Category Archives: General Cynicism

The Commonwatlth Fund’s review of U.S. health care provides assessments of our non-system’s efficiency, equity, access and quality.

Some good news can be found in an exception to the overall pattern of U.S. performance: rapid progress on quality metrics that have been the focus of national initiatives and public reporting efforts. Hospitals, nursing homes, and home health care agencies are showing marked improvement in patient treatment and outcomes for which data are collected and reported nationally on federal Web sites and as part of improvement campaigns. There has also been significant improvement in the control of high blood pressure, a measure that is publicly reported by health plans; increasingly, physician groups are being rewarded for improving their treatment of this and other chronic conditions. Better management of chronic diseases also has likely contributed to reductions in rates of avoidable hospitalizations for certain conditions, though rates continue to vary substantially across the country.

Of great concern, access to health care significantly eroded since 2006. As of 2010, more than 81 million working-age adults—44 percent of those ages 19 to 64—were uninsured during the year or underinsured, up from 61 million (35%) in 2003. Further, the U.S. failed to keep pace with gains in health outcomes achieved by the leading countries. The U.S. ranks last out of 16 industrialized countries on a measure of mortality amenable to medical care (deaths that might have been prevented with timely and effective care), with premature death rates that are 68 percent higher than in the best-performing countries. As many as 91,000 fewer people would die prematurely if the U.S. could achieve the leading country rate.

The summary also notes the cost burden and the lack of improvement in many health system indicators:

such as preventive care, adults and children with strong primary care connections, and hospital readmissions—likely stems from the nation’s weak primary care foundation and from inadequate care coordination and teamwork both across sites of care and between providers. These gaps highlight the need for a whole-system approach, in which performance is measured and providers are held accountable for performance across the continuum of care.

A nice chart shows some of the savings that would accrue if we actually had a system:

Medicynical Note: We spend more and have worse health care. Only in the U.S.

Administrative costs in health care are a silent epidemic. Our inefficiency is costly to patients, providers, insurers, and government.

Ewe Reinhardt observes:

In many ways, our health care system mirrors our tax code — especially in its financing and health insurance facets. These can be made so complex and have been made so complex in the health care system in the United States that many decision makers in health care — patients, physicians, hospitals, employers and so on — need in-house or external consultants to find their way through the maze.

and:

Consulting firms help physicians bill private and public insurers or help patients submit claims to insurers after an illness. Legions of insurance brokers help prospective clients through the maze of the nongroup or small-group health insurance market. Large employee-benefit consulting firms, helping large companies, establish what amount, in effect, to analogues of the health-insurance exchanges in the Affordable Care Act, and many more consultants of many stripes are involved.

Medicynical Note: Yes the U.S. has the number 1 health care system in the world–it’s the most inefficient by far.

Interesting Economix by Uwe Reinhardt on money flow in health care:

He notes:

In fairness, it must be added that traditional Medicare basically sets prices and then just pays bills. It makes no active attempt to manage care (utilization controls, disease management, coordinating care and so on), because it has not been allowed by Congress to do so. It is almost as if Congress did not want traditional Medicare to be a prudent purchaser of heath care for the elderly. (Medicynical emphasis)

From the viewpoint of prudent purchasing, most economists would probably judge these prices too low. On the other hand, the fact that traditional Medicare just pays bills more or less passively may be precisely the reason that it is still so popular among the elderly. Traditional Medicare still offers beneficiaries completely free choice of providers and therapy — a degree of freedom that many younger Americans in insurance plans with limited networks of providers no longer enjoy.

Medicynical Note: Until we approach the issue of value in medicine (What works? Bang for the buck?) we’ll have the most expensive least efficient health care non-system in the world. What’s bugging us, the US, now is how to get to such a system.

Is health care part of the package of being a US citizen? Providing Medicare to the elderly and many with chronic illness implies such a commitment. Does required access to ER care for all, whether they can pay or not, point to a civic responsibility to assure access to care to the rest of the population?

If our republican friends really believe that health care is not a “right” then a large swath of citizenry are going to be in trouble as republicans follow through on this philosophy. Interestingly these rightist purists for some reason tout ER access for all as adequate health care in our non-system. Why they would choose the most expensive, least efficient care in the world as their means of providing health care is unknown.

If there is an explicit right to health care in our country, more efficient ways to provide it must be found. It should assure affordable care to citizens, including the elderly and those with illnesses. One problem has been that private insurers, ironically, want little to do with either of those populations.

A recent Archives of Internal Medicine study of primary care physicians noted:

Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians).

It was also noted in a Reuter’s piece about the Archives article that:

Four in 10 also believed that other primary care physicians would order fewer tests if those tests didn’t provide extra income. (Of course, just three percent thought that financial considerations influenced their own practice style.)

“I’m not saying that physicians do tests in order to make money — there is a potential to be a real cynic here — but I think that the reimbursement model for most healthcare encourages utilization in a variety of way,” Sirovich said.

Medicynical Note: It’s not cynical to acknowledge reality.