Health and Care

With all the shouting going on American health care crisis, many of which may be difficult to concentrate, let alone understand the causes of the problems we face. I find myself disappointed at the tone of the discussion (although I understand — those who fear) as well as perplexed that anyone would consider themselves qualified enough to know how best to improve our health care system simply because they see it, when those people who have spent entire careers studying (and I do not mean politicians) are not sure what to do themselves.

Albert Einstein was reputed to have said that if he had an hour to save the world, he would spend 55 minutes defining the problem and only a 5 minute break. Our health care system is much more complex than most that offer solutions to admit or recognize, and unless we focus most of our efforts on defining the problem and a thorough understanding of the cause, any changes we make is only possible to make them worse because they are better .

Although I have worked in the American health care system as a doctor since 1992 and has a value of seven years experience as administrative director of primary care, I do not consider myself qualified to really evaluate the viability of most of the advice I ‘ve heard of to improve care systems our health. I think, however, at least I could contribute to the discussion by describing some of the problems, taking a reasonable guess at their cause, and outlines some general principles that should be applied in an attempt to solve them.

COST PROBLEM

There is no dispute that health spending in the U.S. has increased dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $ 8,160 per person per year by the end of 2009 compared to $ 356 per person per year in 1970. This increase occurred about 2.4% faster than the increase in GDP in the same period. Although the GDP varies from year to year and therefore a perfect way to assess the increase in health care costs compared with other expenditures from one year to the next, we can still conclude from these data that during the last 40 years the percentage of our national income (personal, business , and the government) we have spent on health care has increased.

Despite what most assume, this may or may not be bad. It all depends on two things: the reason why health care spending has increased relative to our GDP and how much value we are getting for every dollar we spend.

WHY BE A HEALTH so expensive?

This is a difficult question to answer than many would believe. The increase in the cost of health care (an average of 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the increase in inflation (4.4% on average during the same period), so that we can not attribute the increase cost for inflation only. Spending on health care known to be associated closely with the country’s GDP (the rich nations, the more spent on health care), but even in the United States remains an outlier (Fig. 3).

Is it because spending on health care for people over age 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show demographic trends explain only a fraction of the growth in health spending.

Is it because the benefits of health insurance companies horrible raking in? Probably not. This is admittedly difficult to know for sure because not all insurance companies have a balance of public and therefore available for public review. But Aetna, one of the largest companies publicly traded health insurers in North America, reported second-quarter 2009 profit of $ 346.7 million, which, if projected out, predicts annual profit of about $ 1.3 billion from about 19 million people they insure. If we assume that their profit margins on average for their industry (even if true, it probably is not much different from the average), total profits for all private health insurance companies in America, which insured 202 million people (the points 2 ) in 2007, will come to about $ 13 billion per year. Total health care spending in 2007 was $ 2.2 trillion (see Table 1, page 3), which produces private health care industry profit of about 0.6% of total health care costs (although this analysis a mixture of data from different years, it may be permissible as the amount does not vary by an order of magnitude).

Is it because of health fraud? Estimated losses due to fraud range as high as 10% of all health expenditures, but it’s hard to find hard data to support this. Although some percentage of fraud is almost certainly not detected, probably the best way to estimate how much money is lost due to fraud is to look at how much the government actually recovered. In 2006, this is a $ 2.2 billion, only 0.1% of $ 2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it because the cost of pharmacy? In 2006, total spending on drugs is about $ 216 billion (see Table 2, page 4). Although this is by 10% from $ 2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and therefore must be considered significant, are still only a fraction of the total health care costs.

Are the administrative costs? In 1999, total administrative costs estimated $ 294 billion, 25% full of $ 1.2 trillion (Table 1) in total health care spending that year. This is a significant percentage in 1999 and it is difficult to imagine it shrinks to a significant degree since then.

In the end, though, what may have contributed the largest number to increase health care spending in the United States is two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and healthcare providers themselves.

Technological innovation. Data demonstrating increased health care costs due largely to technological innovation is surprisingly difficult to obtain, but estimates contributing to rising health care costs due to various technological innovations in anywhere from 40% to 65% (Table 2, page 8). Although we mostly only have empirical data for this, some examples illustrate the principles. Heart attacks used to be treated with aspirin and prayer. Now they are treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You do not have to be an economist to figure out which scenario is finally becoming more expensive. We can learn to perform the same procedure is less expensive from time to time (the same way we have found a way to make computers cheaper) but decreased as the cost per procedure, the total amount spent for each procedure go up because of the many procedures performed up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the second level has increased by 60%. As technology advances become more widely available they become more widely used, and one big thing we did in the United States is making the technology available.

