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Monday, March 19, 2018

Comparing the US with other high income countries: how do we pay so much for healthcare?

Healthcare costs in the US are significantly greater than in any other developed country and for this we have a shorter life expectancy than they. We also develop cutting edge technologies and miracle cures and are world leaders in medical research. Just how do we compare with other economically advantaged nations?

In a Special Communication article in the JAMA (Journal of the American Medical Association) this week, Harvard researchers Irene Papanicolas, Liana Woskie and Ashish K. Jha analyzed data from Japan, Australia, Switzerland, Germany, France, the Netherlands, the United Kingdom, Canada, Sweden and Denmark about healthcare and social spending as well as outcomes. It is a huge amount of data gleaned from diverse sources and the authors have presented it beautifully. I will only comment on it and can't possibly do it justice. Still, there are several really interesting facts to point out, so I will dig in.

In US dollars, our spending per person per year is higher than any other country in this group. We spend the equivalent of $9403 in public and private money on healthcare for each of us. Our closest competitor is Sweden at $6808 and the UK comes in at $3377, in last place. This is 17.8% of our gross domestic product. Sweden spends 11.9% of its GDP and the UK 9.7%. How did we get so expensive?

First, the researchers wanted to test the assertion that American healthcare is expensive because people use too much of it. That is a complex question, but generally speaking the answer is no. We place right in the middle of the pack in hospitalizations for heart attacks, pneumonia, lung disease and mental illness. Germany is the leader there. We do get more cardiac bypasses and angioplasties, far more knee replacements and a few more caesarian sections and CT scans. We don't get more hip replacements. We have more outpatient visits but not more hospitalizations. This is not the key issue.

They also wanted to test the hypothesis that we spend more in healthcare because we don't allocate as much on "social spending" which is defined as benefits to people who are in bad circumstances. We are neither the highest nor the lowest in this category, though we are on the low end, near Australia and Canada. I'm not at all sure that supporting people once they are in trouble should be the definition of "social spending." It seems to me that money spent on education or a healthy environment, walkable cities, good jobs and opportunities for vibrant aging would be more likely to affect healthcare spending than social welfare. Perhaps spending on those is difficult or impossible to measure.

Health expenditures are quite different in different countries. The US, for instance, spends much more than the other countries on administration, think billing clerks and insurance companies. We spend 8% of our budget on this stuff. Surely we could follow the examples of Japan, France, Denmark, Sweden and the UK, all of whom keep these costs to under 3%. That would be an enormous amount of money saved without jeopardizing vital services.

We are neither high nor low in our spending on preventive healthcare, though I think they are doing different prevention than we are.

We have fewer primary care physicians compared to specialists than France and Canada, but not than the rest of the countries, which surprised me.

We spend more money on prescription drugs than any other country, equivalent to $1443 per person, twice as much as the average for all of the countries combined. We lead the pack in use of generics, but apparently that doesn't matter because even our generics are expensive.

There is a measurement called "horizontal inequality" which I hadn't heard of before. It is the likelihood of seeing a doctor in the last 12 months and whether that correlates strongly with wealth. In the US it does. Wealthy people see doctors pretty often and poorer ones do not. We are significantly worse in this regard than in Canada, France, Germany or the UK. The other countries did not have data to evaluate that. The reason for this is pretty clear: in every other country healthcare is available at a cost that is affordable, either by private insurance or government coverage, to 99-100% of the population. We are at 90%.

We do not look very stellar when it comes to certain outcomes. Our maternal mortality is 3 times as high as the next highest country, the UK. Our infant mortality is also higher, though not as egregiously so. Our life expectancy is 3 years shorter than the average of all of these countries, at 78.8 years. We are among the best, however, in mortality from strokes and heart attacks, and it is easier to get in to see a primary care doctor or specialist in the US than most other places.

We are more obese (70% obese or overweight), but not more likely to smoke or drink to excess. Our doctors are paid considerably more, but there are fewer of them per number of patients, so that apparently balances out.

Americans are the people least happy with their healthcare system. 19% feel the system works well and 23% believe it needs to be completely rebuilt. But none of these privileged countries to which we are compared is doing a great job, in the view of their citizens. Germans are happiest, but only 60% of them think their system works well. Canada pleases only 35% of its people. Worldwide, it seems like there may be quite a bit of room for improvement.

