Category: Rationing Health Care

Report: Breast Cancer Death Rates Decline, but More Slowly Among Poor

Report: Breast Cancer Death Rates Decline, but More Slowly Among Poor:

A new report from the American Cancer Society finds that deaths from breast cancer in the United States continue to decline steadily. However, the decline has been faster for women who live in more affluent areas. Women from poor areas now have the highest rates of death from breast cancer.

“In general, progress in reducing breast cancer death rates is being seen across races/ethnicities, socioeconomic status, and across the U.S.,” said Otis W. Brawley, M.D., chief medical officer of the American Cancer Society. “However, not all women have benefitted equally. Poor women are now at greater risk for breast cancer death because of less access to screening and better treatments. This continued disparity is impeding real progress against breast cancer, and will require renewed efforts to ensure that all women have access to high-quality prevention, detection, and treatment services.”

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Medical debts put patients at risk of financial collapse | Detroit Free Press | freep.com

Medical debts put patients at risk of financial collapse | Detroit Free Press | freep.com:

Frances Giordano found out she had lung cancer in June. After that, the bad news just kept coming.

First, she discovered that even with a good job and health insurance, her medical expenses were more than she could afford on disability.

Then she started slipping into debt, like millions of other Americans who don’t have the cash to cover their medical bills. Hospitals expect to be paid promptly and offer little leeway to insured patients. Unpaid bills go to collection agencies, damaging a person’s credit history for years.

Finally, she learned that fighting for her life was not her only battle or maybe even her toughest. When she finished her chemotherapy in December, she was fired. “Due to changes in business operations,” wrote her employer of more than six years, “we can no longer hold your position open.”

It arrived nine days before Christmas.

“I’m a good person,” the 58-year-old Giordano said. “I worked hard. Isn’t having cancer enough?”

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Parsimony & Medicine

[This is cross-posted on Doctors for America’s Progress Notes and DailyKos.]
I wasn’t planning on writing about rationing of health care again, since we covered it in my last post prompted by Don Berwick’s resignation from CMS.
But two stories came up recently that prompt me to do it again. The American College of Physicians released their revised Ethics Manual this week, and included language regarding the use of cost effectiveness as a criteria for providing care, and even urged parsimony by physicians. In an accompanying editorial, Ezekiel Emanuel, lauds the ACP for this language, noting the physician’s obligation to society as a whole, and not just to individual patients. (As we noted last time, the Charter on Medical Professionalism  and the AMA Code of Ethics emphasize the physician’s duty to social justice in the distribution of finite health care resources.)
All well and good, but NPR did a story on the Manual, and out it came. Scott Gottlieb, MD, of the American Enterprise Institute noted the general acceptance of cost effectiveness data in medical decision making, but then followed up that parsimony “really implies that care should be withheld. There’s no definition of parsimonious that I know of that doesn’t imply some kind of negative connotation in terms of being stingy about how you allocate something.” (The definition I linked to above notes that parsimony can mean simply being careful with money or stingy.)
Daniel Callahan of the Hastings institute also got the vapors: “If you say certain things will not be cost-effective, they’re not worth the money, well that’s rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that’s where this all becomes a real viper’s pit.”
As we noted previously, America rations health care ruthlessly, largely by income and inability to pay (yes, I know that’s a link to an NPR story), but also on quality of insurance, most acutely with private health insurance and Medicaid. I won’t run through all of this again, please reread the last post for the details, but I cannot help but find it exasperating that supposedly knowledgeable people, like Gottlieb and Callahan, act as if utilizing cost effectiveness strategies necessarily means “withholding care,” and, by extension, that all care, effective or not, cost-effective or not, is beneficial.
But more irksome is the implication that we don’t ration now, and that this new, threatened “rationing,” is somehow anathema to America. Which brings me to the second story that came up this past week, concerning money troubles in the British NHS and a regression in some areas to longer waiting times for certain procedures. The NHS had done quite a bit to repair their reputation and significantly shorten waiting times, but are apparently losing ground due to governmental austerity measures that (surprise!) actually effect people in real life. I noticed that conservative web site Townhall.com covered the story as an indictment of all health care, all over the world (and, of course, missing the irony that conservative austerity measures were the source of the problem). I pointed out over there with a flurry of comments that we’re not so hot on this score ourselves, but also noted that Germany and France, in particular, provide health care for all, far more frugally (parsimoniously, even) than we do, and have no waiting times, no significant rationing of services compared to us. We remain the only industrialized nation that thinks nothing of rationing health care – and I mean this more literally than usual – as many of us give no thought to those struggling and suffering and dying for health care.
A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy–a country that switched to Japanese cars the moment they were more reliable, and to Chinese T shirts the moment they were five cents cheaper–has loyally  stuck with a health-care system that leaves its citizenry pulling out their teeth  with pliers. 
                    – Malcolm Gladwell, The Moral Hazard Myth

Why Doesn’t No Mean No? – NYTimes.com

Why Doesn’t No Mean No? – NYTimes.com:

We talk, as a society, of our need to get health care costs under control. Conservatives, in particular, insist that Medicare must be reformed. Here is an enormously expensive drug that largely doesn’t work, has serious side effects and can no longer be marketed as a breast cancer therapy. Yet insurers, including Medicare, will continue to cover it.

