Centerfield

Interesting C3,

"The United States is on the wrong track. Health care costs are escalating and the
numbers who are uninsured or underinsured are growing ever greater."

A conclusion that certainly connects immigration with rising health costs. I wonder if increasing global warming can be added by the end of the decade as well. This would link all American worries listed above together. Of course, these healthcare concerns don't include an even greater medical nightmare cost: terrorism and the dollars in safeguards now being added to the total cost of healthcare to deal with the inevitiable. Republicans had a hard time coming up with even the money to test and monitor the lungs of NYC first responders. Protecting blood supplies and ramping up plans to deal with biological and radiological attacks are a real concern. The growing number of hospital death is also driving up costs. There is little mention of the cost of litigation or the failure of insurance coverage in supplying "all credible therapies" to cure pathologies. With increasing cures, there will come increasing costs as baby boomers try to live forever.

The report doesn't talk about what complete overhauls would entail. What is the verdict in Boston so far concerning their solution?

Funny, I heard horror reports this summer about other countries with healthcare problems. Of course, the rising cost of energy is also a drag on the overall healthcare cost.

Posted by: Maxtrue at August 20, 2006 02:13 PM

I worthless study based on polling. So, people who do not work in health care want to tell the medical community how to do their jobs. Does that mean that the nurses should be able to tell the automotive industry how to organize itself because they get their cars fixed occassionally? I do not see the point of the study.

Posted by: superdestroyer at August 20, 2006 04:26 PM

Superdestroyer, I think you are missing the point. I don't think anyone was telling Doctors or nurses how to do their job. It seems to be that the poll states complaints on cost and management of healthcare. Most of those are in the hands of administrators, insurance companies and lawyers. I know that I have gotten good care; but it has been innefficient and wasteful as hell as of late. A procedure that cost $150 and was done in the doctors office 10 years ago for me was done for a total cost of $7500 and required two other vists and for me to take extra time off from work last year. The results were the same. The only thing that changed was the legal and insurance situation that dictated a more wasteful solution. That is where the complaints are. Not with the doctors and nurses themselves(with the exception of the medical profession not doing a good job of running out quacks). Take insurance company mandates and the inflated cost of malpractice insurance from out tort happy society out of the system and you could probably reduce costs by more than 50% and improve efficiency at the same time.

Posted by: Jim M at August 20, 2006 06:04 PM

Some initial responses:
Max;
It was a survey of people's concerns; not a description "from the inside of what's wrong" nor a prescription for how to change it.
I've not seen good data on the cost of illegal immigrants seeking care (not surprising since most would not likely answer the question about citizenship accurately). The cost of caring for illegal immigrants is certainly not zero. The litigation and "defensive-medicine cost" issue has been raised by many, especially by docs. Unfortunately the data so far is poor. As a doc I can say it definitely exists. At the same time I have big doubts that its elimination would lead to healthcare "balancing the books". As for responsiveness in a crisis I personally think the US system does fairly well, due to the many drills we have. (Folks will raise the issue of Katrina but as far as I know the problems were with evacuation of the populace and incapacitation of the local health care system.) The testing of NY fireman after 9/11 says more about our PUBLIC HEALTH system. Yes it is woefully underfunded.

Destroyer;
As a physician I would suggest 1) if healthcare doesn't meet the consumer's expectation then it has at least partly failed. To use your automotive industry analogy, I wouldn't expect a nurse to tell GM how to make cars but I would certainly expect her to tell GM if she didn't like their cars (especially if she could only buy cars from GM) 2) This IS an opinion poll but I must say as a health care worker the recent don't surprise me. Its what I hear from patients all the time.