The authors of this study conclude that the costs of pharmaceuticals, devices, labor and administration are the main drivers of higher healthcare costs in the US. That is a good starting place for explaining how our system got to be so much more expensive than other countries. I'm curious, though, about how other countries develop good systems, what processes they have that are not good, either inefficient or providing poor care, and how they have evolved, since that could be helpful in moving all of us in the right direction. The United States continues to be one of the most productive innovators in the world, sometimes jettisoning expensive and useless routines and replacing them with ones that serve us better. Our innovations often drive savings and better outcomes in other countries. We need to learn from them as well.

This article is a good way to look at "how is American healthcare so expensive?" The why of it is more complex. Several commentary articles accompany this one, with delightfully different conclusions. It's a fascinating subject. I'll keep looking into it and write when I find the answer.

Sunday, March 18, 2018

Drug costs and copays

Drug costs in the US are higher than in in any other industrialized country in the world. Our cost for an insulin glargine (long acting insulin) pen is $76.80 and in Canada, so very few miles away, it costs $19.60. The latter price is reasonable. The former price can make the difference between being able to afford a life saving drug and dying. It is illegal, however, for a US citizen to buy his or her insulin, or any other drug available in the US, from another country.

Costs of pharmaceuticals in other countries are usually regulated by the government. Not so in the US. This is due to the lobbying power of US pharmaceutical companies. Because US citizens pay more for our drugs, we do have earlier access to newly released products than other countries if we can afford them. Our deep pockets help make new drug development attractive to drug companies. For people whose lives depend on the development of a new drug, this is very important. For the vast majority of patients, however, high drug costs can be at least burdensome and often crushing.

Healthcare costs were a major subject in the most recent issue of the JAMA (Journal of the American Medical Association.) Pharmaceutical costs were discussed in a brief article from the Medical Letter on Drugs and Therapeutics.

Not all drugs in the US are expensive, however. Such staples as lisinopril for high blood pressure and simvastatin for elevated cholesterol cost only a few dollars per month. When we go to the pharmacy and pick up these prescriptions, and the pharmacy submits the claim to our insurance companies, we pay a few dollars as a copay and go away generally happy. The low price we pay, or so we think, is thanks to the fact that our insurance is helping us out.

Tucked in the back of the issue is a letter by four health policy PhD's (Karen Van Nuys et. al.) from the University of Southern California. They researched overpayments at pharmacies by patients for drugs whose actual costs to the insurance companies is lower than what the patient pays. That's right. For some drugs, mostly the less expensive generic ones, the patient pays the pharmacy more than the pharmacy charges the insurance company and the insurance company pockets the difference. In some of these cases, the contract the insurance company has with the pharmacist prohibits the pharmacist from telling the patient about this.

I find this infuriating primarily for the lie involved. I know that insurance companies are primarily interested in making a profit, and so they do. If they couldn't turn a profit, they would go out of business. That's how it works. But it bothers me that they make patients believe that they are helping them pay for medication when they aren't. Each patient usually only loses a few dollars on the prescription for which they are overcharged (except a few on the list they published, including the nasal spray fluticasone and the antibiotic amoxicillin/clavulanate, for which the overpayment was $12 to nearly $20 per prescription), but the insurance company makes a bundle on the huge number of transactions.

Drug costs are crippling to many people, especially those with chronic diseases. Insurance companies should at least be honest about their contribution to this problem.

Thursday, March 15, 2018

South Sudan trip: take 4

I have just returned from Old Fangak, Jonglei State, South Sudan after my fourth trip. I seem to have earned a welcome there for teaching bedside ultrasound to anyone who will learn and doing ultrasound whenever anybody asks. Also I cook a mean soup and make delicious chocolate sauce in which a homesick American can dip a piece of local deep fried bread dough.

The hospital I visit is a community health center which has morphed into a full service hospital for tens of thousands of people displaced by chronic civil war. Jill Seaman, a doctor friend from my home town and a champion of treatment for complex and fatal tropical diseases (particularly Kala Azar and tuberculosis), has coordinated the multiple functions of this center for years. It serves as a distribution point for food aid, a triage center for war wounded when the war is close by, a referral center for treatment of tuberculosis and Kala Azar and now a major outpost for Doctors Without Borders (Medecins sans Frontieres--MSF) in this area of the country. It also takes care of patients with rashes and fractures, splinters and pneumonia, delivers babies, nurses the dying and treats those with chronic diseases such as epilepsy, heart failure, asthma and sadness.

