowering drugs like Lipitor] “are the most potent weapons in that struggle.” Carey notes that Lipitor advertisements claim that the drug “reduces the risk of heart attack by 36 percent…in patients with multiple risk factors for heart disease.” Sounds pretty effective, right?

Hold the phone—there’s more to that number than meets the eye. Carey notes that the 36 percent is accompanied by an asterisk stating that “in a large clinical study, 3 percent [or three out of every hundred] of patients taking a sugar pill or placebo had a heart attack compared to 2 percent [or two out of every hundred] of patients taking Lipitor.”

Now, Pfizer’s number isn’t an outright lie. Pfizer, Lipitor’s manufacturer, says its potion reduces risk by  36 percent because the difference between two patients getting a heart attack on Lipitor and three patients getting a heart attack on placebos is one patient—or about a third the number of heart attacks that would have happened without Lipitor.

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Today, as the first in an ongoing series of updates on what’s new in international health care, I want to take a look at recent reforms in Germany. As a whole, we Americans pay precious little attention to what’s going on in other countries unless the news involves war or David Beckham. I’m hoping to buck this trend a little.

The big story in German health care is Chancellor Angela Merkel’s late 2006 reform that resulted in series of changes that, for the most part, were implemented in April of last year. Below, a look at these reforms; but first a little political background: Merkel heads up a "grand coalition" government, i.e. one where the largest political parties govern in collaboration due to inconclusive election results (a relatively common occurrence in parliamentary systems). In other words, social democrats and conservatives are in a constant tug-of-war. The new plan reflects this fact, juggling solidarity and competition in equal parts. And while this might sound like a good balance, virtually no one is satisfied with the compromise.

On to the big changes:

Mandatory Health Insurance: Many folks think that European health care means, by definition, universal public coverage. Not so. Germany has a public/private system, and before the April 2007 reform, public coverage was only compulsory for those within a certain income range (roughly speaking, working and middle class citizens). Higher-income and self-employed Germans, along with public servants, could opt-out of SHI by purchasing private insurance. They could also forgo insurance all together.

Due to this set-up, until recently some 200,000 Germans were uninsured—about 0.2 percent of the population. As of April ’07, all Germans must purchase health insurance. In the past, private insurers (who traditionally offer plans with many bells and whistles) had the right to refuse coverage for high-risk individuals. Now, they must take all comers. In this way, the new German plan is like Hillary Clinton’s proposal for health care reform: insurers can no longer shun the sick but everyone must sign up—citizens cannot wait  until they are sick to enroll.

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A few days ago, Merrill Goozner at Gooznews posted a great commentary on a recent New York Times article that reveled in the so-called “revolution in medical prognostication.”

This time, the amazing innovation is a DNA test that helps to predict mens’ risk of getting prostate cancer at the low, low price of $300. But as the article points out, this test “cannot predict which men will get aggressive cancers” and thus “could lead to more screening and unnecessary surgery and complications.” In other words, it gauges the risk—not the inevitability, and not the severity—of prostate cancer. Defenders of the test say that if all goes according to plan, men “may want to get the new genetic test when they are young” so that they can get a jump on prostate cancer treatment.

But here’s the problem: prostate cancer treatment is, more often than not, less useful than you might think. Merrill points out that it’s “already overdiagnosed and overtreated with horrendous side effects for thousands of late middle-aged men.” Here at Health Beat, Maggie has also noted that while the risk of prostate cancer is often hyped, almost every authoritative medical body on the matter agrees that the benefits of screening and treatment of early-stage prostate cancer are highly uncertain. There is no evidence that early treatment prolongs life by a single day.  We excel at finding out if there might be the need to do something, but we know very little about the impact of what it is we actually do.

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Yesterday I was watching television and was bombarded with the following infomercial for a dietary supplement called Lipozene:

No doubt your bull-you-know-what detectors are going haywire already, as well they should. But before you write off Lipozene as a joke, consider this: there’s nothing that the manufacturer of Lipozene—the Obesity Research Institute (ORI)—does that prescription drug companies don’t do every day. In fact, by analyzing Lipozene’s marketing, we can get a clear picture of the fundamental building blocks of Big Pharma’s business practices.

