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The Practice of Medicine

Heart Surgery at 2% of the Cost in the US?

Say what you will, when competent surgery can be proposed and completed at 2% of the cost in the US, this is inherently disruptive.

Some differential can be explained by salaries, but this level of difference, unless there is a significant outcome difference, should get the attention of all.

There used to be a clothing and shoe industry in the US. Not any more. They are virtually all off-shore and many a mill town in the Northeast has seen an economic decline as a result of the loss of industry and jobs.

Of course, there are many more barriers to obtaining health care from other countries than purchasing goods, which only need to be loaded onto a container or the hold of a plane and purchased in a local store. Health care requires a personal interaction, and in this case would mean that patients go to India. And licensing restrictions curtail the ability for health professionals to cross state lines and work, let alone international borders.

Any student of business can’t read this article without thinking about ways to take advantage of this remarkable cost spread. Just as insurance carriers make it more expensive for patients to buy drugs that are not generic or in an approved formulary, there are any number of ways to create alliances with foreign facilities, and design incentives for patients to get on an airplane and obtain services in these less costly settings. Whether medical tourism will be a one-up situation for those lacking coverage and possessing a sense of adventure, or it will become a common option for non-emergent procedures remains to be seen. Read more…

Moral Hazards – an Economist Weighs in on Health Policy

Scholarly articles that test behaviors in the real world are fascinating and of potential value if their findings are acted or, or studied further.

This article sites such a study where the impact of co-pays on compliance and on the general issue of compliance when the symptoms of a significant disease are silent or delayed.

We are of mixed mind in considering the implications of social engineering on people’s behavior. On the one hand, adults should take responsibility for doing the right thing, or pay the price when they don’t. On the other hand, paying the price in real terms with respect to poor health decisions, often means that society at large, as well as innocent family members, pay the price of individual ignorance and/or stupidity.

The larger point in this article is that incentives and skin in the game matter with respect to both taking appropriate health measures, as well as avoidance of waste in terms of treatment or diagnostics.

…And the other 367,000 babies born that day

On a quick trip to the grocery store I couldn’t help but notice the dozen or so smiling faces of the Duchess of Cambridge with her new baby while I was waiting in line to make my purchase. But it was this article in Slate.com that MCNtalk found interesting to read – UNICEF statistics and the Slate.com author’s thoughts on childhood diseases, access to secondary education, clean drinking water – things all parents of newborns worldwide ponder to varying degrees.

While it’s all very exciting that this particular baby was born—and I do wish him well—I can’t help but wonder about the estimated 367,000 babies born (roughly 4.3 born a second) around the world on the same day the most important baby ever came to be. While many of those commoner babies were also born into a world of relative privilege and safety—though not royal family levels of privilege, by any means—many of them were not. Many of the babies born that Monday are inheriting a world that is dangerous and even deadly, often for reasons that could easily be prevented.

Medical Tourism – Another Example of a Seriously Flawed US System

This article on hip replacement costs and the experiences of a medical tourist in Belgium highlights any number of issues. Yet most readers would yawn at the obvious – that we pay in the US multiples more for equal or lower health outcomes. The story describes a patient who was quoted a price of $78,000, NOT including surgeons fees for a hip replacement from a local US hospital. The patient was able to receive the same operation INCLUDING round trip air, for $13,660 at a private hospital in Belgium, including the surgeon’s fee. And the hip joint was made by the same US company that sells the device in the US for more than the cost of the entire procedure in Belgium.

Interest groups and politics (including partisan bickering), lack of courage at confronting and tackling the matter,  government indifference, and lack of economic skin in the game by patients mean we all get less for more. Government interference is decried by many, but it seems to work in the case of Belgium and others in Europe and elsewhere that regulate the medical market. The alternatives in settings like the US where healthcare is largely regarded as “free” by those who receive it has resulted in what we in America experience. We patients pay little more than a copay or deductible with the rest covered by private or government insurance. We have no incentive to shop, price compare and demand price transparency. But the cost borne by government and private payers is very real and the billions of dollars in excess GDP means that these funds are not available for other productive uses.

If cars, electronics or food were five times the price in the US than Europe, regardless of the logic, there would be a grey market and a hue and cry by those individuals footing the bills. Where is the outrage at the metrics described in this article? It is inconvenient and in the case of emergent situations, impossible to get on a plane and travel abroad for much cheaper care. And the patient who has no economic driver to do so has little reason to consider it.

In the end, we all pay via lower salaries, higher taxes, or both – fueling a bloated health care system enabled by indifference and ignorance.

Worldwide Decline in Ancient Scourges

We in the US fight about our bloated health-care system and the extraordinary waste and inflated prices that are emblematic of the problems and challenges we face.

While we engage in these squabbles there are millions in the world who are helped by simple, inexpensive interventions, leading to restoration of life or meaning of life.

Nicholas Kristof of the NY Times illustrates examples of these in his recent column. The column and his work are useful and enlightening, as are the comments of readers in the online version we are linking to.

These Deaths Are Not Statistics…

In medical school and residencies the teaching is that narcotics have no place in the treatment of most chronic pain, especially musculoskeletal pain. But these teachings have been ignored and people are dying as a result. This article cites findings on significant death rates among women due to opiate overdoses, including from Oxycontin. These are prescription drugs, either received directly or drugs diverted to the street. These deaths are disproportionately the poor, single mothers, and the defeated. Federal data shows a quintupling of deaths among women due to prescription pain killers since 1999, climbing at a rate higher than men, with the gender gap narrowing.

More women die from these drugs than from homicide or cervical cancer. These deaths are not statistics. They are men and women who did not need to die and most likely did not need the narcotics.