Overutilization of health care resources by both patients and healthcare providers themselves. We can easily define overutilization as unnecessary consumption of health care resources. What is not so easy is recognizing it. Every year from October to February the majority of patients who come to the Urgent Care Clinic at the hospital I was, in my view, no need to do it. What they come for? Colds. I can offer support, the belief that nothing is seriously wrong, and advice on over-the-counter drugs — but none of these things will make them better more quickly (although I often I was able to reduce the level of attention) . Furthermore, patients have a hard time believing the key to arrive at a correct diagnosis lies in collecting the history and careful physical examination rather than technology-based testing (not that the latter is not important — just less than most patients believe). Just how many patients are encouraged overutilization costs the health care system is difficult to pin down as we have mostly only anecdotal evidence as above.

Furthermore, doctors often disagree among themselves about what constitutes an unnecessary consumption of health care. In an excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variations in the overutilization of health care resources with the best doctors account for regional variations in Medicare spending per person. He went on to argue that if doctors could be motivated to control their overutilization in areas of high cost country, it would save enough money to keep Medicare solvent for 50 years.

A reasonable approach. To get it going, however, we need to understand why the doctor overutilizing health care resources in the first place:

1. Judgement vary in cases where the medical literature is unclear or unhelpful. When faced with the dilemma of diagnostic or treatment of diseases that standard has not been established, variations in practice always the case. If a primary care physician suspects the patient has gastritis, whether he treats himself or refer to empirically tract to endoscopy? If certain “red flag” symptoms are present, most doctors will refer. If not, some will and some will not depending on the training and implementation of tangible judgments.

2. Experience or a bad assessment. More experienced doctors tended to rely on history and physical examination of more than doctors who are less experienced and consequently to test less and less expensive. Studies show primary care physicians spend less money on tests and procedures of sub-specialty counterparts but get the same results and sometimes even better.

3. Fear of being sued. This is especially common in the Emergency Room setting, but extends to almost every field of medicine.

4. Patients tend to demand more rather than less testing. As mentioned above. And physicians often have difficulty resisting the demand of patients for many reasons (for example, want to please them, afraid of missing a diagnosis and be sued, etc.).

5. In many situations, overutilization doctors make more money. No there is no reliable incentive for doctors to limit their spending to pay them unless they receive a capitated or a straight salary.

Gawande article implies there is some level of resource utilization of optimal health care: using too little and you get errors and missed diagnoses; use too much and the excess money will be spent without outcome improvements, paradoxically sometimes causes the results are really bad ( probably as a result of complications of all the additional testing and maintenance).

Then how can we get physicians to use either a uniform assessment for ordering the correct number of tests and treatment for every patient — the “sweet spot” — in order to produce the best results with the lowest risk of complications? Not easy. There is, fortunately or unfortunately, the art of health care resource utilization is good. Some doctors are more talented at it than others. Some of the more diligent in keeping current. Some care more about their patients. An explosion of studies of medical tests and treatment have occurred in recent decades to help guide clinicians in choosing, the most effective safe, and even the cheapest way to practice medicine, but the diffusion of evidence-based medicine is a tricky business. Just because beta blockers, for example, has been shown to improve survival after a heart attack does not mean every physician knows or provide them. The data clearly shows many are not. How to spread information from the medical literature into medical practice is a subject worthy of the post itself. Getting it to happen in a uniform has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with excessive with doctors working in a system that motivates them to practice medicine much better than drugs, and patients are demanding the former think it produces a second.

But even if we could snap our fingers and magically eliminate all overutilization days, health care in the U.S. will still remain among the most expensive in the world, takes us to the next request —

WHAT ARE WE GETTING VALUE FOR DOLLAR WE SPEND?

According to an article in the New England Journal of Medicine titled Burden of Health Care Costs for Working Families — Implications for Reform, growth in health care spending “could be defined as affordable as long as the percentage increase in income devoted to health care does not reduce the standard of living. When the increase in absolute income can not keep up with the absolute increase in health care spending, the growth of health care could be paid only at the expense of consumption of goods and services not related to health care. “When did it ever become acceptable state of affairs? Only when the additional costs of health care purchasing additional value equal or greater. If, for example, you are told that in the near future you will spend 60% of your income on health care but as a result you will enjoy, say, 30% chance of living to age 250, perhaps you’ll judge that 60% of small price to pay .