If we’re not willing to say no to a drug like Avastin, then what drug will we say no to?

This is the nub of the argument to control health care costs. We have to say no to things that don’t work, whether they have excellent lobbyists or not.

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Huge Profits for Health Insurers as Americans Put Off Care – NYTimes.com

Huge Profits for Health Insurers as Americans Put Off Care – NYTimes.com:

“The nation’s major health insurers are barreling into a third year of record profits, enriched in recent months by a lingering recessionary mind-set among Americans who are postponing or forgoing medical care. “

I know, I’m shocked, too.

How to Lower Cancer Care’s Costs | The Health Care Blog

How to Lower Cancer Care’s Costs | The Health Care Blog:

In the NEJM last week, two oncology specialists — Thomas Smith and Bruce Hilner of Virginia Commonwealth University — took up the challenge. They created a “top five” list of common oncology practices, which, if limited to situations where they were truly clinically useful, would sharply lower the cost of cancer care. Their lead paragraph noted the need for taking these steps:

Annual direct costs for cancer care are projected to rise — from $104 billion in 2006 to over $173 billion in 2020 and beyond. This increase has been driven by a dramatic rise in both the cost of therapy and the extent of care. In the United States, the sales of anticancer drugs are now second only to those of drugs for heart disease, and 70% of these sales come from products introduced in the past 10 years. Most new molecules are priced at $5,000 per month or more, and in many cases the cost-effectiveness ratios far exceed commonly accepted thresholds. This trend is not sustainable.

Look closely at the second to last sentence of that paragraph: “In many cases the cost-effectiveness ratios far exceed commonly accepted thresholds.” It’s worth noting that there are no commonly accepted thresholds for cost of care in the U.S. That’s not true in Great Britain, where the National Health Service, based on recommendations from the National Institute for Clinical Excellence, will refuse to pay for certain drugs when their costs exceed certain levels. But in the U.S., Medicare, which is the primary payer for most cancer care since cancer is primarily a disease of aging, is forbidden by law from taking cost into consideration. If the Food and Drug Administration has approved a specific approach, and the doctor prescribes it, Medicare will pay for it. If the oncologist tries an approach that is not specifically approved by the FDA — either as an “off label” use or combination of approved drugs — the Centers for Medicare and Medicaid Services will still pay for the treatments long as the approach is listed in clinical practice guidelines. And when it comes to most testing and imaging, most insurers including Medicare will pay for whatever the doctor orders, even though the medical literature is loaded with studies suggesting their lack of usefulness in many situations where commonly used.

A good piece exhorting us to begin to address the out of control costs we have built into our care delivery.

Physician Incomes Internationale

Responding to my post about doctors stepping up for health reform over at FireDogLake, wigwam linked to a couple great pieces from the NY Times. ( I have a Google Alert on “physicians salaries incomes,” so I don’t know how I missed them, but, here they are now.)

In order, Uwe Reinhardt pointed out in a post about Rationing Doctors’ Pay

When Medicare reduces its payments to doctors, it rations money to them. It does not directly ration the health care the doctors might render patients.

If physicians refuse to treat patients at the lower fees, it is they who ration health care, even if the incentive to do so came from Medicare.

While I doubt that the payments to radiologists and cardiologists actually will be cut by 21 percent soon — more on that next time — let us suppose it were so. Would there then be “few radiologists and cardiologists working” after such a fee cut?

Presumably, the afflicted physicians would withhold their services only from Medicare and Medicaid patients, assuming that private insurers pay more. But
could most radiologists and cardiologists actually earn an adequate livelihood only from privately insured patients? I have my doubts.

Like everyone else, radiologists and cardiologists certainly can claim to be sorely underpaid relative to the extraordinarily high compensation of bankers and corporate executives, which appears to have little correlation with contributions to society. But relative to their colleagues in internal medicine, pediatrics and family practice, radiologists and cardiologists actually are very well paid.

…

So even if Medicare cut fees of radiologists and cardiologists by 21 percent, the income of these specialists would still exceed that of their colleagues in primary care by 60 percent or more.