Physicians who prescribe them casually and the companies that create and promote them aggressively should rethink their motives and their practices. It is easy to say yes to drugs. It is harder to listen with one’s heart and mind to the real pain that underlies many of these lost lives. Collectively we must find a different path. Read more…

Diagnosis: Insufficient Outrage

There is no shortage of legal and government sanctioned abuses that are flagrantly displayed in our health care system. One is hard pressed to know what to be more concerned about — the abuses, or the complacency of the average consumer. This article on hospital pricing describes the normative practice of variable fees in health care for the same service, with little logic and no link to quality or efficacy. That payers are willing to tolerate so-called facility fees, where significantly higher charges are paid for a service that is performed in a hospital vs. in a non-hospital location, is difficult to understand or justify. Unfortunately the average patient cares not at all about this sort of abuse. After all, they don’t pay directly. They just expect that insurance should cover whatever charge is leveled for their care. The average patient does not ask about price on services costing thousands, but likely scans the prices on mayonnaise at the grocery store to ensure the best deal. Of course they produce their own hard-earned cash for the latter.

Health care reform does nothing to change consumer behavior with respect to caring about cost. The burden and duty to address these abuses must be assumed by the payers, including employers and government. Be assured that those who benefit from the current regime will politicize efforts to control abuses and excesses, as has already taken place in the partisan attacks against health care reform.

Interestingly, the problem has been largely defined as excessive costs. However as the article references, excessive utilization is of equal importance. An overpriced procedure costs nothing to the patient who not only does not need it, but does not undergo it. Patients should follow the money and be ready to question the need for procedures recommended on their behalf. Will one really learn much from a particular study or test? Is that surgery really necessary and is that drug likely to make a difference? Our health care system is very good at driving utilization and consumption. There is little difference in behaviors between many non-profits and for profit systems when the underlying economic model is fee for service. If one provides the service, one generates a fee. The good deed of restraint and judgment, when it leads to non-consumption, is rewarded with virtue but little else.

A profound article, and must read for all patients and physicians

By Brian L. Grant MD

This article on doing no-thing is the best medical article I have read in some time. Properly applied, this technique would do more to solve our health care crisis than all the PPO discounts, new drugs, payment reforms or other interventions and improvements to our system. Doing no-thing, properly applied would reduce prescriptions of unnecessary harmful drugs, surgery, diagnostics, and more. So much of health care is not necessary. Sometimes this can only be learned in hindsight, but often it is obvious from the start.

Doing nothing is perhaps a bit of a misnomer. The act of listening, empathizing and caring – when active interventions are not of benefit to the patient.

The comments on this article are well worth a read. Some are highly critical of the author and others are most supportive. Read more…

Kennedy, Vaccinations, Autism, and Junk Science

It’s been quite a while since MCNtalk has posted on the subject of childhood vaccines—since our February 12, 2012 post, “More Doctors ‘Fire’ Vaccine Refusers.” But the issue has not gone away. As this article in Slate points out, there are still those who argue publicly that there is a link between autism and childhood vaccinations, specifically that a vaccine preservative called thimerosal causes autism when injected into children.

It is important to understand that the original study in 1998 linking childhood vaccinations and autism has been thoroughly debunked multiple times using rigorous standards of scientific evidence. (Read “Vaccinations and Autism—Junk Science Is Not a Victimless Crime” for a summary.)

Robert F. Kennedy Jr. gave this year’s (May 24) keynote address at the Autism One/Generation Rescue Conference in which he strongly argued for a link between childhood vaccination and autism. The Slate article touches upon the speech and subsequent conversation between Slate and Kennedy as well as neatly summarizing pertinent facts on the issue. Why is this important? Because when people are not vaccinated, they needlessly put not just themselves at serious health risk, but their entire community as well.

We refer to people who say vaccines cause autism with the shorthand “anti-vaxxers” or say that they are part of the “anti-vaccine movement.” Kennedy said that he is “very much pro-vaccine” and that “vaccines have saved millions and millions of lives.” They will save even more lives if he and his colleagues stop spreading fear and misinformation about them. Kennedy is a passionate guy with practically unique name recognition, powerful connections, and the ability to command attention. He could reverse the course of the anti-vaccine movement today if he announced that his concern about vaccines had been well-intentioned, but that research has shown that vaccines don’t cause autism after all. It would be a proud legacy, one worthy of his name.

Read more…

Release of the DSM-V

The American Psychiatric Association unveiled this past week the fifth edition of its handbook of diagnoses, the D.S.M-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth edition), after 14 years in the making.

This article in The New York Times neatly summarizes a major, on-going discussion over the publication. Per the author,

The media will trumpet the release of the new D.S.M., but practicing psychiatrists will largely regard it as a nonevent. Unfortunately, the same cannot be said for other institutions — insurance companies, state and government agencies, and even the courts — which will continue to imbue the D.S.M. with a precision and an authority it does not have.

Psychiatrists tend to treat according to symptoms. However, the manual carries a fair amount of clout with the rest of society: They are the passports to insurance coverage, the keys to special educational and behavioral services in school and the tickets to disability benefits. Sometimes a diagnosis of a condition like autism, A.D.H.D. or conduct disorder is necessary for students to qualify for special therapies. And diagnoses also figure in disability determination.

As noted, the D.S.M. is an imperfect guide to predicting what treatments will benefit patients most — a reality tied to the fact that psychiatric diagnoses are based on clinical appearances that tend to cluster, not on the mechanism behind the illness, as is the case with, say, bacterial pneumonia.

There are definitely changes in the D.S.M.-V over the fourth edition, and as the article notes much of this this will most likely change as researchers learn more about genetics, brain circuitry and cognitive data to fashion better guides to what to prescribe for patients, and in terms of what new compounds to develop. Read more…