Category Archives: Healthcare

Why Aren’t More Students Applying To Medical School?

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Did you know that there are only two applicants for every place in U.S. medical schools?

In Canada, surprisingly, close to four students apply for each opening. The training in the two countries is very similar; indeed, the Association of American Medical Colleges (AAMC) accredits medical schools in both countries.  And, in the U.S., at the high-end, physicians  can hope to earn far more than Canadian doctors.

Why then do so few Americans apply to medical school?

The answer is that we have priced a medical education well beyond the reach of most middle-class students.  In 2004, tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to a 2005 study published in The New England Journal of Medicine. 

The author, Dr. Gail Morrison, Vice Dean for Education at University of Pennsylvania School of Medicine, tacks on $20,000 to $25,000 a year for living expenses, books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools.  I’d add that, in many American cities, students would be hard-pressed to cover rent, food, clothing, utilities and transportation for $20,000 a year—let alone books and equipment.

This helps explain why 60 percent of all medical students come from the wealthiest one-fifth of all U.S. families. Another 20 percent come from families lucky enough to be on the fourth step of a five step ladder.

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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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The Ten Most Overused Medical Tests and Treatments

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I often write about how difficult it is to evaluate the quality of health care.  There is no Consumer Reports (CR) for healthcare, I argue, because while CR can rate mid-priced refrigerators briskly and clearly, in a way that makes comparisons easy, it is often all but impossible—even for a physician—to be positive of the relative benefits of a great many medical treatments. 

But if it’s hard to sort out the “best” healthcare, it may be easier to spot both negligent and unnecessary care.  As a hospital CEO once told me, “Our patients know whether they like the food, and the views, and whether the nurses are pleasant. They really have no way of knowing whether they are getting very good care or mediocre care . . . Though,” he added, “they are more likely to be able to tell if they are getting bad care.”

With that thought in mind, it might be worth taking a look at Consumer Report’s list of the 10 most overused medical tests and treatments. Thanks to  Gary Schwitzer of the University of Minnesota’s  School of Journalism and Mass Communication for calling attention to this list on his always interesting Schwitzer Health News Blog.
As Schwitzer points out, “You can quibble with the list, but you can’t help but commend CR for raising public awareness about the medical arms race.  And this list is just part of a broader special section on overspending on overtreatment.”

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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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Hospitals & Nurses: Behind the Scenes

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Recently I’ve begun reading allnurses.com, a website that offers an eye-opening window on conditions in U.S. hospitals.  (I found the site when allnurses reprinted my post about the nursing shortage).

Clearly nurses and doctors know more than virtually anyone else about what is going on in our hospitals, but they also realize that they risk reprisals if they speak out. When I was writing Money-Driven Medicine, I was surprised by how many physicians returned my phone calls. The great majority did not know me; I expected responses from perhaps 20 percent. Instead four out of five called back. To a man and a woman, they were most passionate about what many saw as the declining quality of healthcare. “We want someone to know what is going on,” explained one prominent Manhattan physician as he described how much care had deteriorated in many of New York City’s major hospitals. “But please don’t use my name,” he added. “You have to promise me that. In this business, the politics are so rough–it would be the end of my career.”

Nurses are in an even more vulnerable position. I could not find any who were willing to be interviewed. I e-mailed quite a few, promising anonymity, but not one responded.

On allnurses.com, however, nurses speak freely, knowing that their identities are protected and that their audience is composed of other nurses.  Here is what I have learned from some of the polls and forums on the site:

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A Transaction Based on Trust

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The consumer of health care is unlike any other consumer, and the product he purchases is unlike any other product. This is something that those who embrace “consumer-driven medicine” choose to ignore.

Advocates like Harvard Business Professor Regina Herzlinger insist that if we just
put the consumer in the driver’s seat, giving him both  transparent pricing and a little “skin in the game,” the consumer  could put a lid on health care prices while demanding the best quality care.  Herzlinger is particularly hopeful that the baby-boomers, a group she describes as “the most manipulative, the most narcissistic and the most effective generation this country has ever seen,” can do the job. (Why one would want such a group setting priorities for our health care is beyond my understanding; I’ll return to this point in a later post.)

Last week I spoke at the Massachusetts’ Medical Society’s Leadership Forum on the rising cost of care.  In two earlier posts (here and here) I’ve described what other speakers had to say about how and why Massachusetts is running into trouble trying to fund its experiment in universal care.

In my speech, I explained why I don’t think that “consumer-driven medicine” is the answer. I don’t believe the “consumer” can rein in healthcare spending.  As an alternative, I proposed a “patient-centered” model of health care which depends on patient and doctor, working together.

Begin with the flaws in the consumer-driven model. First, it assumes that the patient has the same power that a buyer has in the commercial marketplace. But in truth, the patient does not have nearly as much leverage as other consumers.

