Monday, April 23, 2018

Our Outrageous Healthcare Costs: It's Not Just Drugs

It's been known for years that the US spends about twice as much on health care and has the lowest quality compared to other high-income countries. Why? Our sick and wounded do not go into the hospital in any greater numbers than those in comparable countries. And although our socia  So why do our sick people cost more and die younger? Our social spending (i.e. on the elderly, education, family, and housing) is slightly lower than average, but it is not the worst.

A new study comparing our system with that of 10 other comparably wealthy countries may help identify the basis for our horrendous costs and dismal quality.  The nations were the UK, Germany, Sweden, France, the Netherlands, Switzerland, Denmark, Canada, Japan, and Australia.  Of note, all of the comparison countries have universal health care, which is a major factor in their cost advantage (as well as quality).

Drug Prices Are too High
In general, our prescription numbers are actually lower than in the other countries compared here. However, we spend more on drugs for each person, $1443 compared to a range of $466 to $939 in the other high-income countries. One reason is our far higher preference for brand-name drugs over their generic siblings. And one factor for this is the courtship between drug companies and US doctors. In 2015 nearly half of US physicians received more than $2.4 billion from the drugs companies, typically in the form of meals and small gifts that sales reps spent on individual doctors. According to some research, when these interactions are restricted generic prescriptions go up and brand sales go down. But there's more. Our brand-name prescriptions also cost a lot more than in the rest of world. For example a person in the Netherlands with acid reflux spends $23 for Nexium; her fellow American sufferer will pay $215.  Why? It's simple.  Other countries with large unified health care systems have the clout to negotiate with pharma. With our fractured system and Medicare restrictions against negotiation, we don't.

Doctors Get Paid Too Much
Our physician and nurse workforce rate is about the same as in other rich countries, and contrary to previous research, we appear to have the same proportion of primary care physicians to specialists.

However, the US pays all of them a lot more. For example, an American family doctor earns an average of about $200,000 compared to a range of $87,000 to $154,000 for their peers in other countries. Furthermore, our specialists are paid about 40% more than in the other nations. One reason (but not the only one) for this: American doctors leaving medical school drag with them an average debt of about $175,000, with 25% owing more than $200,000. Given the interest on these debts, primary care physicians (who are paid the least among US docs) typically never close the gap.  Many of our comparison countries largely bear the cost of medical school and in most of them tuition costs are far less than ours.  Medical school costs aside, most doctors who aren't salaried charge per procedure or per patient, with these fees set by a committee made of physicians—almost all of whom are specialists. In many other countries physician compensation is set through collective negotiations with the government or large healthcare systems.

Drowning in Paperwork
Our cacophony of multiple insurer types—both private and government—and discordant reporting regulations have created a horrendous Kafkan bureaucracy that tortures anyone working in the health care system. Nearly three quarters of US doctors spend 10 hours or more a week on paperwork, and this bureaucratic overload is the primary reason why nearly half of them report being burned out. And the paperwork is costly. Administrative costs were estimated to be over $300 billion this year.  They comprise 8% of our total health care costs compared to 1% to 3% in other counties. Here's where a single- or a consistent-payer system could go a long way to reducing both the costs and emotional burden placed on heatlhcare staff.

Over-Testing and Over-Treating
We actually spend less on patients who are in the hospital than all other comparable countries except Canada. However, common surgeries and testing procedures are more costly, and we perform far too many of them.  For example, we toss an excessive number of our patients through MRI and CT scanners.  Comparing our usage to the other countries, MRI imaging is used in the US at a rate of 118 per 1000 patients compared to 82 in the comparison countries; CT scanners by 245 per 1000 in the US versus 151 in other countries.

One reason for our over-testing and -treating? Doctors get paid for piecemeal work.  The more they do, the more they earn. (Remember those fees-for-service that the specialists themselves set?)  In addition, they fear being sued if they miss a serious ailment. It's not in their interest to perform fewer procedures or fewer tests. And don't forget, those excessive treatments and tests are not making us healthier.  Too often, in fact, these procedures themselves can lead to harm. One solution is to change the way doctors are paid (more on this in another blog), so that they are encouraged to use best evidence and not best paycheck when making decisions.  And, although not popular with Democrats, changing the liability laws could help.

In Summary
Reducing costs is not just strong-arming pharma (although it would help).  The following are some suggested steps.

First and foremost, establish a universal system of health care (not necessarily single-payer, but more on that later). Such a system will have the capability to:

1 Negotiate drug prices.
2. Reduce administrative tasks with a simplified bureaucracy
3. Establish a process for physician collective bargaining with the major payers (government or a few non-profit insurers)
4. Reduce medical school debt with either free tuition (particularly for primary care physicians), fewer years in school, and/or creating a process for debt forgiveness.
5. Provide evidence-based guidelines for physicians to use to determine appropriate tests and treatments
6, Create a rational process of lawsuits

Monday, March 26, 2018

Ding, Dong, the Dickey Is Dead – Not

What is the Dickey amendment?

There was a flurry of misguided excitement last week after the passage of the federal budget bill, because it appeared to soften the blow from the nefarious Dickey amendment. For those who still don't know what that is, in the mid-nineties the NRA complained that CDC research was tainted by predetermined outcomes in favor of gun control. So, Arkansas Representative Jay Dickey did the required GOP bend-over and, in 1996, introduced an amendment to an appropriations bill, which said “none of the funds made available for injury prevention and control at the CDC may be used to advocate or promote gun control." And it passed.
 Now, nowhere in the bill was research on gun violence forbidden, But over the next two decades CDC funded studies on this issue effectively stopped. In fact, the years between 1998 and 2012 saw a 64% decline in such studies from all sources. 

