Category Archives: Uncategorized

Hip Replacement–US vs Belgium, $100,000 vs $13,000

Great series on costs in the NY Times by Elisabeth Rosenthal here and here.

Nice discussion of the issue with Rosenthal on Fresh Air at this link .

Medicynical Note:  Why do hospitals, equipment suppliers, and drug manufacturers charge so much?  Because they can.  There is no competition in our non-system of health care.  Rather the deck is stacked to favor everyone but the patient. 

In Belgium, and virtually all other industrialized nations,  the health care system limits what  suppliers can charge. 

Amazing

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American Physicians: High Costs? Don’t blame me!

America’s health care non-system is the place where the “most informed” believe they have the least responsibility.   It’s everyone else’s fault.  So says the recent JAMA (Journal of the American Medical Association) study Views of US Physicians About Controlling Health Care Costs

A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%).

Read the article.

Medicynical Note:  The irony is that those who are (used to be) the most informed claim least responsibility for the mess that is our non-system of care.  Physicians have abdicated everything except keeping the current fee system intact.

The questionnaire was a loaded one with obvious “right” answers.  for example

Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.”

The problem is that most of the “new” agents in medical oncology, for example, offer limited benefit, that is, in most cases of advanced disease the treatment will give a month to a few months survival benefit and only occasionally provide longer term survival.  At over $100,000/year the cost of the buying, if you will, an additional year of survival, is in the hundreds of thousands of dollars/QALY.  

It used to be, that such drugs were cheap (5FU) in colon cancer in the 70’s and 80’s.  ($10-15/dose–you read that right)  In such a case you could try the drug anyway you wanted.   If they worked great (about 10% of patient’s responded) if it didn’t you did not bankrupt the patient, insurer or system. 

Someone has to be responsible in the new era of mega-expensive medications.  It’s clear that physicians have punted and that the pharmaceutical industry is only interested in their bottom line.  Insurers simply pass through the costs.  So it’s left to government.

 

Healthcare Costs: We lead the world…..

The American way of Birth is the costliest in the world.  In part this is because insurers are reluctant to provide policies that cover pregnancy and delivery.

Though Ms. Martin, 31, and her husband, Mark Willett, are both professionals with health insurance, her current policy does not cover maternity care. So the couple had to approach the nine months that led to the birth of their daughter in May like an extended shopping trip though the American health care bazaar, sorting through an array of maternity services that most often have no clear price and — with no insurer to haggle on their behalf — trying to negotiate discounts from hospitals and doctors.

The bottom line is that our families  pay two to three times as much for their babies as in any other country in the world.  And if you are without coverage you are more or less at the mercy of the hospitals and providers.  They will charge their “list price” (the MSRP or the used care salesman’s asking price) rather than offering the negotiated price, i.e. that given insurers.

But it’s worse than just money.

Medicynical Note:  In a money driven health care non-system the emphasis is on making money than saving lives and providing quality care to those who need it.

Read the article to find out just how bad our approach is.  Once again we lead the world, in costs.  We are number 1.

The Sequestration Bites: NIMBY to the Nth Power

This is not strictly a medical topic but does reflect the incompetence of our congressional leadership and members, mainly republican.

The point of sequestration was to force congress and the executive into making difficult budget choices in a budget.  Republicans in congress decided it was easier and in a perverse way better for them to simply accept the 10% across the board cuts in the sequestration than negotiate with a Democratic president.  .  The  executive branch warned of the impact both before and after it’s passage. .  Republicans in Congress ignored the warnings and now are claiming ignorance…and they are right.

This is frankly embarrassing in the leader of the free world…..it’s more like what happens in those “socialist” countries in Europe.  Actually it’s worse because of the wilful stupidity.

He said that he and others at the Transportation Department had been warning since February, before the sequester took effect, that it would cause layoffs that would create air traffic delays, adding that the agency had done everything it could to limit the impact.

And:

But Mr. Rogers insisted, “You didn’t forewarn us that this was coming; you didn’t ask advice about how we should handle it.”

Medicynical note: I wouldn’t trust a repub congressman to drive a car, much less run the country.  Too bad they can’t be sued for malpractice.

