Saturday, July 25, 2009

Health Care
“Those who are not liberal in their youth have no heart. Those who do not become more conservative with age have no head” -- George Clemenceau

I have waited to wade into this debate for a long time, since 1992 when I was 14 and a 1st year medical student taking “Medical Care Organization” in second semester. In the last 18 years I have been in the medical community, I have been a son & a brother, a patient, student, a resident, an attending physician in academic practice, a teacher of trainees, an overseas surgeon, and a researcher managing a budget of a lab group of about 10 people. These prisms of perspective inform my writing below. Although I have not (yet) been a husband, a parent, or a private practice physician, I hope I can take into account those frames of reference as well. I have also had the great fortune & privilege of knowing & working with citizens and physicians of Canada, Australia, Japan, and Britain who have lived in the US as well.

The health care issue is not just about cost, access, quality, value, profit, or innovation (we’ll get to those later), but about first principles:
  • What is a right vs. an earned privilege?
  • What is a public good vs. a private good?
  • What is the proper balance between harm reduction vs. personal responsibility?
  • What is the role of finance and profit in taking care of people? And how big of a sector should health care be in the broader economy?
My thoughts on these questions are that some things in health care (e.g., vaccinations, regular preventive care, a baseline level of prescriptions, and treatment for catastrophic or acute life-threatening injury or disease where there is reasonable hope for good outcome) are key elements for equal opportunity to life, liberty, and the pursuit of happiness, for being a productive and contributing member of society, and as such, should be ensured by society. Other things (e.g., Viagra, private rooms, brand-name medications when generics will do fine, LASIK, treatment which is in all medical likelihood futile) I think belong in the realm of personal and private choice and thus cost. Further, personal responsibility in taking care of oneself (in areas of diet, exercise, habits, risky activities/behaviors, adherence to treatment) should be acknowledged and rewarded. On the last question (profit motive in medicine), I’ll address that last. Now to cost, access, and quality. First, let me tackle the (glib) indictment of the American health care system, which usually goes like this:
· We pay more than other countries
· Our outcomes (e.g., infant mortality, life expectancy) are worse
· 47 million people have no health insurance

That we pay more is beyond dispute. On outcomes, the oft-cited statistics on infant mortality and life expectancy are, to say the least, unfair. America has significant minority populations (which Japan, Canada, and much of Western Europe do not) and these groups have a variety of socioeconomic and historical issues that compromise health outcomes (poverty, drugs, gun violence, out-of-wedlock births, distrust of doctors and non-adherence with medication, follow-up, and diet regimens,). Further, on infant mortality, Western European societies have a lot more abortion and make much less effort to save preterm infants born under 28 or 30 weeks of gestation (such births there are often recorded as stillbirths), whereas in the US, NICUs routinely take care of preemies born at 24 weeks or even younger.

On the 47 million people without health insurance point, that too is a statistic where there is less than meets the eye. First, health insurance does not equal health care (there are not just emergency rooms but cash-based clinics, and conversely, a lot of people with insurance don’t get good health care). Second, of that 47 million, 14 million are already eligible for existing programs (Medicare, Medicaid, veterans’ benefits, SCHIP) yet have not enrolled, 9.7 million are not citizens, 9.1 million have household incomes over $75,000 and could but choose not to purchase insurance, and somewhere between 3 and 5 million are uninsured briefly(<2 months) between jobs. That leaves about 10 million Americans who are chronically without insurance. Needless to say, extending the blanket of coverage to this group should not cost $1.5 trillion and require a wholesale overhaul of all of medicine.

Further, there is a lot of good in the American system. Far more foreigners come to America for their health care than vice versa. Same goes for physicians who want to practice medicine. Yes, Americans on the borders go to Canada and Mexico for prescription drugs, but Canadians and Mexicans come to America for surgery and even neonatal ICU care, evidence of a far superior infrastructure for high-intensity services. And, most importantly, our research, development, and innovation is unsurpassed – indeed, there is a good argument for saying that Americans subsidize other countries’ populations by allowing drug companies free rein in price-setting here (other countries have price controls, while we do not, which allows companies the breathing space for investment in R&D).

