Categories
culture politics

Causes and Symptoms


Photo by Center for American Progress

In the practice of medicine we have come a long way from the days when doctors could do little more than treat the symptoms their patients were experiencing and hope that they were physically strong enough to recover from the underlying condition that was producing the symptoms. There are still times when doctors are limited to treating symptoms – such as when a condition has not been diagnosed yet or when it is so far advanced that it is beyond the reach of our available medical care – but generally in modern times our doctors seek to treat the underlying cause of a problem rather than the symptoms. We need to do more of that in the healthcare industry – especially as it relates to our most pressing chronic condition in the industry: uncontrolled costs.

The first step in treating an underlying problem is to correctly identify it. As is often the case with health problems, our healthcare industry is suffering from multiple underlying problems which interact with each other in ways that magnify their combined effects and often make an accurate diagnosis difficult to make. Thankfully we have had people interested enough in this issue for long enough to have made some headway in identifying at least some of the more pronounced underlying problems. These include the cost of new medicines and health care technologies, weakening of market influences in our health care decisions, misaligned incentives in the system, and inefficiencies in the practice of medicine (like misdiagnoses, inaccurate record keeping, reliance on emergency care by some patients, and problematic record sharing between parties).

I can’t claim to have solutions to all of these underlying problems, nor can I be sure that these represent a complete set of the real problems driving our symptom of skyrocketing costs. On the other hand, I am confident that the way we will solve the problems in our healthcare industry will follow the same pattern that people used to solve the problems that the practice of healthcare has become so adept at addressing. It will require many individuals and groups tackling the problems from a variaty of perspectives and experiementing with a variety of solutions. It won’t be done simply by turning the problem over to government and expecting them to insist on providers not charging outrageous amounts for the care we wish to receive (which is essaentially the premise behind the Affordable Care Act).

While I am anything but optomistic about the eventual benefits of the Affordable Care Act, I am encouraged at many other examples of private organizations taking steps to identify and address various of the systemic problems that afflict our health care system. Some of the initiatives I know of which give me hope is the innovative ways that some companies try to reduce health care costs without reducing employee benefits (Walmart, for example), the growing prevalence of individuals having high deductible insurance plans coupled with health savings accounts (which helps to introduce stronger market forces and healthier incentives into the health care system), efforts to bring more transparency to health care from groups like Pricing Healthcare, experiments in combining data-mining with hands-on care to reduce the costs associated with statistical outliers, and the rise of Direct Primary Care Practices and retail clinics.

We are nowhere near solving this problem and we need much more in the way of innovation and fresh perspectives but we have reason to hope that this problem will be cured in time.

Categories
culture

The Scary Flu Monster

Flu ShotsPhoto By UIC Pharmacy

It always frustrates me when politics and fear drive institutional decisions rather than making decisions based on facts. One of my biggest pet peeves in this area is the hype surrounding the flu vaccine. I was reminded of this today when I heard about the new study casting doubt on the effectiveness of the vaccine.

To be clear, I am not at all opposed to people choosing to get vaccinated, nor am I opposed to organizations providing incentives such as free access to the vaccine in hopes of helping more people to choose to get vaccinated. My problem comes when organizations mandate that people get vaccinated – which is becoming more and more popular in health care organizations regardless of whether any employee or class of employees has any significant likelihood of having any patient contact. I also have a problem with all the public disinformation campaigns where the flu vaccine is heavily pushed by giving the impression that they are more effective than they really are.

The study that I heard about today indicates that the flu vaccine is effective in just over half of those adults who receive it. This is fully 1/3 less effective than has previously been claimed.

Along with that I was disappointed with the way the story was presented by KSL. They talked about the study and how disappointing it was to have this finding coming at the beginning of the flu season. That is in line with their reports last week that the flu was reaching epidemic proportions already early in the flu season. That statement would not bother me except that it’s hard to call this the beginning of the flu season when they were reporting 5 months ago that flu season was right around the corner. That made me question how long flu season is. As is often the case – Wikipedia provided the answer:

In the United States, the flu season is considered October through May. It usually peaks in February.

In other words, this is halfway through the flu season and approaching the peak. I guess they could argue that we are at the beginning of the peak of flu season but that is misleading at best when they have been promoting the flu shot for 5 months already.

