Category Archives: General Cynicism

Individual Mandate: Be careful what you wish for

Be careful what you wish for.  This cuts both ways.

The incidental economist notes: (Austin Frakt)

If one wants to address the problems in health insurance markets and/or to get providers to accept payment reforms, the mandate–or something like it–is the political price. Yes, it’s about money. What else?

Put it this way, if one wants to retain a private market-based health insurance system (which ours largely is), it takes a mandate. Reject the mandate without replacement with a similar mechanism and the whole thing unravels, not just as a matter of health economics (adverse selection) but as a matter of politics.

Medicynical Note:  We’ve created the most dysfuntional, expensive healthcare non-system in the world.  Yes we’re number one.

Employer sponsored health care is a mess.  Employers don’t have to provide their employees health care–in many instances they can’t afford to provide it; “contractors” are not employees and don’t qualify for employer provided benefits;  if you get sick and can’t work, you lose your insurance.  Remarkable.

Our health care costs are twice that of many other industrialized countries and thousands more per capita/year.  We have 50 million uninsured and have a “system” that encourages “free” use of the most inefficient, most expensive health care provider in the country–emergency rooms.

We all pay.

No System of Health Care, Life Style = Suboptimal Longevity

It’s no mystery why our people in the U.S. don’t live as long as elsewhere in the industrialized world.

1.  Lifestyle:

For U.S. males, life expectancy at birth increased by about 5.5 years (from 69.9 to 75.5) from 1980 to 2006. That’s good, but it still lags the average life-expectancy gains of 21 other countries. For U.S. women, life expectancy at birth increased by about three years (from 77.5 to 80.7) from 1980 to 2006, which also ranks lower than other developed nations.

Why aren’t Americans living the longest given the amount spent on health care? According to the report, about half of the gap between U.S. life expectancy and countries with higher life expectancy is because of heart-disease rates in the United States. Moreover, among U.S. women, smoking appears to account for lower life expectancy relative to other countries.

Obesity may account for one-fifth to one-third of the shortfall in U.S. life expectancy as compared with other countries, the report states.

Also:

Three to five decades ago, smoking was much more widespread in the U.S. than in Europe or Japan, and the health consequences are still playing out in today’s mortality rates, the report says.  Smoking appears to be responsible for a good deal of the differences in life expectancy, especially for women.  The habit also has significantly reduced life expectancy in Denmark and the Netherlands, two other countries with lower life expectancy trends than comparable high-income countries.

 

Because there appears to be a lag of two to three decades between smoking and its peak effects on mortality, one can predict how smoking will affect life expectancy over the next 20 to 30 years.  On this basis, life expectancy for men in the U.S. is likely to improve relatively rapidly in coming decades because of reductions in smoking in the last 20 years, the report says.  For U.S. women, whose smoking behavior peaked later than men’s, declines in mortality are apt to remain slow for the next decade.  Similarly, life expectancy in Japan is expected to improve less rapidly than it otherwise would, because of more-recent high smoking rates.

Obesity’s contribution to lagging life expectancies in the U.S. also appears to be significant, the report says.  While there is still uncertainty in the literature about the magnitude of the relationship between obesity and mortality, it may account for a fifth to a third of the shortfall in longevity in the U.S. compared to other nations, the report says.  And if the obesity trend in the U.S. continues, it may offset the longevity improvements expected from reductions in smoking.  However, recent data suggest that the prevalence of obesity in the U.S. has leveled off, and some studies indicate that the mortality risk associated with obesity has declined.

2.  A non-system of health care in which many people have limited access:

Lack of universal access to health care in the U.S. also has increased mortality and reduced life expectancy, the report says, though this is a less significant factor for those over age 65 because of Medicare access.

Medicynical Note:   The health care industrial complex has excelled at making money not improving longevity and public health.  Somehow this needs to change.

Incomes and Health Care



Our non-system of health care has average per capita costs of $7000/year. I’t even more if you have a pre-existing illness.