Ok, you say, but why does health care cost so much? So let’s look at the health care dollar, where it comes from, and where it goes. The US spends about $2.5 trillion on health care annually, and here's the percentage breakdown:

And the money is coming from:

Not well-accounted for in these figures are the costs of malpractice insurance and claims (approximately $10 billion per year) and of defensive medicine (estimates ranging from $60 billion to $100 billion per year; in some states, obstetricians and some surgeons must pay well over $250,000/yr in malpractice insurance premiums). With respect to health insurance companies, in 2007 they reported ~$15 billion in profits plus an additional ~$16 billion in stock buybacks (monies not used for paying claims or investments)

So to save on costs, the areas where significant monies could be squeezed from would be:
  • Hospitals and nursing homes
  • Physicians, dentists, and other providers
  • Drug companies
  • Insurance companies
  • Trial lawyers
Now, how would I go about deciding what to cut and how to save money and “bend the future cost curve”? I would rate behaviors & services on a scale of evil (which for this discussion I define as greed:utility ratio). So things that I’d like to see happen that I think would curb costs without degrading current or future quality of care would be:
  1. Significant tort reform where arbitration is used to weed out frivolous lawsuits and a system where negative outcomes are compensated reasonably, while criminal misbehavior is handled criminally. HMOs should no longer hold their privileged immunity from malpractice relative to physicians.
  2. Assigning the cost burden of unnecessary or likely futile services to patients or their families
  3. Eliminating television and direct to consumer pharmaceutical marketing (which all started only in the late 1990s) (drug company marketing is now about $57.5 billion annually, according to a PLOS study by Gagnon & Lexchin in 2008, which nearly equals the $58.8 billion spent in R&D by the drug industry. This would help reduce costs by allowing physicians breathing room to recommend older yet equally effective medications to their patients.
  4. Breaking the oligopolies of health insurance coverage present in many states & regions. 94% of insurance markets are highly concentrated. If ever there was a reason for anti-trust intervention, this is it. Consumer choice is constrained by such circumstances and costs are dramatically increased to patients and physicians. The solution to this is not creating a government monopoly of health care, but using deregulation & anti-trust law to allow cross-state insurer competition, and nurturing novel health care coverage systems through unions, community groups, civic associations, patient co-operatives, and physician-run organizations. Government could do a great service by jumpstarting the infrastructure to create such a true free market but it should not take over such a market.
  5. Encouraging charity care: Lawyers can treat pro bono work as a tax deduction; hospitals treat charitable services (which are often overcharged in the first place) as a tax write-off and get income tax exemption for being nonprofits. Physicians currently have no such benefit.
  6. Cost Transparency: A friend of mine who is a student in a professional school recently had an appendectomy and got a surgeon’s bill of $~3000 and facility bills of $13000. Insurance paid most of it, but he still paid $5000 out-of-pocket. By contrast, Medicare payment for appendectomies for the surgeon is $561 and for inpatient facility care is about $3000. Patients are charged wildly different amounts, and quite often indigent patients get stuck with full charges while Medicare or large insurance company patients get charged much less due to contractual arrangements. This process is just insane. If the rich or foreigners want to pay for concierge care and first-class service, so be it. But for the system as a whole, doctors should be allowed to set their own fees (which we, alone among professions, cannot – Medicare sets rates which we are obligated to accept if we accept Medicare patients), waive standard fees for the poor (remarkably, underbilling is considered fraud), and charges should be transparent and consistent. This ties back into the charity care issue, where some hospitals write off charity care at grossly inflated charge rates yet still make life incredibly difficult for the poor.
  7. Encourage innovation: Increasing tax credits for R&D, establishing prizes for translating discovery for big problems, and extending patent protection for new molecular entities while limiting patent extension for me-too drugs maneuvers turning Prozac into Sarafem or Wellbutrin into Zyban, would promote advances in drug and device development and maintain America’s edge in science & technology.
  8. Improve primary care: On this score, I think other countries like Australia and Canada are doing a better job. I feel lucky that as an ophthalmologist (which is mostly self-contained and which is alien to most other physicians), I can be the patient's doctor for almost anything eye-related, which helps me build the trust and rapport to exercise good judgment in deciding how frequently to monitor a condition, what medicines to use, what test to obtain, when to do surgery and when not to, and when to accept that there is an end of the road in certain situations. I feel that patients are missing that too often in their general health - before ophthalmology, I did a full 3 years of internal medicine residency, and care was so fragmented that patients (most of the time) did not have a doctor, in the classic sense of the word, someone who knew them, was their advocate, had a broad perspective of their life and values and conditions, and had their trust. This led to patients being dumped on the ER, diagnoses missed until it was too late, lab & radiology tests replacing clinical diagnosis, and great yet often unwarranted & futile efforts in situations without real hope. I think encouraging medical school graduates into primary care (full loan forgiveness, encouraging models like monthly or annual clinic "memberships" for patients rather than fighting for every bill or claim and booking patients every 10 minutes to make ends meet) would prove a long-term boon to patients and physicians.