Secondly, since I was at Wikipedia I wanted to get some information about the effectiveness of the vaccine that was not tied to this shocking new study. What I found there was even more disappointing to me. All my life I have been taught that the flu vaccine was most important for the physically weaker members of society like elderly and young children. Imagine my surprise when Wikipedia informs me that:

The group most vulnerable to non-pandemic flu, the elderly, is also the least to benefit from the vaccine.

So now I can see that the vaccine is less effective than previously claimed and that those who have been most encouraged to receive it are least likely to benefit from it. In a final blow to the hype surrounding this vaccine I also learned that, although we are strongly encouraged to get vaccinated each year:

protection without revaccination persists for at least three years for children and young adults.

This leads to one of two conclusions. Either vaccination every year is excessive or else we are fighting a losing battle against a disease that mutates every year so that we must be perpetually subjected to a vaccine that is barely 50% effective.

I don’t know about other people but that tells me that mandating that people receive the vaccine is based on an agenda that goes well beyond the facts – and I hate the very idea of such fear mongering.

Categories
culture politics

Do We Have Reason To Celebrate?

Photo by malfet_

It’s July 4th. Many of us in the United States are taking the day off from whatever our occupation. We will generally be spending time with family and/or friends. Food will be a big part of the day for many. Fire season may prevent this for some but fireworks are traditionally part of the experience. If you ask people what today is the answers will vary. Some will tell you it is the Fourth of July. Surely we are not simply celebrating a random date on the calendar. Others will say it is Independence Day. (My son just called it Parade Day.) What independence are we celebrating?

I know some people who will complain that those who celebrate the 4th of July are failing to see what we are supposed to be celebrating – they insist that it should be called Independence Day. Personally I like calling it Independence Day but I don’t think that what name a person attaches to the festivities is a reliable indicator of how well they remember the original purpose of the celebration.

This morning as I try to get prepared for all the running around with seven children (hoping that with sufficient preparation we can experience real enjoyment rather than hyper exhaustion) I began to wonder, do we have reason to celebrate anymore?

Categories
life

Today’s Adventure

Laura called at 9:42 this morning and told me that she needed to take Alyssa to the emergency room at Primary Children’s Hospital with a cut on her face. I told a couple of people at work so they could cover for me as necessary while I helped Laura. Thankfully it turned out that Alyssa only needed three stitches and was very brave about the whole affair. We even ran into our cousin who has been there with RSV for a few days.

After the whole thing was over I just had to think that we have been very much blessed that this is only the second time that we have ever had a child in the hospital (Isaac’s bout with RSV two years ago being the other time).

Categories
National politics

Delving Into “Six Steps”

Joe Jarvis is a doctor and a candidate for the Utah legislature. I was very interested in exploring the six steps to bring about true health-care reform in Utah that he outlined in the Salt Lake Tribune. He has been kind enough to answer some of my questions and I want to share what I have learned from him and from digging into his sources.

Health underwriting

Every critically ill or injured person will be treated in our health system whether they have health insurance or not.

The realization that doctors and hospitals are obligated under the law to treat people in need should really change the way we look at the issue of universal coverage and the underwriting process. It deserves to be one of the areas we look at to make fundamental change to improve our health care system.

Unsafe hospital practices

Another cause of inefficiency in the system. Dr. Jarvis pointed me to studies by the Institute of Medicine demonstrating the statistical results of accidents and poor industry practices. (I say statistical to make it clear that the above link does not lead to grotesque images of hospital injuries.)

Inappropriate care

Inappropriate care seems to be the symbol of all that is wrong with our system. It appears to be a direct result of a medical industry that is being controlled by the insurance industry which is more interested in avoiding legal repercussions than in keeping people healthy

Perverse incentives

Dr. Jarvis quoted an article from the Wall Street Journal on April 5. I was unable to find that article to confirm the numbers he quoted (“if everyone in America went to the Mayo Clinic, our annual health-care bill would be 25 percent lower (more than $500 billion) and the average quality of care would improve.”) I did find an article from April 7th in the Wall Street Journal, More Choices Drive Cost of Health Care, that appeared to be the same except that it had different numbers ($50 billion saved over 5 years). (Follow the link here to see more than the free preview.) While I could not verify the numbers he quoted, the concept that we must eliminate the perverse incentives that drive the health care system is sound.