It sits on the bank of the Zaraf River, so named for the giraffes that roamed here before they were killed or driven off by war and hard times. The river is a beautiful slow moving thing that flows past the hospital on its way to the Blue Nile and then to Juba, South Sudan's horribly dysfunctional capitol city. Tropical birds of vast variety roost in the tamarind trees at the hospital and fish in the river, including egrets, kites and ibis. There is a vibrant open market, selling mostly cheap Chinese goods but also fish and locally grown vegetables, teas and nuts. (Also delicious dough creations for dipping in chocolate sauce when you get the chance.) The war seems always to be going on somewhere, but this year it was not too close. Still, nearly everyone has suffered some terrible loss.

My niche, other than cooking, is to teach ultrasound and be an internist. The ultrasound teaching is an extension of my enthusiasm for bedside ultrasound which is very useful in a place like this, where there are two portable ultrasound machines (one in French, through MSF) and no x-rays or CT scans. Being an internist has benefits too, since internal medicine is all about making sense of multiple complex symptoms or chronic diseases. I learn more tropical medicine each time I visit, but am hardly an expert. What I can do is recognize patterns of disease that can lead to effective treatments, and improvise treatment from what is available.

My trip in ultrasounds:

Before I arrived in Old Fangak, in the week before I left home, I got an email from Jill with a brief clip of an ultrasound of a boy's heart.



This clip was taken by pointing an iPhone camera at an ultrasound machine and shooting a little video. It shows a normal boy's heart surrounded by a huge collection of fluid. The boy was short of breath, but had walked in. The condition had come on slowly. In Old Fangak, collections of fluid around the heart and lungs are usually due to tuberculosis and often respond quite quickly to a combination of steroids (prednisolone) and anti-tuberculosis medication. I told her that it was what she thought it was and that she should try her usual trick. Jill has gradually expanded her comfort with ultrasound beyond obstetrics but this was such a dramatic finding that she wanted another pair of eyes. When I arrived, this boy was one of the first patients I saw, and his pericardial effusion was almost gone about a week after starting treatment.


In the next bed in the hospital was another teenage boy with heart failure. He had been coming to the clinic for shortness of breath but despite medication had become so swollen and weak that he had been admitted. His ultrasound showed that his mitral valve was the problem.

Rheumatic fever is overwhelmingly a disease of poverty and lack of access to medical care. It starts with strep throat, then a few weeks later develops into an inflammation that can involve the heart. Years later the heart valves can become scarred. In his case, there is severe mitral stenosis, with very little blood flow through the valve separating the left atrium and ventricle, leading to stretching of the left atrium, abnormal heart rhythm and increased pressure in the vasculature of the lungs. Seeing this condition will lead to more appropriate medication and possibly even a heart procedure if he can get to the doctors in Khartoum (in the country of Sudan) who do free heart surgery.

Tuberculosis is common in South Sudan and the hospital at Old Fangak is a major treatment center for people who live with it. Patients who are diagnosed with TB take up residence in the TB compound in the village where they get daily observed treatment for the 6 months it takes to cure the disease. The compound is an area with a few buildings, a couple of latrines and enough flat ground for people to camp while they get their daily tablets. The patients get enough food, a mosquito net, a blanket and a dedicated though thinly stretched staff of mostly nationals who help them to survive while they get better. At clinic a few days after I arrived, a guy who was getting treatment for TB came in feeling short of breath even though he had been on appropriate treatment for a few weeks.



The ultrasound of his heart showed some thick stuff between the pericardium and the heart which doesn't allow the heart to fill properly. He had tuberculous pericarditis which had transitioned to a nasty constrictive effusive mess. He was treated with steroids in addition to his TB tablets which may reduce the inflammation and allow the heart to function properly. In a perfect world he would also have the option of surgery to remove the rind of constricting tissue.

