Health In America

Stanford Social Innovation Review:

We spend far more on health care than any other nation—a breathtaking $2.6 trillion annually... The US Department of Health and Human Services estimates that health care expenditures will be 25 percent of US GDP by 2025, twice what many developed countries currently expend.
The burden of rising health care costs falls not just on individuals—half of all personal bankruptcies are at least partly due to medical expenses—but also on US companies. At General Motors, health care costs put the company at a $5 billion disadvantage against Toyota...
Despite such spending, US health indicators are among the worst of high-income countries. Since 1960, the United States dropped from 12th to 46th in infant mortality rankings (below Cuba and Slovenia), and from 16th to 36th in life expectancy (below Cyprus and Chile), according to the CIA’s World Factbook. In certain neighborhoods in Baltimore, Chicago, and Los Angeles—and other communities across the country—life expectancy for subsets of the population is lower than in Bangladesh.
...Primary care doctors are the key to improving value-based care: By focusing on preventive services, care coordination, and disease management, they can reduce unnecessary health care costs. In the 1960s, half of the doctors in the United States worked in primary care. Today, barely 30 percent do. And this trend is deepening: From 2000 to 2005, the percentage of US medical school graduates who chose to enter primary care dropped from 14 percent to 8 percent.

Overtreated Vaginas and Tonsils

Most pelvic exams are unnecessary, but they are frequently required by doctors before they will give a prescription for one of the most commonly prescribed medicines: birth control pills.  There are more birth control pill prescriptions each year than antibiotics.  

The US Preventative Services Task Force, an independent group of national experts that makes evidence-based health care recommendations, released new guidelines declaring definitively that women over 30 don't need a Pap smear more than once every three years unless they have a couple of risk factors, which I don't have. The American Congress of Obstetricians and Gynecologists has said that birth control pills can safely be prescribed without a full-on exam. Doctors, though, don't seem to be in any hurry to give up old habits. ...I emailed my doctor, citing the new guidelines, and asked if he could give me a new one-year prescription for birth control pills without a pelvic exam.

He wrote back, "Yes, one can argue about whether or not you need a pap, but ...I would still like you to come in. See you soon?"
The doctor had me over a barrel. As it turns out, my experience isn't unique. Doctors regularly hold women’s birth control prescriptions hostage like this, forcing them to come in for exams that research is increasingly showing are too frequent and often unnecessary and ineffective. A 2010 study published in the journal Obstetrics & Gynecology found that 33 percent of doctors always require a pelvic exam and Pap smear for a hormonal contraception prescription, and 44 percent regularly do so, even though there's no medical reason for linking the two.
Indeed, there's a growing body of evidence that the entire annual ob-gyn exam, with the mandatory and miserable pelvic exam where doctors poke around one's uterus and ovaries with their fingers, is largely obsolete. For instance, there's no evidence that doctors can diagnose ovarian cancer with a pelvic exam in women showing no symptoms. A clinical trial found that doctors were unable to identify any cancers in test subjects by pelvic exams alone, and the National Cancer Institute no longer recommends the tests for postmenopausal women. ...The scientific basis for much of the traditional well-woman ob-gyn annual check-up is so slim that "the routine pelvic examination may be an example of more service leading to worse outcomes," Dr. Carolyn Westhoff, an ob-gyn at Columbia University, wrote in the Journal of Women's Health last year.

Virginia Postrel suggests that the controversy between the Catholic Church and the US government could be mostly solved by eliminating the prescription for oral contraceptives.  Making them available over the counter would eliminate the controversy as it applies to oral contraceptives, and it would make them much cheaper.

Right now, the American women who have the most choice are those who live near the border with Mexico, where pharmacies sell oral contraceptives without a prescription, generally for about $5 for a one-month supply. A group of researchers [] conducted extensive interviews with more than 1,000 women who live in El Paso, Texas....One result from the El Paso study surprised researchers. “Women who got the pill in clinics were significantly more likely to stop using it during the study — even though they still didn’t want to get pregnant,” Grossman says. That’s a big deal. In fact, he says, “my hope was that we would show that continuation was no worse for the OTC group, but in fact we showed it was better.”