Jim;
A lot of good research on the added "administrative cost" of healthcare in the managed care era. Unfortunately, it has not increased costs %3000 (i.e. $150 to $7500) On the other hand their decent evidence to suggest that the overall effects of managed care have been to slow (but not eliminate) healthcare inflation. Much bigger factors for increased costs are the cost of new technologies, the increased consumption of healthcare and the aging of the population (i.e. the older you are the more healthcare you consume per capita)

Posted by: c3 at August 20, 2006 07:52 PM

My money example had to do with overall practice that has been influenced by all the factors. Instead of a family practitioner simply removing the cyst I had in his office with a minimal amount of time, I had to go see a specialist, then schedule time for out=patient surgery that required much more then was required for what needed to be done. As far as administration, I worked on the insurance side for twenty years. I saw how messed up things got on the insurance side too. Especially in the way it has a bad habit of avoiding taking care of things early. It is a combination of all these facts. Technology adds to it. Sometimes, I have to wonder if some of the stuff gets used just to justify the fact it was purchased. That part is the cynic in me, though.

Posted by: Jim M at August 20, 2006 10:01 PM

Jim;

Instead of a family practitioner simply removing the cyst I had in his office with a minimal amount of time, I had to go see a specialist, then ...

This touches on a key underlying problem with the US Healthcare system. Unlike almost any other health care system we have a minority of primary care physicians. Many health planners have suggested the ideal ratio of primary care to specialty care is 60-40 up to 70-30, primary to specialty . In the US the ratio is reversed at about 33%-66%.

Posted by: c3 at August 20, 2006 11:23 PM

Chris, isn't that skewing largely because specialists have more power to set their own rates and thus earn a great deal more, while primary care physicians must accept much lower rates and see many more patients in order to be approved providers for most HMOs? The financial incentives and improved working conditions/hours leads more doctors to become specialists than PCPs?

Posted by: PatHMV at August 21, 2006 01:19 AM

things are tough all over, health wise.
I was searching the web for health care problems in other countries. I came across one powerpoint display about the problems in the UK. The basic problem is economic - unlimited wants (more & better health care) versus limited means (finances). I know this is a "duh" statement, but in order to revamp the system, we need to go back to this basic idea and maybe we can succeed from there, like
1. define good health - do we want tolerable or perfect?
2. what is our limit - should we have a limit - to achieve this health? (think extremely ill and elderly patients)
3. what are the societal parameters of good health?
(permanently disabled and mentally "ill") and should we take care of them?
4. how do we deal with privacy with public health care?

Posted by: Rachel at August 21, 2006 09:18 AM

Pat;

Chris, isn't that skewing largely because specialists have more power to set their own rates and thus earn a great deal more, while primary care physicians must accept much lower rates and see many more patients in order to be approved providers for most HMOs? The financial incentives and improved working conditions/hours leads more doctors to become specialists than PCPs?

Simple answer: NO. But to your specifics, rates are based on history and historically subspecialists and "procedural" specialists got paid more "per widget". That's the foundation; the power in rate negotiation today is all over the place. A group of specialists may command higher reimbursement if they're in short supply and/or the contracted businesses demand "group X' be on the plan. At this point in time neurosurgeons are commanding high dollars but CV surgeons (while still very well paid) are experiencing much competition. How many patients you see per day isn't a factor in what you get paid per encounter.
The wave of the future: Pay for Performance (i.e. if you demonstrate consistently excellent work you get paid more or better put you don't get paid less and/or you have more patients available to you).
Probably biggest drivers of med students going into specialties are debt and a sense of greater prestige garnered from the subspecialty-dominated world of the medical school medical center.

Posted by: c3 at August 21, 2006 09:51 AM

Rachel;
Yes most every western nation is over budget with health care. AS to your specifics. We have pretty good definitions of what comprise "good health". That however, doesn't nessarily lead to less health care costs. Imagine a place where everyone was smoke-free, alcohol -free, limited meat and exercising regularly. But that in spite of this they all died quickly at age 65. They'd all be in great health but spend very little on healthcare. If we're looking at reducing overall cost (which will lead to better access) then we should focus first on those healthcare interventions that have been demonstrated in good research to make a difference in terms of living longer or living better (evidence-based medicine). Once we know those (and we know many) we can go after the easy targets such as new, expensive procedures that haven't yet proven themselves. The harder ones are the every day ineffective interventions (i.e. antibiotics for colds).

We also need to figure out how to deal with consumer demand for ineffective care.

