Congress is afraid to talk about the critical issues, like how much can we reduce the money we spend on health care. The obstructionists in both parties refer to this as “rationing”, which serves their real interest, protecting the current system, and preserving the flood of cash that system gives them.
In this post, I tried to estimate the amount of money we could save in a public option that looked like a standard insurance company but was operated by the government, without the pressure to produce ever-increasing profits demanded by Wall Street and rich investors. The numbers are big, but the real money is changing the way we provide health care.
One major part of the financial picture is more efficient treatment. David Leonhart of the NYT tells us about five different treatments of prostate cancer, ranging from “watchful waiting” to several kinds of radiation therapy to treatment with a proton accelerator.
Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. Most die of something else before prostate cancer becomes a problem.
In a similar vein, Atul Gawande, in the New Yorker, discusses the different motivations of providers around the country, focusing on the amazing differences between the Mayo Clinic and the town of McAllen, TX, and trying to explain this:
In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.
This tells us that one crucial area for the public option is a fully funded and extensive program to study and make decisions about best practices, and a mandate not to pay for other treatments unless there is a demonstration of a benefit to a particular patient.
Another crucial issue is end-of-life care. From Reuters:
The one in 20 Medicare patients who die each year use up almost one-third of expenditures by Medicare, the government health insurance program for the elderly and disabled.
One third of expenses in the last year of life are spent in the final month, according to the report, with aggressive treatments in the final month accounting for 80 percent of those costs.
People who choose non-aggressive treatment spend substantially less. And this is a realistic choice. Jane Gross in the NYT gave a moving description of the choices made by a community of aging nuns.
On average, one sister dies each month, right here, not in the hospital, because few choose aggressive medical intervention at the end of life, although they are welcome to it if they want.
“We approach our living and our dying in the same way, with discernment,” said Sister Mary Lou Mitchell, the congregation president. “Maybe this is one of the messages we can send to society, by modeling it.”
This is a community we can all learn from, just as so many of us did in our early years.
No one thinks medical treatment is fun, and no one wants to waste money on it, at the end of our lives or in the middle. The health care industry has persuaded all kinds of people that it can accomplish much more than it truly can. Education about the wisdom of treatment at all stages, both for physicians and patients, is the best thing we can do to insure lower costs.
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Nicely executed piece. I would add reforming preventive care – vaccinations, physicals and routine check-ups, office visits to monitor chronic conditions and react early to changes in prognosis. Insurers fight such immediate expense even though I believe they reduce total medical costs per patient life. What is irrelevant to their profits is what money is spent in the current, one-year coverage contract. An arrangement ripe for reform, do you think?
I just don’t see a place for private insurance companies. Aetna pays about $2bn a year to investors. All that money comes out of the health care system, on top of all the money HCA and other hospital companies suck out. It makes no sense.
There is something that bugs me about this – who decides it’s “end of life” and backs off on treatment? I ask because both of my parents were faced with decisions like that, and in one case one parent lived three years due to aggressive treatment, in the other, my other parent is cancer-free for over a year from Stage 3 cancer due to aggressive treatment. Both were in their late 70s when these decisions were made. I get a whiff of “you’re old and useless and using up medical care dollars – die already” from this, and it don’t smell so good. Nobody knows whether treatment will be successful before it is done.
Thanks masaccio.
There are tremendous opportunities through transparency for single payer to be a huge success. The current system doesn’t foster competition.
Drug firms’ cash skews doctor classes: Company-funded UW courses often favor medicine, leave out side effects
Emphasis mine.
That is a question only you and your family can answer, with the best advice you can get from medical professionals. That is true in the convent as well, as the quote shows.
Exactly. Competition among health insurers only leads to culling the aged and unhealthy from their policy holders, not to any efficiency gains or improvement in health outcomes. It makes as much sense as privatizing the fire departments among various companies, who will then only insure buildings that are unlikely to burn down, and when fires do start, they will find reasons not to spend money putting them out, on the ground that they did not disclose some “pre-existing” fire risk.
“Congress is afraid to talk about the critical issues”
Do you really believe this?
Doesn’t it make more sense that rather than being “spineless”, they are simply representing the big money that got them elected and keeps them there?
I mean, wake up and smell the coffee. It’s money that rules the system, and this kind of talk that they are simply ‘unwilling’ flies in the face of the very reality that is before us.