This, in my opinion, is what the debate about health care spending really need to be around. Of course we have to work on ways to eliminate the overutilization. But the real question is not what the absolute amount of money is too much to spend on health care. The real question is what we get for the money we spend and is it worth what we have to give up?

People concerned with the idea that as policy makers increased health care costs may decide to ration health care do not realize that we are already rationing at least part of it. It just does not appear as if we are because we allotment is on a first-come-first-serve — leave at least partially up to chance rather than policy, which we define and enforce uncomfortable. So we are not aware of the reasons we are 90 year-old father in Illinois can not have a heart that he needed was because the 14 year-old girl in Alaska into the first row (or perhaps our father was in the first line and get it while 14 year-old girl is not). Given that most of us still feel uncomfortable with the idea of ​​rationing health care based on criteria such as age or utility to society, as technological innovation continues to drive health care spending, we are very likely at some point have to make critical judgments about the medical innovation that is worth the whole community we give access to other goods and services (unless we are so stupid to repeat the critical error to believe that we can keep borrowing money forever without having to pay back).

So what value do we get? It varies. The risk of death from heart attacks has dropped 66% since 1950 as a result of technological innovation. Because heart disease ranks as the number one cause of death in the U.S. is likely to rank high on the scale of values ​​for a large proportion of the population benefits in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, psychosis and even much better than anyone could imagine even until the mid-1980s (when it was first released Prozac). Clearly, then, some of the rising cost of health care has resulted in tremendous value we do not want to give up.

But how do we decide whether we get good value from new innovations? Scientific studies have proven innovation (whether a new test or treatment) actually provides significant clinical benefit (Aricept is a good example of drugs that work but do not provide clinical benefit of patients are crazy — score higher on tests of cognitive ability while in it but probably not significantly more functional or significantly better able to remember their children than when they are not). But comparative effectiveness studies are very expensive, time consuming to complete, and never can be perfectly applied to each individual patient, all of which means that some health care providers should always apply a good medical evaluation for each patient’s problems.

Who is best positioned to assess the value for the benefit of an innovation — that is, to decide whether the benefits of an innovation that justifies the cost? I think the group that ultimately pays for it: the American public. How the public views can be reconciled and then effectively communicated to policy makers are efficient enough to influence actual policy, however, lies far beyond the scope of this post (and maybe anyone’s imagination).

ACCESS PROBLEM

A significant proportion of the population uninsured or underinsured, limiting or eliminating their access to health care. As a result, the group found the road a bit (and cheapest) — — resistance is an emergency room that has been significantly impaired the ability of our nation’s emergency physicians to truly make timely emergency care. In addition, the survey shows looming shortage of primary care physicians relative to the demand for their services. In my view, the imbalance between supply and demand explain most of the patients faced poor customer service in our system every day: long waiting times for doctors’ appointments, long waiting times at the doctor’s office once they arrive a day pledge, then spent a brief time with the doctor in the exam room, followed by difficulty reaching their doctor between office visits, and finally the delay in getting test results. This imbalance may be only partially solved with less health overutilization by patients.

GUIDELINES FOR SOLUTION

As the authors Freaknomics Steven Levitt and Stephen Dubner states, “If morality represents how people want the world to work, then economics represents how it really does not work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to produce behavior that benefits both suppliers and consumers and thus society as a whole. But when the incentive out of whack, people start to behave in ways that continue to benefit them often at the expense of others or even their own expense on the road. Whatever changes we make to our health care system (and there are always more than one way to skin a cat), we must be sure to align the incentives so that the behavior that results in every part of the system contributes to the sustainability and not its destruction.

Here then is a summary of what I consider the best recommendation I’ve come across to solve the problems I have outlined above:

1. Changing the way insurance companies think about doing business. Insurance companies have the same objectives as all other business: maximizing profits. And if the public health insurance company and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to customers who really are paying for them. It’s harder for them to spread the risk (a function of each insurance company) relative to say, an automobile insurance company, because people are much more to make health insurance claims from car insurance claim. It would seem, therefore, from the perspective of consumers, private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an additional incentive for them to pay for them). Allowing and encouraging competition aross-state insurers will do at least partially free market forces to lower insurance premiums as well as open up new markets for local insurance companies, benefiting both consumers and insurance providers. With their customers are now armed with the all-important power to go to other places, health insurance companies may come to see the quality that they actually provide services to their customers (ie, paying claims) as a way to maintain and grow their business. For this to work, or near monopolies should be disbanded or at least discouraged. Even if it does not work, however, the government will probably still have to tighten regulation of health insurance industry to ensure some heinous violations occurring now stopped (for example, insurance companies should not be allowed to stratify consumers into sub-groups based on age and increasing premiums based on risk higher average older group of diseases because healthy older consumers then end up being penalized for their age than their behavior). Karl Denninger suggests some interesting ideas in a post on his blog about requiring insurance companies to offer a price identical to businesses and individuals as well as creating the “open enrollment” shall where participants can only select or out of the plan on an annual basis. This will prevent individuals from buying insurance only when they are sick, eliminating the problem of adverse selection that encouraged insurance companies to refuse payment for pre-existing conditions. I would add that, however the replacement price for specified health care providers in the future (again, a whole separate post), all health insurance plans, whether private or public, need to replace the health care providers with the same percentage to eliminate the existence of “good” and “bad” insurance which is currently responsible for motivating hospitals and physicians to limit or even deny service to the poor and who may be responsible for the same thing happen to the elderly in the future (Medicare reimbursement only slightly better than Medicaid ). Finally, the notion of “public option” insurance plan open to all, I am afraid that if it is significantly cheaper than a personal choice while providing near-equal benefit of the whole country will rush to it in bulk, driving private insurers out of business and force us all to subsidize the health care of each other with higher taxes and fewer choices, but at the same time if the cost to consumers of a “public option” remains comparable to personal choice, the people who were meant to help not be able to afford it.

2. Motivating people to engage in healthy lifestyles that have been proven to prevent disease. Disease prevention may save you money, although some argue that living longer increases the likelihood of developing diseases that would not otherwise occur, leading to overall consumption of health care dollars more (though even if it is true, the years of extra life will be judged by most large enough value to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let us not put the cart before the horse). However, the idea to prevent a potentially bad outcome in the future only weakly psychologically motivate, explain why so many people having so much trouble getting yourself to exercise, eat right, lose weight, quit smoking, etc. The idea of ​​financially rewarding the behavior that desirable and / or financially punishing the unwanted behavior is very controversial. Though I’m afraid this kind of risk strategy that enforces policies that might impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we can harness the power of a strong motivation to help people achieve their health goals to be achieved. After all, most obese people to lose weight. Most smokers want to quit. They may be more successful if they could find a more powerful motivation.

3. The decrease overutilization of health care resources by physicians. I agree with Gawande that finding ways to get doctors to stop overutilizing health care resources is a noble goal that will significantly control costs, that it will require a willingness to experiment, and that it will take time. Furthermore, I agree that focusing only on those who pay for our health care (whether public or private sector) will fail to address this issue adequately. But how exactly we can motivate doctors, who pens are responsible for most of the money spent on health care in this country, to focus on what is truly best for their patients? The idea that an external body — whether the insurance company or government — the panel can be used to set the standard care physicians must follow in order to control the cost of strikes me as ludicrous. Agency does not have the training or as a major concern for the welfare of patients could be trusted to make their judgments. Why would we need a doctor if it does not employ their expertise to implement nuanced approach to complex situations? During their work in a system that is free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments that are worth considering given patient, as long as they are careful to avoid paternalism confidence ( refused to get a CT head for headache may overconfidently paternalistic, refusing to offer chemotherapy for colds do not). So maybe we should eliminate the financial incentives doctors have to care about anything but the welfare of their patients, which means that doctors’ salaries should be cut off from the number of operations they’re doing and the number of tests they order, and instead should be determined by market forces. This model already exists in health care centers do not seem to promote academic and bad treatment when doctors feel that they are paid fairly. Clinicians need to get a good life to compensate for years of training and a large amount of debt that they collect, but there is no financial incentive to the practice of medicine more should be allowed to attach itself to that life is good.

4. The decrease overutilization of health care resources by patients. This, in my opinion, require at least three interventions:

* Provide appropriate resources to correct the problem (so that patients will not be to the ER for colds, for example, but rather to their primary care physician). This will require hitting the “sweet spot” with regard to the number of primary care physicians, the best on the front line gatekeeping, rather than health care spending as long in the HMO model, but the triage and treatment. It will also require re-calculate the level of reimbursement for primary care services relative to special services to encourage more medical students to enter primary care (as opposed to an alarming trend we have seen over the last ten years).

* A massive effort to increase public health literacy to improve its ability to triage the complaint itself (so the patient does not really go anywhere for a cold or the MRI request their backs when they trusted doctors to tell them it’s just a strain). This is probably best done through a series of educational programs (although remember that nobody in the private sector have an incentive to fund such programs, in fact probably one of the few things the government should — We’d just need to learn and compare programs