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Wednesday, October 28, 2009

relieving suffering and reducing risks

Do patients actually know what they are getting from their doctors, and do they want it?

As I understand it, most patients want from their doctors primarily relief from suffering. And if they can't get relief from suffering, they would like to be heard and they would like to come closer to understanding the cause of their suffering.

When we prescribe cream for a rash, antibiotics for pneumonia or set a broken bone we are really right on the money. When we counsel and comfort we are doing the job we were hired for. When we get into the business of prevention, we are on a bit more shaky ground.

Much of our energy is spent haranguing, wheedling, threatening and assigning tasks. This is all in the service of preventing suffering, which isn't a bad goal when you think about it. We nag patients to take cholesterol pills, we assign them to go to obscure destinations to see specialists, we convince them to have painful and undignified tests like colonoscopies and mammograms. Many patients think that we are doing all of this to make them healthier, but that's not really it. The prevention gig is more of a very complex game of chance. A mammogram does not make a person healthier, in fact very much the opposite. Giving a person an 18 hour case of diarrhea followed by a potentially lethal dose of anesthetic, as is done for a colonoscopy definitely doesn't make a person healthier. Cholesterol drugs lower the risk of heart attack, and maybe strokes, but they don't make a person healthier. Their cholesterol numbers may be lower, but they are not healthier.

Much of this revolves around a rather abstract statistical indicator called the "number needed to treat." For many of the most accepted screening tests and preventive medications, the number needed to treat, which is the number of people who need to get the procedure or medication in order for one to not get the dire event it is meant to prevent, is anywhere for 20 on up to over 100. This means that 20-100 people have to do whatever it is in order for one of them to benefit. I guess you could say that everyone benefits, to the extent that they feel like they are doing the healthy thing, but I would say that's a bit of a stretch.

I don't mean to say that standard preventive medical testing and treatment is wrong, only patients need to understand that their chance of benefiting from these things, in actual fact, is nowhere near universal, and in many cases may be less likely than randomly pulling a one-eyed jack from a deck of cards. Costs, including the cost of loss of dignity and loss of time that could be spent on actual healing, need to be evaluated in this light.

Assuming, say, for treatment of high cholesterol, that the number needed to treat to avoid a heart attack is 20. The drug costs 100 bucks a month, and a person has to take it for 20 years. That's looking like over 20,000 bucks for a 1 in 20 chance of avoiding this dire event. Certainly something to consider. If the treatment costs only 5 bucks a month, the price tag is certainly more tolerable, and that represents the difference between a generic drug and a brand name. A certain number of people who take this drug will have a side effect, as well, and this human cost needs to be part of the equation as well. If the suffering and the money spent by all of the people who take the drug is less than the money and suffering of the one person who gets the benefit, then from a public health standpoint it is good medicine to encourage everyone with high cholesterol to take it. However, 19 out of the 20 people who take the drug are essentially "taking it for the team" and not actually doing any better than if they had avoided it all together. I am not entirely sure that people are aware when they take a drug or have a procedure done to prevent some bad health outcome that they are personally unlikely to notice any good effect.

Tuesday, October 27, 2009

dialysis in the very old

As people age, their kidney function gradually goes down, usually keeping pace with overall needs. In people with longstanding diabetes or high blood pressure, though, sometimes the kidneys fail before the rest of the body does. In this situation, various toxins build up in the blood and such a person gradually becomes weaker and eventually dies.

Enter kidney dialysis.

With a machine that runs the blood through a filter, much as the kidney is a filter, the toxins can be removed from the blood. Unfortunately all of the blood needs to be run through that filter, which is somewhat tricky, and it takes about 4 hours, and needs to be done about 3 times a week.

This is barely tolerable, but better than dying, usually, if you are pretty young, or only have to do it for awhile, as you wait to receive a kidney transplant.

If you are very old, though, dialysis is physically stressful. The heart has to tolerate the movement of blood out of and back into the body, and all of the organs have to tolerate the rapid shifts in electrolytes and blood volume that are part of the process.

Not surprisingly, older folks, those over 80 for instance, don’t have much more in them than the 3 time a week dialysis sessions, and so don’t benefit in terms of energy from being dialysed, other than not actually dying of kidney failure. A study done at Stanford showed that, in fact, most nursing home residents lose their abilities to take care of themselves after starting dialysis, and within the year, almost half of them die anyway. But the over 80 crowd are in fact the fastest growing population of patients getting dialysis in the US.

Dialysis is a big business. It is a procedure and therefore is reimbursed generously by insurance companies. Dialysis centers are popping up like mushrooms, and must have patients to continue to make money. A single dialysis session will be billed at about $1200, sometimes more, and be reimbursed by medicare for maybe half that. Private insurance pays considerably better. No matter how I calculate it, that is considerably over $100,000 a year.