Currently, compared to the other top thirty causes of death, gun violence is the least-studied and second least funded. (Only research on death from falls gets less money than gun violence). For example, gun violence and sepsis kill about the same number of people. But funding for gun violence research is about 0.7% of that for sepsis and publication volume about 4%. 

So if the Dickey amendment did not prohibit gun research, why didn't the CDC fund it?
And the answer to that is simple: money. Every line item in a CDC budget has to be approved by the House appropriations committee, which can reject any they like. In 2012, under Obama, $10 million was earmarked for firearm violence prevention studies. The GOP-dominated committee crossed it out that year, and again the next year, and the year after. The money was deleted once more in 2017. In the new budget, CDC got an increase in research funding, but not for studying firearms.

So, although last week the new budget bill added reassurance that the CDC can research gun violence, it's not relevant and, without money, it's useless.

Furthermore, the wording that allows gun research isn't included in the 2232-page budget bill itself.

It's in a report attached to the spending bill and it says,"…the Secretary of Health and Human Services has stated the CDC has the authority to conduct research on the causes of gun violence."

So this doesn't smell like law to me. In fact, it could be worse, since it gives the Secretary of HHS the power to allow (or not) research on gun violence –an autonomous, and, let's face it, a potentially partisan decision. (By the way, I've only seen a PDF of a photocopy of this document with "Xerox" scrawled at the top. I haven't been able to find any official document online with this wording. If somebody can get a link, let me know.) 

And, the worse part of the Dickey amendment still stands: the new budget bill continues to prohibit promoting or advocating for gun control, not just by the CDC but by all federal agencies!

Why is this prohibition on the CDC particularly harmful?
Because that's what the CDC does. It advocates and promotes evidence-based interventions for basically every condition and situation related to public health. It offers recommendations on preventive measure for virtually every chronic and infectious disease, as well as for injuries and handling disasters. The CDC employs the best evidence available to make immunization guidelines, to recommend healthy-lifestyle choices, to fight tobacco interests, to promote seat belt use. It promotes and advocates measures for dealing with every possible national disaster, including volcanoes and tsunamis. And it provides preventive advice for every possible injury, including from nail-guns! But not from real guns.

The CDC's advocacy and promotion of sound preventive measures provides the gold standard used by doctors and nurses for their treatment and recommendations to patients related to safe and healthy living. And local, state, and national governments are guided by the CDC in making public laws and regulations.

Without the CDC's muscular research and recommendations on gun control our struggle for sound laws will continue to be up hill, and we will remain at the mercy of our opponents' flawed arguments and fake facts.

In Conclusion

In a 2015 NPR interview, two years before he died, Dickey publically expressed regret for his amendment. "It wasn't necessary that all research stop. It just couldn't be the collection of data so that they can advocate gun control. That's all we were talking about. But for some reason, it just stopped altogether... All this time that we have had, we would've found a solution... And I think it's a shame that we haven't." By then, however, the damage was done. And so it goes.

Tuesday, March 13, 2018

Killing the ACA in a Short Term

Remember Tom Price, the orthopedic surgeon/Secretary of Health and Human Services, who wanted to rip the heart out of the Affordable Care Act (ACA) but instead was sent packing after racking up at least $400,000 taking private jets for short flights (eg. DC to Philadelphia)?

Well, you may not have paid much attention to his replacement, Alex Azar, but we all should.  He's a bit more complicated than his predecessor.  He was the Deputy HHS Secretary under George Bush, followed by a stint as President of the US division of Eli Lilly, a giant drug company. For better or worse, he has far deeper knowledge of the health care system than the bone carpenter from Oklahoma.  And he could be far worse. 

He is an abortion opponent, has a history of vocal opposition to the Affordable Care Act, and he's allowing states to impose work requirements on Medicaid recipients.

But so far he's enforcing the regulations, including those introduced under Obama.  The latest example was his rejection of Idaho's outright illegal and jug headed decision to simply ignore the ACA requirements.  Under Governor Otter, Idaho insurers could sell plans without its essential benefits, notably maternity care and vision and dental for kids. These plans would have deductibles in the thousands of dollars and cap annual benefits at $1 million—also not allowed under the ACA. Premiums for older adults compared to younger one would increase significantly.  And for people with pre-existing conditions, premiums would go up by 50%; in fact, these individuals wouldn't get any coverage at all for a year if they had been uninsured for 63 days.

Blue Cross of Idaho called these "Freedom Blue"plans.   Question, why does "Freedom" for Republicans generally involve the rich being free to take anything they want and the poor being free of basic rights and necessities?    

But, although Azar did a good thing in blocking Governor Otter's plan and therefore other state governments from adopting similar ones, he has proposed a nefarious play that could undermine ACA's entire foundation—the extension of short term plans.  

These plans are currently allowed under the ACA as temporary insurance for people who need it but have missed the open enrollment period for coverage under the health exchanges. They are intended to provide insurance for three months at most and they don't need to cover the following:
  • ·      Pre-existing conditions, including chronic pain.
  • ·      Essential benefits
  • ·      Preventive care
  • ·      Prescription drugs outside the hospital

The short-term plans can’t be renewed or used as full-time coverage without paying a penalty.  They are only intended to fill the gap until a person can be covered under a full ACA-compliant insurance package. 

Well, no surprise, the Trump administration has been salivating over these weak but legal plans, and Azar now intends to Frankenstein them into year-long and renewable Monsters. (Several insurers have already sidestepped the rule by packaging consecutive 90-day plans, with a one-time review of a patient's medical history.) Thus, these plans, originally created to be a temporary aid, will become the Republican's grotesque tools for stomping on the ACA's critical benefits, weakening the market for healthy people and increasing premiums, including dramatically for those with pre-existing conditions. Once again we become vulnerable to the exorbitant costs of our obscene medical system.