Accountable Care: Brakes in the System?

In this blog we’ve talked about health care costs ad-nauseum and how our non-system has the highest costs in the world, in part, because everyone sees a benefit to themselves by doing more and spending more.

Patients believe that they need to do everything to maximize their care, no matter the cost or efficacy of the intervention.     Moreover most believe they are entitled to do everything and have someone else (insurance/Medicare/the VA whatever) pay for it.  Providers and hospitals figured out a long time ago that doing more means more income.  Insurers learned that they could simply pass through the costs without affecting their 20% or share of premiums–check out insurance executives salaries.  Suppliers understand that there is no real price competition in health care and if they charge more, someone will pay.

Adding insult to injury Congress in it’s infinite (well lobbied and paid for) wisdom protects manufacturers and suppliers by not allowing the largest purchaser of health care in the country (Medicare) to bargain on price.

So it’s encouraging to find a model that puts in place a braking system  to slow expenditures.

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

And

Under Advocate’s deal with Blue Cross Blue Shield, certain patients are assigned to the accountable care framework — about 380,000 — and their health costs are projected. If Advocate achieves savings below that amount while meeting explicit quality targets, it splits the money with the insurer. If not, its revenue is at risk.

Read the article for more.

Medicynical Note:  It will be fascinating to see whether this “innovation” is effective, and if patients and the other players in the health care game allow it to work.  Previously you will recall, a very similar system of cost containment ran into patient and industry opposition in the 90’s. 

Just so you know I am covered by a HMO/medicare advantage program and like it.

Cancer Treatment Centers of America: Billfold Biopsies and Skewed Data

This company has claimed better results from their treatment approach.  If it’s too good to be true, it probably isn’t.

It turns out their approach is to not accept patients unless their insurance is “preferable.”  They minimize Medicare and Medicaid patients in their population—unlike other facilities.  They arbitrarily don’t accept certain patients.  They don’t report on patients who do not receive all their treatment at their facility.  As a result when they report outcomes the results are skewed by small numbers and careful patient selection.  They are under pressure to change as noted in the article.

Hilborn had seen CTCA’s website touting survival rates better than national averages. His call secured Vicky an appointment at the for-profit, privately held company’s Philadelphia affiliate, Eastern Regional Medical Center. There, the oncologist who examined Vicky told the couple he had treated other cases of histiocytic sarcoma, the cancer of immune-system cells that she had.

“He said, ‘We’ll have you back on your feet in no time,'” Keith recalled.

Vicky’s cancer treatment was forestalled by an infection and other complications that kept her at Eastern Regional for three weeks. In July 2009, when she got back home, things changed. Despite Keith’s calls, he said, CTCA did not schedule another appointment. As his wife got sicker, Keith, a former deputy sheriff in western Pennsylvania, was reduced to begging.

Read the article to get the full flavor of this type for profit beast. 

Medicynical Note:  What’s missing is an accounting of cost of treatment at this facility that provides “free transport” and limos to their hospitals.  It’s little wonder that medical care is bankrupting us.  More on this in Brill’s recent Time essay

In fact there is no magic in cancer treatment.  The reality, bad cancers that have spread have bad outcomes, with few exceptions.

No this is not the “gospel of hope,” but it is the truth.

Johnson and Johnson ASR Hip: Fails 40% of the time within 5 years

It’s remarkable that so called “ethical” pharmaceutical companies are anything but…..ethical.  Johnson and Johnson and it’s DePuy Orthopedics division appear to have suppressed and/or ignored early information that the devices were faulty and would fail prematurely.

Johnson & Johnson never released those projections for the device, the Articular Surface Replacement, or A.S.R., which the company recalled in mid-2010. But at the same time that the medical products giant was performing that analysis, it was publicly playing down similar findings from a British implant registry about the device’s early failure rate.

The company’s analysis also suggests that the implant is likely to fail prematurely over the next few years in thousands more patients in addition to those who have already had painful and costly procedures to replace it.

Medicynical Note:  As we’ve noted before these companies are not about patient care or good outcomes.  They are about the money.