In our small town there were no dialysis facilities available, so everyone who needed to have dialysis needed to travel at least 45 minutes to a dialysis center if they wished to have it done. With much wrangling and organizing, the hospital eventually put in a dialysis center, which seemed like it would probably not be very busy, since there just aren’t that many people living with kidney failure around here. They opened their doors a month ago, and then, as if by some kind of evil magic, there were two dialysis centers, in a town of 20,000 people. The second one is in a mini-mall at the edge of town. Competition is good, when it can bring down cost and increase quality, but costs for these things is based on what insurance will pay, which is static, and quality is pretty well controlled by standardization. Perhaps they will compete on the quality of the cookies they serve in the waiting room? The second dialysis center was started by a specialist who was not the proprietor of the first dialysis center, and figured he could hold on to his share of the patients by building his own.

Now perhaps I shouldn’t be fussing. What harm could it do if two companies want to open up and offer services that don’t really hurt anyone in town, and in fact potentially save lives? What I’m worried about is the large population of over 80 year olds in town who will now most likely experience rather powerful marketing as both of these centers struggle to make ends meet.

These folks and their families will now be faced with the expectation that they should not let nature take its course when their kidneys quit, since dialysis is common and easily accessible. If this made them healthier and happier it would be one thing, but I predict it will not go that way.

Wednesday, October 21, 2009

unthinkable thoughts, hypothetically

Last night I participated as a member of a panel speaking to medical students about issues relating to health care reform. Next to me was a respectable Blue Cross executive from the state capital, next to him a health care economist from the university and then two of my doctor colleagues. Our first starter upper question from the gathered masses was what we thought was the major problem with health care in America. The insurance guy and the economist said that people don’t take good care of themselves and so are in lousy health, and that they ought to take more personal responsibility for being healthier. This is what I keep hearing from Washington DC folks not in medicine, and although it is a truism, is it actually true?

Clearly, from the standpoint of bang for the buck, health and happiness and overall simplicity of delivery, the prevention of illness by avoiding overeating, drinking, smoking and drug addiction is powerfully attractive. Add to that physical activity with all of the associated intrinsic benefits of getting out and about and using one’s body as it was intended, and the recipe is really hard to beat.

But what if the finding in the New England Journal of Medicine last year that cessation of smoking eventually would actually lead to higher health care costs due to the fact that people would live longer is also true for all the rest of the things we do that make us healthier?

That is to say, what if being healthier means we live longer, and use up more health care resources because in America that’s just what happens?

This is a hypothetical question, and the answer might include a suggestion that however healthy we become, it will still be necessary to reduce health care costs.

It is certainly a more attractive idea that being healthier is also less expensive, but then one gets into the question of how to make people make choices that make them healthier.

Studies throughout the last 20 years have shown absolutely pitiful results from doctors counseling patients about lifestyle changes. So, hypothetically again, is it possible that beyond giving relatively casual advice, doctors really shouldn’t be in the business of delivering messages related to lifestyle changes? Would it, perhaps, be more efficient to have public health people do this? Maybe making exercise and healthy food more attractive and available would work better than nagging?

A somewhat different subject, but also nearly unthinkable, is the concept I’ve been rolling around in my mind lately about the source of our willingness to pay excessive prices for procedures and drugs compared to their value to us and their objective value in a global market. Is it possible that the introduction of public insurance, medicare and medicaid, in the last 50 years, has resulted in acceptance of actually generally unaffordable health care costs? On public insurance, in most cases, anything ordered by the doctor is paid for, without a significant bill to the insured. So there is very little reason for these insured people to protest the cost of things. I am absolutely positive that medicare and medicaid have saved lives and livelihoods for the many years they have been in existence, and that if they simply disappeared today havoc and misery would ensue. But is it just possible that they have been a primary player in the creation of our financially extravagant medical care in the US?

A single payer system might have the motivation to act like a patient/consumer would, and have the clout to reduce prices and increase quality, but lacking that how can we get insurance companies to do this? And why do that not act this way?

Insurance companies, when they first started to pay the bills, paid "usual and customary" fees for doctors and for procedures, set by what had been the market forces acting on them. As time went on, insurance companies standardized what they would pay for things, due to a great variation in regional billing, and then billing began to match, or rather slightly exceed, what insurances paid. Billing for these things gradually went up, and insurance payments went up, slightly trailing billing, and here we are. But as technology got better, the cost of x-rays and cat scans should have been able to come down. Procedures could have become cheaper, and drugs that had been around for years could have come down in price.

Saturday, October 17, 2009

Hawaii and the free market

Hooray for Hawaii! Apparently they have managed to get employers to cover just about everyone with adequate health insurance and their health insurance costs and other markers of health care efficiency are marvelous. Could it be the sea air?

So I am brought back to the dilemma that keeps popping up in the health care debate. Can we submit the business of caring for peoples’ health and diseases to market forces and bring down costs? As long as health insurance continues to protect people from exposure to the real costs of things, I don’t see market forces adequately coming into play. Only if health insurance companies actually acted like consumers would that really happen.