Until people accept that our entire system is broken and corrupt due to money, and call it for what it is, rather than calling Dems “spineless” or whatever, nothing is going to change.
Dems aren’t “spineless”, they’re simply as corrupted by money as the other side of the aisle.
This kind of framing does nothing to advance the best interests of our country.
…adding, private insurance in health care has no incentive to reduce the staggering increase in the percentage of GDP devoted to the medical-industrial complex, as there earnings are directly based on a percentage of the total amount collected as premiums. As costs rise, premiums and Medicare reimbursement rises, and the 20-30% of the total becomes that much larger. The insurers have just as much interest in rising health care expenditures as Big Pharma.
I live in Japan, am enrolled in the national healthcare plan (which everyone, including short-term exchange students, are required to join) and benefit hugely from the sense of the security that my healthcare needs are covered. I have total choice of doctors, treatments, etc. and scripts (including those for traditional herbal meds) are covered. The monthly premium and co-pay is scaled to income and coverage is by household. The other day I saw a specialist at university research hospital who is monitoring what might be the start of a hernia. My co-pay was $6. At the same hospital, I see a liver specialist and researcher who is monitoring my HepC with bloods works, sonograms etc., to assure no progression to cirrhosis. He is pushing me to do interferon; I have asked if it can wait until I finish my dissertation before starting and he is fine with that, but wants to keep a close eye on things.
Sorry for the personal, medical details, but my point is that it is a system that I can engage with flexibly, where I can seek prevent care because I am not terrified of cost… And no, there is no bureaucrat between me and my drs…
In a previous post, you asked if we need to change our culture to get good healthcare. I would put it slightly differently. I think this is one of those moments when we can become conscious of, question and even renegotiate our social contract; to think about what we get and what we give up. I think if we can back up and think about the real meaning of health and well-being, especially in the last stages of life, we would come up with a very different set of trade-offs. We would move away from technological and medical heroics to an approach that have a much greater emphasis on prevention.
I suppose that it’s downright wicked of me, and I don’t have any desire to fuel animosities based on ethnic or national differences, but sometimes I wish that some group would run a PR campaign on this whole health care mess and show the investors, including whatever Middle East princes, Russian oiligarchs, South American drug lords, and NY Mafiosa are among the ‘investors’.
People seem to forget that anyone can own stock in US companies.
If these stocks were all owned by pension funds of firefighters, or teacher’s retirement pensions, maybe I could stand the thought of it. But this money is almost certainly siphoning right out of the US of A.
You’d think the Republicans and Blue Dog Dems would have figured that out by now.
But as we see….
I’m happy for both your parents. It sounds as though both may have been victims of malpractice.
No, no one knows with 100% certitude, but we ask physicians to give us the precentages.
My Dad was in terrible shape when he had the heart attack that killed him. He could no longer smoke or drink and without those two chemicals, in addition to the other diminished capacity he had, life for him was very miserable. He had a living will and he most certainly did not want to be resuscitated. His cardiologist, however, forgot to tell him that if he wasn’t wearing a “do not resuscitate” medallion, the paramedics had to resuscitate him, put him on the ventilator.
Then the cardiologist wanted to keep him on the ventilator for three days, just to see if he would wake up. The neurosurgeon told us he was already probably brain dead. After three days, the cardiologist still wouldn’t let him off the ventilator. This was a huge pay day for him and the hospital.
As soon as we took him off the ventilator, he passed. He had been dead for four days, the cardiologist, just wanted more money for himself and the hospital.
If I were you, I’d check up on exactly what kind of “aggressive” treatment your parents received. Were the conditions with which your parents were diagnosed really as serious as the physicians claimed? Based on the evidence you provided, it doesn’t sound like it.
You asked, “who decides?” Your parents decide. The patient decides. Aggressive treatments for cancer are incredibly painful. If they want to continue to live, they tell the physician that and s/he acts according to the patient’s wishes.
Wonderful comment, thank you.
“Renegotiate the social contract” is a better way to phrase it. But right now, it isn’t even clear that we as a society know that the social contract can be renegotiated. Cufford, for example, thinks we can’t do it, because all of the political parties are in the pocket of big money.
Yes, we all know this. This isn’t masaccio’s first post.
Unfortunately, no one has brought legislation to the floor that would publicly fund elections. If you check over at FDL’s Campaign Silo, you’ll see we’re doing a lot on the public option for health care.