Overselling technology, Avastin and Circulating Tumor Cells

For years, since the Nixon war on cancer, we’ve oversold our ability to treat cancer. This tendency continues today.

Health Affairs blog has a piece from the Manhattan Institute’s Paul Howard that criticizes the FDA’s revocation of the use of Avastin in breast cancer.  His point seems to be that the drug which in clinical trials has been shown not to improve survival and have significant toxicity appears to work in a small subset of patients.  At present, however, we have no reliable means of determining who will respond and who will only get side-effects.  This in a drug costing between $50,000 and $100,000/year.

The American Cancer Society’s Deputy Medical director Len Lichtenfeld has noted:

“But it is important to understand the decision was based on the advice of an independent panel of experts who noted that larger studies showed some women lives were actually shortened on the drug and that toxicities associated with the drug were significant,” Lichtenfeld says. “Meanwhile, the net benefit for women taking the drug was quite modest.”

“What we clearly need is a way for doctors to more accurately predict which women will have a better chance of benefiting from this important targeted therapy,” Lichtenfeld says. “Until that tool is developed, giving all women with metastatic breast cancer Avastin may harm more women than it helps.”

Howard also talks of using tests for circulating tumor cells (CTC’s) as a way to:

screen for cancer that can replace expensive or invasive tests like mammograms or colonoscopies; to tailor cancer treatments and adjust them based on how many or what type of CTCs are found in a patient’s bloodstream; or make physicians more comfortable adopting a “watch and wait” approach for elderly patients in cases where the underlying cancer may grow so slowly that it will never become life-threatening.

His analysis of the test is  incorrect.  While it may be useful in identifying those with more serious disease it does not appear to have utility as a screening test for early cancer.  When a tumor has reached the point that it’s cancerous cells are in the blood stream, the tumor is not  early  but rather one that is at high risk to  have spread and  metastasize.  I know of no study suggesting use of  CTC’s as a marker or screening test for early cancer–the ones most amenable to being cured.

Medicynical Note:  It would be of interest to know of Mr. Howard’s and Manhattan Institute’s pharmaceutical industry support.

Maybe We Can Learn Something From Canada

McClatchy points out:

Not a single Canadian bank failed during the Great Depression, and not a single one failed during the recent U.S. crisis now dubbed the Great Recession. Fewer than 1 percent of all Canadian mortgages are in arrears.

Also:

“This sounds very simple, but one of our CEOs has said we are in the business of making loans to people who will pay them back,” said Terry Campbell, vice president of policy for the Canadian Bankers Association in Ottawa.

And:

Even so, there’s plenty to learn from Canada’s conservative — yes, conservative — regulatory regime. It requires more rigorous loan underwriting standards and much bigger set-asides by banks for potential losses during market downturns.

Medicynical Note: We can learn from their health care system as well. They have 100% of their population covered by insurance and spend half of what we do. (2006 data, trend persists today) More here. Their outcomes measured by life expectancy, infant mortality, etc are better than ours.

So we pay more, have less coverage and outcomes that are no better than elsewhere. Our non-system is the best in the world? For whom?


Our lax weapons laws bring new meaning to Mad Men

Only in America:  Tucson shootings: Focus is on Arizona’s gun laws – latimes.com.

We’re number one in the world in death by weapons. And the only place in the industrialized world where allegedly mentally ill people can easily buy and carry and use assault weapons.

That’s freedom?


Guns — An American Public Health Problem

Is this the most pathetic story imaginable?

The teenager who worked at a gun show where 8-year-old Christopher Bizilj accidentally killed himself while shooting an Uzi testified today he twice suggested the boy’s father pick a less powerful weapon for the boy to shoot. But Christopher’s father, Dr. Charles Bizilj, insisted that his son be allowed to fire the automatic weapon

Or is this one?

Medicynical Note: American exceptionalism at work.

Addendum: The attempted assassination of Representative Giffords 18 people shot, 6 killed.

Addendum 1/20/2011: Nine campuses were locked down after a school officer was shot outside El Camino High, a day after two students were shot in Gardena. A Bell student was also shot on his way home.