Why are medications so incredibly and jaw droppingly expensive? Especially ones for diseases like cancer and transplants and severe diseases? Because people who have those conditions are ALWAYS insured, or else they die, and are not part of the equation. If they don’t start out insured, they become insured when they run out of resources and go on public assistance. So drug companies know that they will be pain the 10 or 20 thousand dollars a year or a course for whatever new and necessary drug is prescribed. If consumers had to pay for drugs that were this expensive, they mostly would not, and prices would have to come down for the pharmaceutical producers to sell their products.

Coming back to Hawaii (which is always pleasant) we see a system that works by covering everyone with health insurance. It reduces costs by keeping the insured out of emergency rooms, cared for by doctors who know them, and by reducing use of procedures because the culture in Hawaii tends to avoid them. But the costs of those procedures and drugs etc. are still amazingly high, and they are successful only in comparison with the rest of our country.

Tuesday, October 13, 2009

Senate finance bill 10/13/09

A bill has passed the senate finance committee, with "bipartisan support", which means one Republican voted for it. The bill is only a tiny part of a health care reform package that will eventually by voted on in the house and the senate.

This tiny piece provides for more affordable universal health insurance, which is good, and will make those of us who have to negotiate for health insurance breathe a little easier. It would put an end to really heinous insurance company antics, such as canceling policies because people are sick. It allows for competition across state lines, stand alone dental insurance, expansion of medicaid and funding help for consumer driven health insurance options.

So it is good. It is not exactly what we need, but it does address some of the issues.

What we really need is still a radical reduction in costs. Although, as a health care consumer, I welcome anything that will bring some relief to those of us who suffer through having to pay for health insurance, I also recognize that those costs are almost completely driven by the cost of the product that is being paid for.

We focus on health insurance costs because, for those of us who are insured but rarely use medical services, that is what hurts most. And it is true that health insurance companies make obscene profits. Nevertheless, even the obscene profits are a drop in the bucket of what we pay for medical care overall. If we are relieved by improvements in the way insurance is administered and paid for, that relief will only be temporary, because the actual costs will continue to be too high. Costs need to come down.

As we breathe a sigh of relief that not all of our income will be used to pay for insurance, we need to stay focused on the work of rethinking what we want from medical care.

Presently, the culture of medicine, despite improvements in communication between doctors and patients over the years, remains hierarchical. Patients are expected to defer to doctors' opinions, and rely on the idea that doctors will truly know what is best for them. And doctors are still trained to think of the cost of care as being irrelevant. We have been trained in medical school to search for truth, find the diagnosis, even if it may have no important influence on outcomes, and damn the cost. Patients, through long association with their doctors, have come to accept this approach as only right and proper. There has been movement in the direction of providing appropriate and cost effective medicine, but it is by no means the rule.

The rethinking of our medical culture is going to take work, and time, and a willingness to change. As much as I would like to believe that legislation can make it happen, that would probably be unwieldy and heavy handed. Other than substantial federal malpractice reform, changes that need to happen need to happen at the level of health care providers and their patients, agreeing to do things differently, in a way that benefits their well being and remains financially sustainable.

Thursday, October 8, 2009

Health Care--a right or a privelege?

Does every American citizen have a right to health care? How about "affordable health care?"

It's tricky, this question of rights. I would like everyone to have enough food, but everyone doesn't have a right to enough food. Or enough sleep. Or love...

Soon after 9/11, Mayor Giuliani of New York City said that every American has a right to freedom from fear. No, I think, they do not.

Traditionally, as a country, we have made laws that prohibit the government taking away our individual self determination, and placing strict controls on the ways in which our self determination can be restricted in cases of law breaking or conflict. We have also developed institutions by which we care for each others' needs, guarding against letting those who are vulnerable die of poverty.

As a health care provider, I balk at the idea that every citizen has a right to what I produce. It's kind of like telling a dairy owner that everyone has a right to cheese. Nevertheless, as a not-abjectly-poor country, it is consistent with other safety nets we have created, to ensure that health care is available to everyone who needs it. In addition to issues of compassion, provision of universal health care makes business sense.

The present system, if it can be called that, provides expensive health care to some people, and is paid for at least partly by expensive insurance which increases the expense of the care by being ridiculously complex. The expensive insurance is paid for by employers, at least in part, and is part of what makes them competitive for good employees. They are cornered into buying the expensive insurance if they wish to do effective business. Our country lives or dies on its ability to be economically successful, which means that a health care system that strangles business, as it is doing, strangles the US of A.

Compassion drives many of us, but it need not drive the push for reform and universal health care. Health care does not need to be a right in order for it to be something that we, as a nation, agree to provide for all of our citizens.

I would love to see legislation that pushes us in the direction of smarter and more efficient health care delivery. But even if we don't get what I want, we need, at the very least, to reform the way in which health care is paid for provide adequate and affordable coverage to everybody.