On this blog, we have often debated these questions: “Why is U.S. healthcare so expensive? Why is it that states like Massachusetts and California just can’t seem to find a way to provide high quality, affordable medical care for all of their citizens?”

In the past, I have suggested that the answer can be found in the work done by Dr. Jack Wennberg and his colleagues at the Dartmouth Medical School. The story that I have posted below provides the narrative behind that assertion, tracing how, over a period of thirty years, Wennberg and his team uncovered the incredible, incontrovertible waste in our health care system.

Wennberg’s work reveals that roughly one out of three of our health care dollars is squandered on unnecessary tests, ineffective, unproven, sometimes unwanted procedures and over-priced bleeding-edge drugs and devices that are no better than the less expensive products that they have replaced.

Only a Luddite would fail to appreciate the wonders of 21st century medical technology. And Wennberg is no Luddite. He is quick to acknowledge that the most expensive, aggressive care that U.S. doctors and hospitals provide is often the most effective care.

But not always. This is what is less obvious. It would seem that by spending so much more than other countries, we would be buying the best care on earth. But the evidence shows that, often, we are not. And therein lies the conflict at the heart of our money-driven health-care system: while more health care equals more profits, it does not necessarily lead to better health.

The story below, which I wrote for the winter issue of Dartmouth Medicine, will, I think, give readers a much clearer understanding of the importance of the Dartmouth research. It begins in the early 1970s, when Wennberg realized that if his home were located just 100 yards farther north, his children would be in a school district where 70 percent of all children received tonsillectomies. Instead, they lived in a school district where there was only a 20 percent chance that they would undergo the operation.

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As some readers may have noted, a recent post of mine discussing some of my concerns about virtual medicine has been met with some hostility—mostly (but not in all cases) reasoned, intelligent hostility– but dislike nonetheless. That’s fine, but here’s the issue: what’s being framed as a litany of inaccuracies is really just a difference of opinion.

First thing’s first: there is one hard fact on which I misspoke. Companies that facilitate online doctor-patient conversations like Medem, Inc. and RelayHealth have been around for close to a decade. I erroneously referred to them as new. For that, I apologize.

But here’s the thing: my post wasn’t about these companies, and even less about their age. I was writing about some concerns I have over virtual consultation—primarily, how much of the hubbub over virtual medicine will really translate into addressing what I feel are our most pressing health priorities.

Some people took offense. A comment from Matthew Holt, editor of The Health Care Blog, suggested I was “slagging off technologies that have some slight promise”—a sentiment he repeated on the front page of his blog. This is an overstatement. In my post, I made perfectly clear that I understand the excitement about online consultation and would most even likely use it myself. My reservations come from the Internet-as-messiah mindset.

One concern is with access—web medicine seems like another innovation that will benefit the “haves “more than the “have-nots” in part because poor Americans have less access to the Internet. Matthew counters my worries about the digital divide by saying that Internet penetration might be uneven in homes, but it is very high in schools, libraries, and workplaces. This is true, and it’s this sort of broader definition of Internet access that informs statistics celebrating America’s near-universal web presence.

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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 Center for Public Integrity, a public interest investigative journalism organization, has obtained copies of a Centers for Disease Control and Prevention (CDC) study of environmental and health data in eight Great Lakes states that was scheduled for publication in July 2007. The report, which pointed to elevated rates of lung, colon, and breast cancer; low birth weight; and infant mortality in several of the geographical areas of concern has not yet been made public.

A few days before the report was slated to be released, it was pulled. Meanwhile, at precisely the same time, its lead author, Christopher De Rosa, has been removed from the position he held since 1992.  The Center for Public Integrity is asking why.

The study, “Public Health Implications of Hazardous Substances in Twenty-Six U.S. Great Lakes Areas of Concern” was developed by the CDC’s Agency for Toxic Substances and Disease Registry (ATSDR) at the request of the International Joint Commission, an independent U.S-Canadian organization that monitors and advises both governments on the use and quality of boundary waters.

The CDC report brings together two sets of data: environmental data on known "areas of concern" — including superfund sites and hazardous waste dumps — and separate health data collected by county or, in some cases, smaller geographical regions.

The study does not try to prove cause and effect. Instead, it outlines areas for further study and data collection on the link between pollution and health.

"Let’s say we have a superfund site and we also find elevated risk of leukemia in the county — is that related? We don’t know, but people living in the area can logically argue that we ought to find out," Dr. Peter Orris, a professor at the University of Illinois School of Public Health and one of the peer reviewers of the study told Oneworld.net.

Since 2004, dozens of experts have reviewed various drafts of the study, including senior scientists at the CDC, Environmental Protection Agency, and other federal agencies, as well as scientists from universities and state governments, according to consumeraffairs.com. Orris is just one of the several experts who reviewed the study and who, along with the International Joint Committee in a December letter to the CDC, have called for the report’s publication.