But most everyone agrees that we must drive out costs that don't add to health

Posted by: c3 at August 21, 2006 10:01 AM

We all know that the American health care system is fundamentally broken. That is why every year, Americans fly to other countries for complex and innovative surgeries, why rich European businessmen do not fly to America for such surgeries, and why virtually no important drugs come out of American research. Uh....No, wait.

You have to pick your poison. The American system works fabulously well at treating and developing treatments, and I suspect that it has been able to do so precisely because it hasn't been bound down by the kind of problems that beset the Europeans. It has the problem that if you're poor, you're kind of out of luck. The difficulty is, how to fix the bottom end without compromising the top-end. At a time when we should, in my view, be talking about how to get government out of education, it's amazing that people want to talk about how to get government into healthcare.

Posted by: Simon at August 21, 2006 11:25 AM

Right. It's fundamentally expensive, for a variety of reasons. The costs continue to represent a growing share of average personal income, I believe. But broken? People aren't exactly dying in the streets in droves, are they?

If there's a problem, it's that we (as one group of "the electorate", not as individuals) don't seem especially willing to pay for what we're getting, we'd prefer to continue enjoying the entitlement of continually demanding more and better, but paying for as little as possible of that more and better. And paying while pretending we don't...

Any reasonable approach to healthcare "reform" has to be constrained by reconciling what we want with what we are willing and able to pay for. And as Tully always points out, we're already rationing healthcare.

Is this going to get worse or better as the population grays, costs continue growing at a relatively steep rate compared to other costs, and we continue to expect employers to pick up the lion's share of the tab? Sooner or later we're going to have to face the question of whether we really think each and every one of us deserves to live as long as science can keep us alive. Which I think culturally we sort of assumeas a group is morally correct and should sort f be a given, but which we don't really ever seriously face.

The thing is that, bottom line, every additional day of life provided by extraordinary science is going to cost more than the last one, and that's a VERY BIG problem. It most likely means more rationing. We have to face this in order to ensure that the way things unfold matches what the people think is right. If the people don't face it that way, the rules will keep being made for us while we look away.

We're going to have to face that a growing class of procedures and treatments are going to be classed as luxury items or simply extraordinary measures of low efficacy compared to cost that many people just won't get. Such measures will end up being paid for only via one of two ways: either one will pay for it out of pocket, or one will opt to pay A LOT extra for super-duper insurance. In fact, we're very likely to see health insurance and life insurance overlap and/or converge, if this has not happened already.

If you don't have bunch of dough of your own to pay for the fabulous advances of the future or you haven't bought super extra coverage, you won't get every treatment available. I don't see any way around this.

Did anyone catch any of last night's 60 minutes about wealthy older people receiving treatements of gray-area legality to keep them young. I didn't watch it all, but it boiled down to middle aged people receiving the sorts of treatments that pro athletes are precluded from using, like steroids, human growth hormone , and so on. The people availing themsleves of such treatments seemed pretty pleased by them.

Does anyone else see this as a new and growing area for political/philosophical schism, one that might be an obsession in the 21st century?

Posted by: bk at August 21, 2006 12:10 PM

Rachel;
I previously posted

Imagine a place where everyone was smoke-free, alcohol -free, limited meat and exercising regularly. But that in spite of this they all died quickly at age 65. They'd all be in great health but spend very little on healthcare.

Sorry wong example. Better example: many if not most men between the ages of 21 - 50 have poor health habits (i.e. smoking, drinking, poor diet) but they don't go to the doctor very often and usually don't spend much money. Ironically, many just up and die at say age 53 of a massive heart attack. So they've had "bad health" but spent little on healthcare.

Brian;
Good points. Obviously, with cost such a big issue we will use a "cost/benefit ration"-type analysis. This leads to some very uncomfortable analysis regarding elder care. At a baseline a healthy elder (age 75) will spend more money than a healthy 60 yo. If you have a debilitated, multiple chronic illness 72 year old who needs dialysis for renal failure we know the cost but how does it benefit the individual beyond life prolongation, how does it benefit society. This gets even more complicated with "longevity medicine". I have no doubt there will be a GREAT DEBATE regarding such issues in about the year 2020 between retired boomers and the Gen X'ers and Millenials who would by then be footing the bill.

Posted by: c3 at August 21, 2006 02:48 PM