Why do I think these are key measures which would be effective?
Our litigious system of jackpot justice does cause of a lot of unnecessary testing and drives a lot of medical practice, unnecessarily, to the ER or ICU where the full resources of a hospital are easily marshaled and engaged.
Costs in the last six months of year of life consume the lion’s share of health care spending; should the bill for that be covered by the hospital, the insurance pool, the taxpayer, or (in my view) the patient & family?
As for as marketing, television and direct-to-consumer marketing has exploded in the last 10 years, which has greatly distorted care, as patients often come in demanding specific medications, tests, or procedures. This has driven up costs but does not contribute to quality at all.
On the competition aspect, there is no free market in health care. We have the worst of socialism (regulation, poor service) with the worst of capitalism (corporate greed that seeks to distort and monopolize markets and imprison consumers into their own cartels of delivery networks).

Is the likely Democratic plan a good idea?
I have to say no. Expanding Medicare & Medicaid for all (which is basically what it boils down) opens the door to government price controls, which will devolve into wait-lists, poor quality personnel, salaried staff (who by definition are incentivized to give minimum effort), increasing physician refusal to see Medicare & Medicaid patients, and underinvestment in research and facilities (see Great Britain, and Canada). The Australian system, where public hospitals are well-funded and physicians can choose to accept government rates or charge higher, might be a viable option. The VA system (which was held up as an example by Hillary Clinton) is good at certain things (electronic prescriptions, some routine elements in primary care, traumatic brain injury, spinal cord injury) but is poor at infrastructure maintenance, efficient clinic and surgical flow, and customer service; further, its costs are held down as much of VA health care is in reality delivered by residents. The proof of the pudding on the VA is that the vast majority of VA patients are enlisted personnel; the retired officers go elsewhere.

Which of the plans bouncing around have useful ideas?
I think the Daschle-Dole idea of giving tax credits to all who pay income or payroll taxes to purchase health care is a good thing – equalizing the playing field of those with employer health coverage and those without. We want health insurance to be available to all contributing or productive members of society, but we don’t want free health care as a dole to contribute to persistent unemployment. The Daschle-Dole, Wyden, Ryan, & McCain ideas of capping the employer health benefit tax deduction , creating exchanges/marketplaces, small business pooling, and allowing cross-state and nontraditional insurance coverage and competition are all also great ideas.
Health savings accounts have potential but what I have noticed is that patients tend to use them to buy “nice things” – e.g., LASIK, nice glasses, a nicer wheelchair, etc. and then rely on government when they need their medications or life-saving surgery.
Encouraging preventive care and discouraging risky behaviors are all nice things but I’m not sure I want the government as nanny. However, certain employers (e.g., Safeway, my university) give lower insurance rates for enrolling in wellness programs.

What things should we keep in mind going forward?
As a society gets older and richer, it naturally will spend more on health care. Further, innovation and research cost money along the way - NICU care was probably not cost-effective 15 or 20 years ago, but is now. Neither of these points are in and of themselves bad. But we should allow patients the freedom of choice and with it, the responsibility to take care of themselves and limit unnecessary costs. Yes, in acute situations, it is unseemly and unfair to ask a patient, before anything else, what insurance do you have? And that is a great advantage of Canada that we can learn from. But some patients do abuse the system (refuse to take medications and then come in when they are really sick, or come in to the ER at 2 in the morning for itchy eyes which they've had for 2 weeks without pain or change in vision), and such behaviors should bear the costs.

We do not want to destroy a system that has led discovery and contributed so much to the world and led to unprecedented advances in life expectancy over the last century. As for profit, medicine should not be a business where the profit motive trumps all. Yet money does make the world turn; indeed, money from high-margin services helps support and allow the presence of charitable care, research, teaching, and humanitarian work (much as first class on airlines helps subsidize the rest of coach class). Removing money as an incentive for performance, R&D, and innovation would be stifling. Humans are naturally lazy, and greed can & should be harnessed to useful ambition. But corporate greed, market-distorting greed, and the greed of corruption and unnecessary services should be checked.