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A reader sent me this provocative piece on Canadian healthcare, written by someone who knows care on both sides of the border. It comes from the Campaign for America’s Future website. And it is, as advertised, a “myth-buster.” I look forward to Part II.

Mythbusting Canadian Health Care Part I                
By Sara Robinson                
February 4th, 2008

2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning — and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I’m both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I’m in a unique position to address the pros and cons of both systems first-hand. [my emphasis –mm] If we’re going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here’s the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they’re made of.

1. Canada’s health care system is "socialized medicine."

False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.

The proper term for this is "single-payer insurance." In talking to Americans about it, the better phrase is "Medicare for all."

2. Doctors are hurt financially by single-payer health care.

True and False. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:

First, as noted, they don’t have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

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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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Today, the New York Times reported on a “troubling new report from the Agency for Healthcare Research and Quality (AHRQ), which analyzed hundreds of studies in an effort to advise men about the best treatments for prostate cancer. The report compared the effectiveness and risks of eight prostate cancer treatments, ranging from prostate removal to radioactive implants to no treatment at all. None of the studies provided definitive answers. Surprisingly, no treatment emerged as superior to doing nothing at all. [my emphasis]

“When it comes to prostate cancer, we have much to learn about which treatments work best,” said agency director Carolyn M. Clancy. “Patients should be informed about the benefits and harms of treatment options.”

The Times went on to quote the agency saying “Considerable over-detection and over-treatment may exist.” 

I have written about this issue here  and here; Niko has written about it here.

I am not going to repeat what we have said in the past. But let me emphasize that the AHRQ looked at practically every treatment now being used:

“The agency review is based on analysis of 592 published articles of various treatment strategies. The studies looked at treatments that use rapid freezing and thawing (cryotherapy); minimally invasive surgery (laparoscopic or robotic-assisted radical prostatectomy); testicle removal or hormone therapy (androgen deprivation therapy); and high-intensity ultrasound or radiation therapy. The study also evaluated research on ‘watchful waiting,’’ which means monitoring the cancer and initiating treatment only if it appears the disease is progressing.”

The agency goes on to warn that “all active treatments cause health problems, primarily urinary incontinence, bowel problems and erectile dysfunction.”

Finally, the Times points out that while “one study has shown that men who choose surgery over watchful waiting are less likely to die or have their cancer spread, another study found  no difference in survival between surgery and watchful waiting.” Moreover—and this is important—“few patients in the study had cancer detected through P.S.A. tests. As a result, it’s not clear if the results are applicable to the majority of men diagnosed with the disease.”

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The worst thing that a journalist can do is to present opinion as fact—especially when talking about something important. To do it on Super Tuesday is particularly irresponsible.

Yet that is exactly what conservative columnist David Brooks has done in today’s New York Times.

Responding to what Paul Krugman wrote yesterday (see my post below, “But There Is A Difference Between Obama and Clinton on Healthcare”), Brooks attacks Hillary Clinton for insisting that if we want universal healthcare, we are going to have to ask everyone to get into the pool. Rich and poor, young and old, healthy and sick—everyone will need to contribute to the national healthcare fund by signing up for insurance. Otherwise, we won’t be able to afford the subsidies that low-income and working class families will need to enroll in the plan.  Hillary’s mandate is much like the mandate that we all contribute to Social Security or Medicare.

As Brooks sees it, the issue “is over whether to use government to coerce people into getting coverage. The Clintonites argue that without coercion, there will be free-riders on the system.”

In other words, the Clintonites are concerned that young, healthy people who earn too much to qualify for subsidies may not sign up—especially since, under healthcare reform, they will know that once they do get sick, insurers will be required to cover them and will not be allowed to charge them more than they charge everyone else. Thus, while older, sicker people pay into the pool, younger healthier people will get a “free ride”—until they need insurance.   

“They’ve got a point,” Brooks admits briefly, referring to Clinton’s position.  It’s really rather hard to argue with common sense. “But,” he adds, “there are serious health care economists on both sides of the issue.”

Who exactly does he have in mind?  Brooks doesn’t say.

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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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Today, I talked to Bob Blendon, who is a professor of health policy and political analysis at Harvard’s Kennedy School of Government, about Super Tuesday’s multi-state primary contests and what they might mean for healthcare reform.

Blendon agrees with the consensus on the Democratic race. Hillary Clinton and Barack Obama are running nose to nose, but Blendon points out, if you take a closer look at the polls, you find an unusual contradiction.  Not only are the voters split between the candidates; there are very split, within themselves.

“When you ask about the issues, Clinton wins on almost every point, including healthcare,” Blendon reports.  But when you ask about character, likability, leadership, ability to inspire—Obama is the clear favorite.

“Usually, people can’t live with that much incongruence,” Blendon adds. “Once they decide who they like, then they decide that person is the best on the issues. Normally, people don’t like incongruence within themselves.”

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