The active ingredient in Lipozene is glucomannan, a complex carbohydrate found in the konjac plant. Since glucomannan is an insoluble fiber, it absorbs water to form a thick gel that coats the stomach, making you feel full—thus reducing your eating.

For all that ORI’s advertisement irritates, it does contain a kernel of truth: the appetite-suppressing effects of glucomannan have been shown to help weight loss. A 1984 study showed that 1 gram of glucomannan before meals helped obese people lose an average of 5.5 lbs over eight weeks. Of course, this specific number is never cited in the Lipozene materials, with advertisements instead touting the fact that 78 percent of every pound loss was pure body fat and that “people were not asked to change their daily lives.”

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Okay, not really—but still, unsettling news from yesterday’s NEJM. According to a report from professors at Oregon Health and Science University, Kent State University, and Harvard, negative studies of anti-depressant publications are much less likely to be published in research journals than positive ones.

The authors compared 74 FDA studies for 12 antidepressant agents, which involved a total of 12,564 patients, to those published in medical journals—the goal being to see which studies made it from the insider circuit to the printed page, and how those that did make the jump were altered for publication.

They found that among the FDA-registered studies, “studies viewed by the FDA as having negative or questionable results were . .  . either not published (22 studies) or published in a way that . . . conveyed a positive outcome (11 studies).” In other words, bad news didn’t make it to the journals—or it was spun to sounds like good news.

Indeed, according to the study, if a reader were to judge the medications solely based on the published studies, they would think that “94 percent of the trials conducted were positive.” But in fact, “the FDA analysis showed that 51 percent were positive.”

Obviously, medical journals are publishing research that over-sells the effectiveness of anti-depressants. But why? The answer is exactly what you think: a big, fat conflict of interest. Medical journals have a lot to gain by giving designer drugs the benefit of the doubt—even if it’s undeserved.

In a well-known 2006 BMJ study, professors from York University and the University of Medicine and Dentistry in New Jersey, analyzed the messy world of “commercial bias in medical journals.” The risk here is self-explanatory: sometimes the business of medicine encroaches on medical research, especially when it comes to prescription drugs.

But despite the ubiquitous for-profit interests circling around medical journals, the BMJ study found that only nine of 30 peer-reviewed general and internal medical journals “had an explicit policy for dealing with editors’ financial conflicts of interest.” The rest pretty much just wing it—a dangerous strategy when their publications are so economically vulnerable.

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You’ve probably heard of retail health clinics (RHCs), “drive-thru” medical centers that offer relatively simple and cheap medical services in stores like CVS and Wal-Mart. They’re all the rage nowadays, with their number doubling over 2007, from 300 to about 600 nationwide. At the end of this year, their numbers are expected to triple, hitting 1,800.

The RHC explosion has caused concern in some circles.  Primary care physicians are particularly worried that the clinics represent a threat to their practice and could disrupt continuity of care. Other concerns come from people like yours truly, who worry that the old formula of profit motive plus market opportunity could lead to a feeding frenzy that would compromise the quality of care.

Retail clinics are so new that these concerns can sometimes seem premature; but judging by one 2007 document that I recently came across, my worries are well founded. Even the people trying to grow the RHC market see these health care problems coming—but they view them as business opportunities.

What people often forget about for-profit initiatives like retail clinics is that they’re bent on growth. They may start small, but they don’t want to stay small. The business plan goes beyond today’s headlines. Investors want projections; they want a roadmap to the future; they want to know that challenges have been accounted for. That means that RHCs aren’t just concerned with the here and now, but also how the market can sustain itself in the future. And according to “Business Intelligence to Achieve the Goals of Retail-based Clinics,” a briefing from the Business Intelligence Network authored by Scott Wanless, the only way to do that is to look well beyond the current RHC formula.

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