If you’re interested in getting progressive Democrats to push for publicly funding elections, as everyone at FDL is, help us “whip” them on health care.
You raise a good point. End of life is different for each person. There are guideposts though. Take people with chronic conditions, say somone with end stage COPD, i.e. emphysema. Short of a lung transplant this is not something the person is going to get better from. If this person has 3 or more hospitalizations in a 12 month period, you know they are on their way out. Each hospitalization becomes a crapshoot. You might be able to stabilize them and get through that particular crisis or you might not. The question for the healthcare system is do you want to continue expending major resources on this patient with each hospitalization or do you want to move them into more of a hospice setting.
Now this might seem sensible to some and harsh to others, but when you have a finite system and resources, you can’t give everyone everything. And so you have to start drawing lines and making tradeoffs.
Congress is afraid to talk about the critical issues, like
how much can we reduce the money we spend on health carehow much lobbyists contribute to their campaigns to keep them from doing anything about health care.That’s better.
Well, maybe I’m crazy but it seems to me that either voting would go way down next time (meaning more extremists than centrists would be elected, as in the late 90s), or else there will be hell to pay at the polls. I don’t have a crystal ball, but I think this is really a key time, and it’s taken years to get here.
We’re already rationing health care, because not everyone can afford the time or money to get the care they need.
What the @#^*s out there probably mean is that they’re afraid that they won’t be getting the kind of care they think they deserve, and that someone else, who has less money (and might not be of their ethnic group) will.
Never happen!! Profit and health care are antithetical of each other! When those who profit(insurance company investors) from someones misery, Profit will always win out. Our health care is broken beyond repair, it must be entirely replaced with the public option as it already has been done is so many countries.
These Insurance Companies must go the way of the Dodo bird and become extinct. These rich bloated bastards have made enough profit on the human misery that is our current health care system. Take all the true worker bees of these companies and bring them into the public system to administer a system for the people and not for the profit of investors. They never wanted to get into the health care business in the first place.
Actually, California put a public finance of elections on a ballot initiative. The lobbyists went into over drive, spent millions scaring the shit out of everyone and it was subsequently shot down.
This btw is what I had to say about the Gawande article at the end of the Feingold thread:
BTW kipsullivan also had a good comment at the end of that thread on the public option:
http://firedoglake.com/2009/07…..nt-1933461
Well there is a way WE can help drive that visit http://www.youstreet.org and read how You can help to make a difference so we can get true public funding of all elections.
Teddy and I are upstairs figuring out who, if anyone, has a marriage legal in California.
The influence of big money on the “reform” process has become obscenely obvious. It was always there, but now it is there for all to see. The obstacles are huge, but I also sense that a lot of things there weren’t in play a few years ago are now are. I think it is our mission to get and keep them in play. Now is the time to push, persistently and with hope, for the things we want and need.
Hugh, I read your comment on that thread, though I missed Kip Sullivan’s. It seems to me that the solution is to insist on a strong research program into treatments to determine best practices. We all know that a rigorous insistence on handwashing is our best defense against MRSAs and other hospital infections. That happens at Mayo, why not everywhere?
As to Kip Sullivan, I agree. I’ve been trying to start a conversation on what the public option would look like, of which this is another installment.
I am suggesting that we ALL stop using the MSM designated ‘isms’ and call shit for what it is.
Healthcare reform by blue dogs isn’t being held up because they are worried about re-election, they are holding it up because they were PAID by the HC Machine to run and win, and the spigot’s never off for the perks.
It’s a bought and paid for system of governance. We should be CONSTANTLY hammering on each and every pol at every level for what they get from the various machines of corporate rule. And not let the MSM frame the distorted reality the various machines pay THEM to publish.
Love your comment.
I agree, though I see no harm in throwing them the bone of offering supplemental coverage. But the insurance products they sell need to be more highly regulated, their offerings made clear. I would require them to be portable and unrelated to employment, not cancellable except for obvious frauds, available to anyone with the premium dollars, etc.
After a relatively short time, only the wealthy would buy them, assuming the public option is credibly run along the French or Dutch models.
But your point is unshakable. Health care costs can’t properly be controlled and monitored without taking money out of the system as well as finding new money to put in. Insurance premiums that require formidable rates of return to “private equity” capitalists, and which are burdened by Wall Street salaries to executives is an exceedingly poor way to provide coverage for all Americans. In fact, it’s the most expensive way possible.