Addendum: 1/24/2011 Think it might be the guns?  Or is it just Americans asserting their 2nd amendments rights?  11 police shot in 24 hours.

Addendum: 1/30/2011 Mother shoots children, they were “mouthy”


How to control Health Care Expenditures — Have A Recession!

It’s reported that in 2009 heatlh care costs increased by the smallest amount in 50 years:

Total national health spending grew by 4 percent in 2009, the slowest rate of increase in 50 years, as people lost their jobs, lost health insurance and deferred medical care, the federal government reported Wednesday. Still, health care accounted for a larger share of a smaller economy — a record 17.6 percent of the total economic output in 2009, the report said.

The economy contracted while health spending continued to grow.

Medicynical Note: This decrease in spending means little when one considers the annual inflation rate in 2009 was -.4%. and as noted the % of GDP spent on health care rose to a record 17.6%. Of course this happens in places where politicians make up their own facts to suit their views.

And that is not only in America.


25% Overuse of Implantable Cardioverter (ICD)

As noted in JAMA, implantable cardioverters are being overused. 25% of patients in the study cited did not have the accepted indications for this expensive procedure. Furthermore:

Patients who received a non–evidence-based ICD compared with those who received an evidence-based ICD had a significantly higher risk of in-hospital death (0.57% [95% confidence interval {CI}, 0.48%-0.66%] vs 0.18% [95% CI, 0.15%-0.20%]; P <.001) and any postprocedure complication (3.23% [95% CI, 3.01%-3.45%] vs 2.41% [95% CI, 2.31%-2.51%]; P <.001).

Medicynical Note: We think of the art of medicine as making treatment decisions using science as well as instincts based on the provider’s unique knowledge of the patient, local standards and what is medically indicated.

In the JAMA study 25% of patients received ICD’s did not have the established indications for the procedure and as a group these patients had worse outcomes. Presumably their doctors felt the use of the ICD indicated (applying the “art of medicine”). As costs have increased (an ICD procedure is $50,000 or more) and better tracking of outcomes reveal that overuse leads to more complications and worse outcomes, I’m not sure we can afford this type artistry.


Spinal Fusion Surgery — Big benefit to doctors, limited benefit to patients

Bloomberg has an interesting article on the limited medical benefit of spinal fusion to patients–but big financial benefits to doctors, medical practices and suppliers (Medtronic). The article documents at least the appearance of, if not actual, conflicts of interest; high costs $135,000 for the surgery (yes on one patient); $800,000/year incomes for the orthopedists–three times that of pediatricians.

The possibility that many of these and other surgeries are needless has gotten little attention in the debate over U.S. health care costs, which rose 6 percent last year to $2.47 trillion. Unnecessary surgeries cost at least $150 billion a year, according to John Birkmeyer, director of the Center for Healthcare Outcomes & Policy at the University of Michigan.

“It’s amazing how much evidence there is that fusions don’t work, yet surgeons do them anyway,” said Sohail Mirza, a spine surgeon who chairs the Department of Orthopaedics at Dartmouth Medical School in Hanover, New Hampshire. “The only one who isn’t benefitting from the equation is the patient.”

There’s lots to this article including evidence that fusion is no better than physical therapy for disc related pain in several studies–only a 47% success rate for surgery in one U.S. study;  high complication rates for surgery;  direct payments from the medical supplier (Medtronic) in the form of royalties and consulting fees to doctors (as high as $440,000/year to an individual doctor and 1.75 million to a practice in Minneapolis).

Medicynical note: Not a pretty picture of American medicine. Costly, open conflicts of interest, use of aggressive expensive unproven procedures over more conservative approaches–with the same or worse outcomes.  Is it any wonder that our costs are one and half to two times that of other industrialized countries.

The “free market” encourages entrepreneurs to find ways to take advantage of markets, sometimes that leads to better outcomes and more efficiency but in medicine it seems to encourage waste, high cost and over-utilization.