A strikingly graceful and beautiful 6 year old girl came to clinic with her equally striking mother, troubled with breathing problems. She was able to walk long distances, but not fast and got out of breath easily. On exam she had a very loud heart murmur. It is not terribly uncommon to see congenital heart disease, and I expected that she had a ventricular septal defect (VSD), a hole in the wall between the two main chambers of the heart. When I looked with the ultrasound I saw nothing at all. Since her heart sounds were a little louder on the right side of her chest, I looked for her heart there. Sure enough, she was turned around. Her liver was on the left, heart on the right. And she did have a VSD.




Jill sent the little ultrasound clip to the heart surgeons in Khartoum. They may be interested. It would be wonderful for her to have treatment at a dedicated pediatric heart surgery department in a major referral hospital because her heart is really weird and repairing may not be straightforward. Such a thing costs a lot of money, and she and her mother have none.

A patient who had fevers and had been in the hospital the previous week with them came to the clinic because he hadn't gotten better. He had an even higher fever and abdominal pain. His thin abdomen clearly had a lump in it. Ultrasound showed that it was a fluid filled mass about the size of a large grapefruit in his liver.




The lump was a liver abscess and in South Sudan the most common cause of this is an intestinal parasite called Entamoeba histolytica, or ameba for short. He was treated with a common antibiotic, metronidazole, and was significantly better the next day. His pain and his lump persisted, though. We worried that he might not be improving, but on the fourth day he felt much better and the lump, which had stayed big all this time, had shrunk to half its size. By the time I left he was looking like a normal guy. Small miracles.

An older lady was brought in by her grown daughters because of fever and pain. Tuberculosis most often presents as a lung infection in the US, but in Sub-Saharan Africa it is not at all uncommon for it to be primarily in other organs, even spread diffusely through the body and sparing the lungs. Her ultrasound showed clear lungs, but a collection of juicy lymph nodes near her aorta.

These would be likely to represent lymphoma in the US, but she probably has TB. Her daughter then pointed out that her leg was swollen. My second generation Vscan ultrasound has a transducer that can look at structures such as veins, and she had a big clot in the right leg, up to the groin. The central circular structure has some grayish material in it and doesn't collapse when I push, indicating that it is filled with clot.

A blood clot in the leg often suggests malignancy, and she may have cancer rather than TB, but TB can be associated with blood clots too! It was possible to order in a shipment of anticoagulant injections for her, and it was there within a few days, so she may be able to resolve the clot. She will not get lifelong blood thinners as she would in the US because it's just not practical. If she has TB, effective treatment may take care of her risk. If she has lymphoma her prognosis is not good.


There are rotating doctors through MSF who staff an emergency room, available to treat patients whose problems can't wait for clinic hours. Sometimes they would ask me to do an ultrasound when the diagnosis was a mystery. A teenage boy came in with the feeling that he couldn't urinate. He had had trouble with his bladder off and on for the previous year. When he had blood in his urine he was dosed with praziquantel, the anti-parasitic medication that treats schistosomiasis. Schistosomiasis is caused by a tiny organism that lives in bodies of fresh water, including the Zaraf River, and most of our patients have been infected by it. A single dose of praziquantel rids the body of the parasite, which can infect the bladder and cause inflammation and scarring. He had persistent irritation when he urinated so had then been treated for a standard bladder infection with antibiotics. He may have improved but his symptoms brought him back to the ER. He was miserable.

His ultrasound showed a round object that made a shadow right in the middle of his bladder. I've seen patients with bladder stones before, but they were always older men with large prostates or chronic urinary catheters. It turns out that bladder stones are not uncommon in the tropics in boys. I find nothing in the far reaching tubes of the internet that explains why, though a 1961 article suggests that there may be some nutritional factor involved. The surgeon rotating through MSF had seen the condition before and did a small operation to remove the stone. The boy was very pleased and showed me the gnarly egg sized thing on evening rounds.
There were other stories, medical and otherwise, and more ultrasounds. Pointing an ultrasound at patients with various illnesses taught me things I couldn't learn from reading. I think I infected some of the other doctors and clinicians with the urge to look inside with ultrasound, and the more they do the better they will get. Once again, it was a privilege to work with Jill and her dedicated staff and the other fellow travelers who swoop in and out like I do, trying to make a difference.