…

The only question then is whether such fee increases [for primary care] will come at the expense of taxpayers or from other parts of the health care sector, perhaps even the more highly paid medical specialties, including radiology and cardiology. That is a political call.

Reading through just a few of the comments revealed this gem:

As someone who is training to be a radiologist, I have mixed feelings about what you’re saying. While you are correct that Radiologists and Cardiologists do make more than primary care physicians, there is also a reason for that. Specifically, it is that when primary care physicians can’t figure something out, who do they turn to? SPECIALISTS. We train for MUCH longer than primary care docs (often times greater than twice as long) and this is the reason that we are paid more per RVU. We also have more responsibility; in fact, the levels of responsibility are worlds apart. While a primary care doctor can always turn to a specialist for help, we have no one to turn to… The buck stops with us, we are the final authority.

Wow. Sounds like our friend suffering amongst us “less skilled physicians” from last year.

Subsequently, CATHERINE RAMPELL cracked open the Congressional Research Service’s analysis of the OECD database to find out “How Much Do Doctors in Other Countries Make?”

As a country’s wealth rises, so should doctors’ pay. But even accounting for this trend, the United States pays doctors more than its wealth would predict.

According to this model, the 2007 report says, “The U.S. position above the trendline indicates that specialists are paid approximately $50,000 more than would be predicted by the high U.S. GDP. General practitioners are paid roughly $30,000 more than the U.S. GDP would predict, and nurses are paid $8,000 more.”

But it’s important to keep in mind, the report notes, that health care professionals in other O.E.C.D. countries pay much less (if anything) for their medical educations than do their American counterparts. In other words, doctors and nurses in the rest of the industrialized world start their medical careers with much less student loan debt compared to medical graduates in the United States.

Rampell also links to the MGMA report on American physician income, which you may find either eye opening or eye popping.

Excess Deaths Due to Lack of Access to Health Care

From coverage of the recent study of Woolhandler, et. al.

As medical care has improved for people with health insurance, the consequences of being uninsured have worsened, according to a new study that says the lack of coverage translates into nearly 45,000 deaths each year among working-age Americans.
Researchers from Cambridge Health Alliance report in the American Journal of Public Health on a study that followed 9,005 adults under 65 years old who took part in a national survey conducted by the Centers for Disease Control and Prevention from 1986 through 1994. After 12 years, 351 people had died. Sixty of them were uninsured and 291 were insured.
After accounting for age, education, income, and other factors, the researchers found that people without private insurance had a 40 percent higher risk of dying than people with private insurance. An earlier study by the Institute of Medicine based on 16 years of data through 1993 found that uninsured people had a 25 percent higher risk of dying than insured people, which translated into 18,000 additional deaths.

I usally quote the 18,000 number as it is from th IOM, a very respected body, but the new figures point to an increase that likely reflects what’s going on “on the ground.”

Survival for $25,000 – TIME 1971

Survival for $25,000 – TIME:

This is an article about the trials and tribulations kidney failure patients faced before Medicare expanded in 1972 to cover kidney diseases theough its End Stage Renal Disease (ESRD) Program.

At 29, Don Shevlin was just two months away from taking his oral exams for a Ph.D. in English at U.C.L.A. Today, two years later, he has neither the degree nor any prospect of a teaching job. Says he: ‘I see myself as perennially pauperized.’

Shevlin suffers from chronic kidney disease, an incurable type that necessitated the removal of the organ. Now, in order to prevent a fatal buildup of toxins in his blood, he must report to the university hospital three times a week for kidney dialysis, a six-hour cleansing process that enables him to survive until he can get a kidney transplant. Since his illness wiped out his small savings, Shevlin lives on welfare payments of $178 a month, while the State of California pays for most of the cost of his treatments —which amounts to $3,000 a month.

Shevlin’s position is not unique. Nearly 5,000 Americans are currently undergoing regular kidney dialysis. Thousands more would choose such treatment if it were more widely available, but none can escape the gigantic cost of staying alive.

One of the questions I get asked is, “Aren’t you worried that ‘The Government’ will take over and start cutting off care or rationing care?” Not under Democrats.

Medicare and the ESRD program are examples of America’s liberal social justice tendencies accomplishing something.

Too bad kidneys aren’t the only organs that go bad, or we’d already have universal health care.

DrMatt: I’m worried about the death panels…seriously…

Over at DailyKos, DrMatt has collected a nice selection of anecdotes for my collection.

I have some more from Doctors for Amercia I’ll try to post later today…

I will be on KDKA Radio Pittsburgh tonight (Thursday Aug 13) at 9 PM with conservative talker Mike Pintek.

You can listen live at www.kdkaradio.com

Cheers,