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Universal Coverage –Why Massachusetts is the Last Place to Begin the Experiment

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At the Massachusetts Medical Society’s 8th Annual Leadership Forum last Wednesday, Dr. Steven Schroeder, former head of the Robert Wood Johnson Foundation
and Distinguished Professor of Health and Health Care at the University
of California, San Francisco, told a provocative story about a poll
that asked patients in the U.S. `Canada,  Australia, New Zealand and
the U.K the following question:

“If your personal doctor told you that you had an incurable and fatal
disease, would you accept that diagnosis or seek a second opinion?

  • In the U.S.           91 percent of patients said they would seek a second opinion.
  • In Canada            80 percent                    “        “       “       “     “     “           “ 
  • In Australia          71 percent                  “        “   
  • In New Zealand     51 percent
  • In the U.K.           28 percent 

“You have to love the British,” Schroeder commented. “You can just hear
an Englishman saying ‘Well, Luv, it’s been a good life, hasn’t it? Now
let’s make a pot of tea and discuss the funeral arrangements.”

At the other end of the spectrum, we find the Americans who, Schroeder
noted, “are the only people in the world who expect to live ‘in
perpetuity’.”

Today, I would like to suggest that our expectations as patients help
to explain why we spend roughly twice as much per person on health care
as most developed countries—even when, overall, it’s not clear that our
healthcare is better. In fact, in some areas outcomes are worse.

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We Can’t Fund SCHIP, But We Can Save Merck

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Today, Bloomberg trumpeted the good news:  “Merck Profit Gains on Cancer Vaccine, Diabetes Pill.”

“Merck & Co., the third-largest U.S. drugmaker, reported a 63 percent gain in earnings,” Bloomberg reported, a victory made doubly by the fact that Merck has seen some rough times. “Competition from generics and the withdrawal of the pain pill Vioxx in 2004 over heart risks have pulled net income down 39 percent since 2001,” the story explained. Indeed, Vioxx gave Merck a black eye, and it’s still battling lawsuits in the courts. But Gardasil, Merck’s new vaccine to prevent cervical cancer, is turning out to be just the blockbuster the company needed. “Gardasil, introduced a year ago [already] has sales of $418 million”

Those of you familiar with my views on Gardasil may want to skip the below section, as it is pulled from an August post. I promise I won’t do this often, but this is an important subject and it’s example of how, if drug manufacturers and their lobbyists work quickly enough, they can sell their story to politicians and to the public before skeptics in the scientific community have a chance to weigh in. Remember the drug industry saying: “It’s important to sell a new drug while it’s still effective” (i.e. before people know too much about it).

On August 27, I wrote:

Earlier this month the FDA announced that the direct-to-consumer ads Merck has been using peddle its new cervical cancer vaccine, Gardasil, are “half-true . . .information currently being advertised could mislead the public.” 

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Massachusetts Health Reform: The Canary in the Gold Mine?

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Advocates for health care reform have been keeping an eye on Massachusetts, hopeful that its new health reform law will serve as a pilot program for the nation.

I’m much less hopeful than I was two days ago.

Yesterday I attended the Massachusetts Medical Society’s Eighth Annual Leadership Forum where I was one of four speakers. This year, the Society (which owns The New England Journal of Medicine)  focused on the cost of health care –with a special emphasis on funding universal coverage in Massachusetts. The new was not good. While the citizens of   Massachusetts believe that everyone has a right to health care (when polled 92% say “yes”), no one wants to pay for universal coverage.   When asked “if the only way to make sure that everyone can get the health care services they need is to have a substantial increase in taxes [should we do it] 55% said “no.”

One speaker at the forum recalled a man who explained why taxpayers shouldn’t have to pick up the bill: “The government should pay for it.” (He didn’t disclose who he thinks “the government” is. )

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The Real Danger of Socialized Medicine by Niko Karvounis

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Last week The Washington Post ran a good opinion piece by Ezekiel J. Emanuel, Director of the Clinical Bioethics Department at NIH (and brother of Congressman Rahm Emanuel) on the insidiousness of labeling any and all positions on health care apart from free market fundamentalism as being “socialized” medicine, doomed to failure.

Emanuel notes that “ ‘socialized medicine’ is when the doctors are state employees; when the hospitals, drugstores, home health agencies and other facilities are owned and controlled by the government…” As Emanuel rightly points out, none of the universal coverage proposals being debated in the U.S. today “can be characterized as socialized medicine. None calls for government ownership or control over U.S. hospitals, drugstores or home health agencies, or for making doctors employees of the federal or state governments.”

This is right on the money—maybe even more so than Emanuel intends. Opponents of “socialized” medicine are wrong three times over: not only do most reformers not want socialized medicine, but even European health care systems (often used as examples of socialized medicine) do not meet the criteria outlined above. Further, publicly-run health care carries with it some significant benefits that are evident right here in the U.S.

To dispel the myth of monolithic government-run European health care, look no further than Germany, where most of the population (88%) receives health care through “sickness funds"–non-profit, third-party pools of money devoted to health services. Sickness funds are built on the principle of “subsidized self-governance”: they receive public funding, but the funds must be financially self-sufficient (i.e. be able to govern themselves) and also allow a high degree of freedom on the part of patients and doctors (the former can choose their doctors and hospitals, and the latter have much flexibility in treatments).

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