Market-based health policy

Dr. Jarvis argues that “health care is not subject to market forces, such as a lowered price increasing demand. No one ever had an appendectomy because the price was right. The occurrence of illness and injury primarily determine demand for health services.” While I would agree with him in the case of an appendectomy there are services (lasik, orthodontics, or well child checkups for example) where demand will rise as prices fall. Besides that, the WSJ article cited above indicates that many people, fueled by a “more is better” attitude, will indulge in available health services that are unnecessary. This would probably not be the case if they had to pay more than a token amount for those extra procedures. Also, at times when the patient is not the driving force behind extra procedures the findings are that

More office visits, hospital stays and diagnostic procedures likely indicate poor coordination among doctors and facilities that can lead to worse care and outcomes.

So far I am not convinced that real market forces do not have a significant role to play in radically improving our health care system.

Benefit denial

I had never previously considered the cost associated with claim denials, but Dr. Jarvis provided some eye opening data. In his article he stated that “Claims costs are at least 10 percent higher in Utah than would be optimally efficient.” He was gracious enough to allow me to look through the data he used to arrive at that figure and answer my questions to help me understand what I was seeing.

Here’s what I learned; the claims cost is the percentage of the insurance company’s revenue that is spent in evaluating and denying claims – it does not count the cost of claims paid, just the cost of processing the claims. The 10% figure is a bit misleading. Let me try to clarify the numbers. The most efficient insurance provider in Utah is apparently the Public Employees Health Plan (PEHP) which spends nearly 4% of revenue in processing claims. The data from the other major health insurance providers (IHC, Blue Cross, Altius, and UHC) shows that they spend between 12% and 19% of revenue on the processing of claims. To put that in perspective, PEHP spends 1 of every 25 dollars in claims processing while the other providers spend between 1 in 8 and 1 in 5 dollars. That is 3 to 5 times higher than optimal. It is a difference of 10% of their revenue but it is not evidence that they spend 1.1 times the optimal amount on claims processing.

Conclusion

Even where I do not fully agree with the details of Dr. Jarvis’ claims about these six steps I do agree that all six of these steps are important issues to address if we are to come up with a decent approach to improving health care in our state. I also agree wholeheartedly with Dr. Jarvis that the system requires a major overhaul, not just some tinkering if we are to avoid the looming crisis in the health care system.

Categories
National politics

Willing Suspension of Disbelief

Reports from the CBO that a Universal Health Coverage Bill would be budget neutral are obviously based on the third kind of lie (namely statistics). Commonhealth sums up the effects of the bill like so:

The legislation:

  1. gets rid of employer based insurance (employers that contribute to coverage would give employees that money at first, and eventually shift to a federal health coverage tax)
  2. requires all Americans to have health insurance
  3. offers subsidized coverage up to 400% FPL (Mass is up to 300%)
  4. sets up purchasing pools (like the Connector)

Could someone please point out to me where this plan gives health care providers an incentive to provide efficient, high-quality care? It seems to me that insuring all our uninsured citizens will never pay for itself in a system that thrives on inefficiency – as the current system does. Adding inefficiency couldn’t possibly pay for itself.

Ending employer based insurance is potentially a good thing. Requiring everyone to buy insurance looks like an incentive for more inefficiency and even price gouging. And one of my senators is sponsoring this. I think he should have his head examined.

Categories
politics State

A Novel Approach

As the clock starts in our efforts to reform out Utah health care system I was encouraged by this Op-Ed in the Salt Lake Tribune.

Making health insurance affordable – forcing carriers to offer so-called “affordable plans” – will not result in affordable health care. . . . our priority must be to restore the health-care provider/patient relationship by providing the patient with cost and performance information and making him responsible for his own care. The government does not tell its citizens what house, car or flat screen to buy, but there is an assumption that when it comes to choosing a health-care service, we are incapable of intelligent decision-making and need intermediaries.