Self-evidently, if insurers have $500 million to spend on lobbying, their share of the health care pie is exorbitantly costly, one that the process of delivering health care in America can no longer afford.
Larue, here is the Open Secrets page on Jim Cooper, Blue Dog and signer of the letter Scarecrow talked about a couple of days ago. He doesn’t get that much money from the insurance guys or the health care guys or any other interested parties as far as I can see, despite the fact that Nashville is the home of many major players in the health care Industry.
Ding!
Leaving the supplemental insurance policies with private companies is a good idea. It is a very well-defined business, and should be subject to normal actuarial statistics.
The Mayo Clinic system is not rocket science. They simply organize differently. One Team of Doctors handle each patient and that gives a more organized method of diagnosis. If you have ever been referred out to many different doctors, you will understand how the costs skyrocket. I’ve had the same test run several times because the Dr’s don’t coordinate. They sort of use a shotgun method of treatment and that way they all get paid more.
Research is one avenue. But as in my COPD example, you also have to decide where to draw the lines.
Another example would be cardiac stenting. This doesn’t increase longevity but it does increase quality of life. We need to discuss what tradeoffs we are willing to make and those we are not willing to make.
A living will should be implied for those who are at the end of their years. Aging people shouldn’t allow practitioners to intervene aggressively to keep them alive. And practitioners shouldn’t advise it. The less aggressive they are at any stage of life, the better. The quality of life is inversely proportional to this practice, I’ll be bound.
Let see folks……….. we give to corporations tax incentives to ship jobs overseas while the use of the tax code as a means of controlling costs in health services, incentives and disincentives is not given consideration? Just a question,how many corporations in the heath services are exempt from taxes??. Corporations as BCBS, and the like who behave as for profit corporations but few are aware of the corporation’s exempt tax status and absurd legal status as a public charity?? “”Relieving or lessening the burdens of government?“”
We have been sold a pile of dung!!!!!!!!!
I recently read a comment that perhaps our Congresspersons should have to wear jump suits such as those worn by NASCAR
drivers so that constituents could quickly identify the owners of said congresspersons.
…just a beggar lookin’ for a ride…
Why the treatment of prostate cancer is inconsistent
No, it’s not because greedy providers have devised needlessly expensive treatment modalities, or just been lax in choosing cheaper alternatives among the many modalities in use. The treatment of prostate cancer is in flux right now because we haven’t had time to adjust our treatment strategy to the flood of early prostate diagnoses created by widespread use in this country of PSA screening for prostate cancer.
Before the PSA, we only found prostate cancer when it had advanced so far as to create symptoms that prompted the patient to seek medical attention, or it had grown so large as to produce a nodule palpable on rectal exam. Now, based on observation of how often prostate cancer found by these means, found clinically, advanced how quickly to life or health threatening behavior, we had established a treatment strategy that dictated what characteristics of the newly diagnosed prostate cancer justified what intervention. What we have found with the PSA is that it discovers prostate cancers that are clearly at least somewhat less aggressive in their time course, and arguably are mostly such slow-growers that the patient is more likely to die with them than of them.
The problem is that the only way to get firm answers about the natural, untreated, history of PSA-discovered prostate cancer is to stand back and not treat such cancers in the tens of thousands of patients you would need to observe for years and decades to start getting these answers. And it is highly problematic to stand back and not treat prostate cancer when the form of it that we have observed, clinically-discovered prostate cancer, is a known killer, one of the leading causes of death among men in this country. On a population health level, I can guarantee that we will never be able to do the direct and obvious study to figure this out, since it would be like the Tuskegee syphillis study, just on a much larger scale. But until and unless we do have more firm evidence that PSA-discovered prostate cancer is such that the strategy of watchful waiting is not a death sentence, on the level of the indiuvidual patient, aggressive treatment, as if we were dealing with clinically-discovered prostate cancer, will have to continue, despite the fact that there is a strong likelihood that much of that aggressive treatment might eventually be proven unnecessary. You can’t wait for “eventually” when your patient has the PSA of 16 and needs a decision today.
