Tuesday, May 08, 2007

Gordian Knot: Healthcare

A good friend of ours recently received the news we all dread: brain tumor. A large tumor has been growing at the base of her skull for years, and now that it has reached the size of a golf ball, it finally began causing mysterious symptoms: a bothersome knee and headaches.

Her experience highlights much of what is good and bad in our convoluted healthcare system. Here's the bad: her symptoms were initially blown off as stress or age-related. The orthopedic doctor who had treated her knee for a running injury realized her distress could not be caused by that long-healed injury, and sent her in for an MRI.

Brain tumors are not that common, and so it's not the first thought most physicians would have regarding headaches and a knee which doesn't seem to get better. But mis-diagnosis is a real problem, and we have to ask: is overwork an issue? Are doctors being "asked" to see more patients than they can adequately care for? Are HMOs and insurance companies paying for "second and third opinions," or resisting such checks on wrong diagnoses?

The good: her team of surgeons was experienced, and the 13-hour surgery was successful in removing about half of the tumor; the remaining parts were too intertwined with critical nerves to risk removing surgically. The next phase of treatment will be targeted radiation. In sum: if you need complex, risky surgery and high-tech treatment, you can get it here in the U.S. with no more than a couple week's delay.

The bad: the hospital (unnamed because I have only the first-hand reports of her husband, who I know is a reliable informant, but one opinion is not enough to form a judgment). According to our friend (the husband), the hospital is overwhelmed; there are not just beggars outside, but inside the facility. An infection the week after the surgery nearly killed his wife, and it was only a visiting friend who happens to be a medical student finishing her residency who observed the signs of dangerous infection.

We all know the debating points: nursing staffing have been cut back to save money, other staff doesn't care/is overwhelmed/is poorly trained--I only know that this is not a unique report within my circle of contacts. The horror list at major hospitals--not some small-town clinic, but major urban facilities where the upper-middle class go to be treated--goes on and on: wrong dosages, wrong meds, you name it.

It's all academic until it's you or your spouse in bed, very ill, and you're counting on a visibly harried/uncaring staff to keep them alive (and hopefully heal them).

Let's grant that medicine is a difficult field; even the best internists are left wondering what ails people with vague symptoms; there are so many possible causes and so few good data points to work with. But look at this chart, which shows that we as a nation spend a much greater amount of money per capita on healthcare than other developed nations. We have to ask: are we getting as much as we're paying for?

There's one more bad: the co-pay. My friend hasn't totalled up their share of the costs, because they're still rapidly spinning upward. If it wasn't for his wife's parents' savings, it would be tough to pay for the hotel and meals for the family to stay in the city to be nearby the patient--never mind the ultimate co-payment ($20,000? $30,000? $50,000?). S

elling their house to pay the bills seems like a likelihood. And this of course is for a middle-class family with a job in a Fortune 500 corporation and healthcare benefits. There doesn't seem to be an end to the negative trends: skyrocketing costs and declining health and coverage. Scan just a few of the hundreds of articles outlining the issues: Annual U.S. Health Care Spending Expected To Double By 2016 To Nearly $4 trillion, CMS Report Finds

The authors of the report wrote, "We are moving incrementally away from traditional sources of insurance, such as employer-based coverage, to a system comprising more federal and state government-provided health care." According to John Poisal, lead author of the report, "We will continue to face tough questions about how we finance our health care bill" as that shift occurs (Wall Street Journal, 2/21). The report did not make health care policy recommendations but warned of the possibility "that we will have to make important sacrifices to pay for health care" and of a need for "constant assessment of the value we associate with our health care investment".

HHS Secretary Mike Leavitt said, "America's per capita health spending is the highest in the world. There is simply no place on the economic leader board for a nation that spends a fifth of its domestic product on health care".

Robert Bixby, executive director of the Concord Coalition, said that the cost of health care "is really the key issue for the fiscal future of the nation," adding, "If health care costs continue to drift up -- unless you dramatically raise taxes -- you will have health care pushing out everything else government does. Nobody can say exactly when you reach a point that it's unsustainable, but you can look at something and say it's unlikely."

Ron Pollack, executive director of Families USA said, "As health care spending increases faster than earnings, it means more and more people will find health care unaffordable and join the ranks of the uninsured and underinsured".

National Medical Spending Attributable To Overweight And Obesity: How Much, And Who’s Paying?
Roland Sturm used regression analysis to show that obese adults incur annual medical expenditures that are 36 percent higher than those of normal weight incur. This analysis, however, was limited to people under age sixty-five. People age sixty-five and older now account for roughly one-fourth of the obese population, and, because of the chronic nature of obesity-attributable diseases, medical spending for treating elderly obese people is likely to be much higher than spending for nonelderly obese people.

Annual estimate of retiree health care costs up nearly 8 percent:
Rising health care costs are eating up more of retirees' savings, with a 65-year-old couple retiring this year needing about $215,000 to cover medical costs after they stop working, Fidelity Investments said Tuesday.

Health consequences of inactivity:
Physical inactivity and diet combined are the second leading cause of preventable death and disease in the United States and a huge economic burden on the state.
Nearly 60 percent of Minnesota adults are overweight and nearly 17 percent are obese.
The proportion of overweight or obese children in the United States has doubled in the last 20 years, to 13 percent.
Mortality, morbidity, and cancer rates are higher among sedentary populations.
Research has shown that many cases of heart disease, hypertension, type 2 diabetes, colon cancer, stroke, osteoporosis, depression and anxiety, breast cancer, and falls among the elderly are attributable to inactive lifestyles.

So what's the solution? Let's start with what any solution must include:
1. Portability. Benefits can't be dependent on employers; workers need to know their benefits travel with them to new jobs. Otherwise, labor markets are skewed away from opportunity to retaining benefits.
2. An emphasis on cost-cutting via patient lifestyle and diet changes, not cutting care. The primary cause of many illnesses is well-known: an unhealthy junk-food diet, and lack of exercise. The answer is simple: we must take responsibility for our own health. No one can predict who might be struck down by a brain tumor, but let's face reality on diseases like type 2 diabetes, which simply didn't exist 40 years ago, and coronary diseases caused by sloppy diets and sedentary lifestyles.
3. A competitive environment of providers, for without this there is no pricing pressure and no incentives to provide first-rate care. Ultimately, when hospitals in India and Thailand are siphoning off enough patients for lucrative surgeries ($100,000 in the U.S., $9,000 overseas with the same or better quality of staffing and facilities) then perhaps some changes which were once "unthinkable" will become very thinkable.

I have long touted Kaiser Permanente as a non-profit HMO model which is scaled for national care and which has a 50+ year history. If there were even a half-dozen such providers competing with each other, that would constitute a pretty competitive environment for care and cost-cutting. If we eliminated the welter of insurance types and paperwork (which consumes an estimated 30% of our total "healthcare" spending), then we'd free up money for actual care rather than paperwork.

There will be hundreds of thousands of jobs lost if the healthcare industry were streamlined; hence the tremendous resistance to any streamlining. But the streamlining will come anyway, for once the last middle-class person sells their depreciating home to pay their medical bills, and General Motors goes belly-up and reneges on its promise of lifetime medical care to its pensioners, and once the Federal Deficit soars beyond what the world is willing to subsidize, the gravy train will end regardless of who's fiddling as the city burns around us.

Check out this week's Readers Journal commentaries for correspondent Fred Roper's comments on national healthcare and James C.'s observations on consumerism run amok.

New essays include Protagoras' take on recent elections in the U.K. and Harun I.'s thoughtful disquisition on global imbalances.

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