Only when the patient is armed with relevant information regarding cost and a providers performance will that patient be able to make informed decisions. Armed with such information, a patient will shop quality and price, which will drive down costs. (emphasis added)

What I really love about this is that it comes from a completely unexpected source – this article was written by the executive director of the Utah Association of Health Underwriters. Along with her valuable diagnosis, Ms. Smith also offers this idea as a possible approach to explore:

For example, an insurance company might give the patient a benefit credit equivalent to the average price of a knee replacement surgery and the patient would shop around with the information given. Based on this data, he might choose a surgeon with a long record of solid outcomes and a lower price than the benefit credit his insurance has given him.

The insurance company could allow him to keep the change in his Health Savings Account for future health-care needs. This practice is already happening on a small scale in several areas where a hospital lists a global price for a heart bypass and gives a 90-day warranty. No extra charges for pain medication, Band Aids or physical therapy – all are included.

This does not require a mandate for our citizens, and might serve as an incentive to bring some people into the insurance pool. It also allows for comprehensive health insurance plans that keep the patient as the one making decisions about how the insurance money gets spent.

As if that was not enough, Cameron drew my attention to an Editorial in the Deseret News written by a doctor talking about how he improved his practice by dropping insurance plans. Though the article is not explicit on the point, it sounds like he eventually dropped all insurance plans and now only deals directly with patients.

{Many physicians} feel that it’s their mission to serve as many patients as possible rather than to provide the best care possible. Most significant, today’s doctors are preoccupied with the bureaucracy of insurance companies. . .

To be sure, physicians are not entirely to blame. With insurance companies dictating how much doctors can charge for services as diverse as a routine checkup or an appendectomy, a doctor has only one route to more income: increase volume.

Does anyone else want to help ensure that these perspectives do not go unnoticed by our illustrious task force?

Categories
politics State

Repeat After Me

If there was one thing that I would like to accomplish related to the health care issue it would be to highlight the fact that having health insurance does not equal having decent, or even basic, health care. The Deseret News perpetuates the falsehood of equating the two:

The task force will begin the design phase of rebuilding a health care system that will ultimately ensure all Utahns have access to basic health care — nearly 300,000 Utahns don’t have insurance now.

Not having insurance is not the same as not having access to basic health care. The dangers of buying into this false association are illustrated later in these words:

Top on the list of priorities is getting everyone into the insurance pool, i.e., the chronically healthy to the chronically ill.

Is there anyone who has not heard the adage “if it ain’t broke, don’t fix it?” Forcing the chronically healthy to get into the insurance pool is a case of fixing what “ain’t broke.”

Categories
politics State

Myth Perpetuation

Just as our Task Force is getting started, NPR has a story on John McCain’s perspective on the issue. They outline his preferred approach – which seems generally right, and then they perpetuate one of the myths that might sink any meaningful reform.

“The problem is not that most Americans lack adequate health insurance — the vast majority of Americans have private insurance, and our government spends billions each year to provide even more,” McCain has said. “The biggest problem with the American health care system is that it costs too much.”

McCain wants to get people to buy their own insurance, rather than get it through their jobs. NPR’s Julie Rovner reports that McCain would accomplish this in a variety of ways: giving people tax credits, encouraging more people to set up tax-advantaged health savings accounts, and letting them buy insurance policies across state lines.

And no mandates for McCain. If you don’t want health insurance, you don’t have to get it.

What do you think of this plan? Would tax breaks encourage you to buy your own insurance? Is a mandate to have health care a good or bad idea? (emphasis added)

A mandate that everyone be insured is not a mandate that they have good health care (it would be impossible to mandate that everyone have good health care). Health Insurance ≠ Health Care. So long as we confuse the two the insurance industry will sway the debate in their own favor. Giving everyone insurance, no matter what method you use, will not guarantee that they have good health care.

As our Utah task force held their first meeting (which I could not attend) I was worried that they would not actively try to include consumers among their stakeholders, leaving the influence to industry professionals and lobbyists. I was very encouraged as I listened to the audio of the meeting when Senator Killpack listed consumers among the five major stakeholders for the task they are tackling.

Categories
politics State

House Members on the Task Force

I wrote to the co-chairs of the HB133 Task Force asking for a full list of the task force members. David Clark responded with a list of all the task force members from the House. My current list of task force members is now:

Now if Senator Killback would respond with the last two senators I would have a full list.