It gets worse. The only two things we can do to treat prostate cancer are inherently quite aggressive. We can suppress testosterone production, because testosterone encourages prostate cancer growth. But that only slows progression, doesn’t cure, and another name for pharmacologically suppressing testosterone production, the name we use when we’re talking about doing this to sex offenders (by the way, it doesn’t work in this role, and doing this to sex offenders is unmitigated cruel and unusual abuse), is “chemical castration”. Nice. But not as bad as the effects of removing the prostate, the other treatment option available. The prostate itself we can arguably do without, but all sorts of plumbing and wiring either goes through or so close to the prostate, that removal threatens to destroy all sorts of other functionality. Fecal incontinence is not fun.
Most of the specific treatment modalities Leonhardt mentions are alternate ways, other than surgery, to destroy the prostate. They are being tried, despite the expense and uncertain risks associated with novelty, because there is some reason to believe that they will allow more selective destruction of the prostate itself, while sparing other functionality. Such sparing of other functionality has its cost savings, human costs mostly, but even monetary costs, that need to be added into the balance sheet. And if any such modality does prove to do a much better job of sparing funtionality, it will become widely used and bring down the costs dramatically as the new equipment’s cost is spread over more and more patients. When I was in med school, CTs were quite expensive, but they proved very useful, and everybody bought scanners. So now the start up costs have all been paid, and a sinus CT is cheaper than a plain film sinus series. None of these modalities is inherently more expensive than scalpel surgery, they’re just all newer and use equipment that hasn’t been universally adopted — yet.
So, the moral of the story is, early detection is bad? No, not at all. In this case of PSA screening, yes, it was arguably wrong for it to have been pushed as a universal standard before we had any idea of how this should impact treatment, any clear reason to find prostate cancer early. On the individual patient level, given the uncertainty of what it tells us, the fact that what we know of clinically-discovered prostate cancer is all we know of this disease’s natural history, and that is not a reliable guide to the natural history of PSA-discovered prostate cancer, the decision to have such testing is very fraught, because of the invasive nature of the only treatments available for a condition whose prognosis is not known. I have chosen to forego testing myself, and I will not order it for my patients until and unless they pay reasonable attention to counseling about these uncertainties, after which a goodly percentage (though <50%) also choose to not be tested.
Messy as this situation is, though, such messes are the way, the only way, for an observational, inductive, science such as medicine to advance. Eventually, but probably only by fits and starts because the brute force method of determining the natural history of PSA-discovered prostate cancer is not practicable (So, do we randomize YOU to the non-treatment group?), we will know if and when to unleash testosterone suppression and prostate removal on prostate cancer discovered by PSA. Perhaps, more optimistically, this tough spot we’re in right now with prostate cancer, will be the spur that gets us a way to remove the prostate without destroying other functionality.
At any given time, most areas of medicine will be more settled than prostate cancer treatment is right now. This is especially true the more common the problem. And after things settle out, very few people have the severity of disease to justify invasive, and therefore expensive, treatment modalities. The treatment of Coronary Artery Disease (CAD), for example, has pretty much quieted down after its recent disturbance created by the introduction of new treatments (CABG, angioplasty) and new diagnostic means (catheterization, imaged functional testing). Very few people have CAD so threatening of death in the near term that CABG is justified. We’re not going to bankrupt the nation making CABG available to everyone who needs it, because so few need it so badly that the risks and other human costs involved justify using it.
In the long term, we are not going to bankrupt the nation making even the most expensive treatments for prostate cancer, or any disease currently in the sort of flux that this cancer is in, available to all who need such treatment. The inherently expensive treatments, the ones whose cost will not go down after they become widely used, are that way because they are invasive, and because they are invasive, they will never be indicated for very many patients.
What I find concerning about Leonhardt’s item, and its citation here, is what many people find concerning about the proposal to reform health care financing. Some thinkers on the subject advance a wholly unnecessary opposition between cost and quality, and thereby create the fear that universal health care will require economies that will squelch medical advances. It definitely doesn’t need to be so, but insofar as Leonhardt’s thinking prevails in the design of the single payer that this country so desperately needs, there is a real danger that an unnecessary oppostion of cost and quality will be decided pre-emptively in favor of low-bid medicine. But we don’t actually face the need to choose between cost and quality. We simply need to follow enlightened self-interest, and avoid being penny wise and pound foolish, or defining our interests on too short a term, and we can have both high quality and low cost in our medical care. One of the things our reformed system will have to allow is for areas of medicine to get messy, confused and more expensive after new diagnostic or therapeutic modalities are introduced, but before our observation of the consequences can catch up.