Oral contraceptives are already available over the counter in most countries of the world, so this can work fine.  Kevin Drum notes that this kind of easier oral contraceptive access produces a big reduction in pregnancy and abortion rates.  This is the difference between women in California who needed monthly prescriptions and women who got a year supply. 

There is a tonsillectomy fad underway in medicine which raises costs and increases risk of iatrogenic illness for most patients rather than healing them:

It turns out we’re in the middle of ...a tonsillectomy epidemic,... Tonsillectomies are the most common procedure, for children, requiring anesthesia. ...The number of tonsillectomies performed spiked by 74 percent between 1996 and 2006. In 2006 alone, more than a half-million children in the United States got their tonsils removed. The only problem is there’s no evidence they work for most children.
The procedure does show some benefits for those with really serious symptoms — very sore throats, fevers and other symptoms at least seven times in the past year — but no improvement for those whose indications are milder.
....“It’s a silent epidemic of unnecessary care,” says the Dartmouth Atlas’s David Goodman, .... “In most instances, it’s done for patients with much less recurrent symptoms than should be indicated. I think a lot of this is unbeknownst to providers.”
...Unnecessary health care is estimated to cost at least $158 billion every year.
...Most doctors are paid for the volume of services they provide, creating an incentive to provide more care even if it might not be indicated. That does not quite explain the surge in tonsillectomies: As a relatively simple procedure, it’s not one that will bring in significant revenue, in the way that more complex treatments, such as those for cancer and end-of-life issues, would. “There’s not a lot of money in tonsillectomies compared to end of life care,” says Goodman. “Providers are by and large well-meaning here.”
Goodman and others have focused a lot on the medical education system as one key culprit. Medical school often focuses on teaching how best to treat patients, with little time spent discussing when treatment doesn’t make sense.

The Health of Nations

Ezra Klein:

Medicine may be hard, but health insurance is simple. The rest of the world's industrialized nations have already figured it out, and done so without leaving 45 million of their countrymen uninsured and 16 million or so underinsured, and without letting costs spiral into the stratosphere and severely threaten their national economies.
Even better, these successes are not secret, and the mechanisms not unknown. Ask health researchers what should be done, and they will sigh and suggest something akin to what France or Germany does. Ask them what they think can be done, and their desperation to evade the opposition of the insurance industry and the pharmaceutical industry and conservatives and manufacturers and all the rest will leave them stammering out buzzwords and workarounds, regional purchasing alliances and health savings accounts. The subject's famed complexity is a function of the forces protecting the status quo, not the issue itself.
So let us, in these pages, shut out the political world for a moment, cease worrying about what Aetna, Pfizer, and Grover Norquist will say or do, and ask, simply: What should be done? To help answer that question, we will examine the best health- care systems in the world: those of Canada, France, Great Britain, Germany, and the U.S. Veterans Health Administration (VHA), whose inclusion I'll justify shortly.

Read the whole thing for a good overview of healthcare around the world.  

Is Health Spending Growth A Sign Things Are Getting Better?

The massive growth in government debt stretching far into the future, Yglesias says,

is driven, everyone knows, primarily by Medicare. Edsall emphasizes the role of an aging population, but the more fundamental issue is that we’ve been fortunate to benefit from untold numbers of useful medical innovations that have changed what it means to be committed to providing health care to the elderly. That is to say, it’s more a crisis of abundance than of scarcity. If we stop inventing new treatments, then costs will tumble as patents (and patients) expire. Indeed, the 2003 bill adding a prescription drug benefit to Medicare has turned out to be cheaper than expected, largely because the pace at which new medicines are invented has slowed. Common sense says that was a bad thing, and that a zero-innovation future would be bleak

Basic epidemiology, psychology, and overprescription

Levitin @ NYT:

Suppose you’ve just found out that you or a loved one has prostate cancer, ...Nearly every urologist would recommend radical surgery to remove the organ. Sounds reasonable, doesn’t it? 
But let’s look at the numbers... Prostate cancer is slow-moving; more people die with it than from it. According to one 2004 study, for every 48 prostate surgeries performed, only one patient benefits — the other 47 patients would have lived just as long without surgery... Moreover, the 47 who didn’t need the surgery are often left with an array of unpleasant and irreversible side effects, including incontinence, impotence and loss of sexual desire. The likelihood of one of these side effects is over 50 percent — 24 of our 47 will have at least one. This means a patient is 24 times more likely to experience the side effect than the cure.
...the “risk for disease,” ...is important to untangling disease statistics. Say a drug promises to reduce your risk of fatal illness X by 50 percent. Sounds great, doesn’t it? But suppose there was only a one-in-1,000 chance that you’d get the disease to begin with: reducing your risk by 50 percent means that you’ll now have a one-in-2,000 chance of getting it. Most medications have side effects, and the likelihood of these may far exceed that of being helped by the medication. For example, the “number needed to treat” for a particular cholesterol-­lowering drug is 300. (For every 300 people taking it, only one heart attack is prevented.) The drug has a 5 percent probability of side effects, including severe muscle and joint pain and gastrointestinal distress. Thus, for every person helped, 15 people (5 percent of 300) will experience side effects and not be cured. In other words, anyone taking the drug is 15 times more likely to experience the unwanted effects of the medication than the beneficial ones.
Of course, none of us want to think of ourselves as a statistic... studies by cognitive psychologists have shown that our brains are not configured to think statistically, whether the question is how to find the best price on paper towels or whether to have back surgery. In one famous study, Amos Tversky and Daniel Kahneman found that even doctors and statisticians made an astonishing number of inference errors in mock cases; if those cases had been real, many people would have died needlessly. The problem is that our brains overestimate the generalizability of anecdotes. Scientists call anecdotes the “n of 1,” pseudo-experiments with no controls and only one subject. The power of modern scientific method comes from random assignment of treatment conditions; some proportion of people will get better by doing nothing, and without a controlled experiment it is impossible to tell whether that homeopathic thistle tea that helped Aunt Marge is really doing anything.
...Returning to prostate surgery, consider that six weeks is the ...recovery period. Coincidentally, the operation will, on average, add six weeks to your life. (This averages across the 47 people who had no benefit from the operation and the one person who did.) To my way of thinking, the decision then becomes this: When do you want to “spend” those six weeks? When you’re relatively young and feeling well, or at the end of your life, when you’re old and only dimly aware of your surroundings? 

GROOPMAN and HARTZBAND @ WSJ:

Consider the case of Susan Powell..., a nurse's assistant now in her 50s. She had been healthy all her life, but when she turned 45, she decided to see a primary-care doctor. Susan ate healthy foods and was physically active, but she was a bit overweight, and her blood tests showed that she had high cholesterol. Her doctor prescribed a statin drug... Statins are among the most commonly prescribed medications in the world. In the U.S. alone, more than 25 million people take the drugs to lower their cholesterol, ...a key factor leading to heart attack and stroke.  Soon after seeing her doctor, Susan spoke with an acquaintance at church who had developed muscle pain after starting to take a statin. Susan also thought of her father, who had high cholesterol and never took ...medication... "People take too many pills," he often told his children. He lived a long, full and active life. 
Susan decided not to take the statin.
Many people decline treatment because they know someone who suffered from side effects... Stories deeply affect all of us, and they can make real the risks and benefits that might otherwise seem abstract—but they can also distort our vision by making the rare appear routine.
Statistics can help to put lessons drawn from stories into a larger context, letting us make a more considered choice...
At Susan's follow-up appointment..., her doctor told her that "by taking a statin pill, you'll reduce your risk of a heart attack over the next 10 years by as much as 30%." The risk of side effects, she continued, was very small, and the benefits far outweighed the risk. Susan promised to give it serious thought.
She continued to search for information, reading everything she could about cholesterol. What caught her eye was a ... "10-Year Heart Attack Risk Calculator."
She entered her age, total cholesterol number of 240, and "good" cholesterol (HDL) of 37. She was not a smoker, her blood pressure was fine, and she was on no medications. The result: "Risk Score: 1%: Means 1 of 100 people with this level of risk will have a heart attack in the next 10 years."
This means that 99 of 100 people like me won't have a heart attack in the next 10 years, Susan told herself. She started to feel much better. She had found a key number in health literacy: her risk for disease without treatment.
Without treatment, Susan's risk for a heart attack was 1 in 100. If 1 in 100 women has a heart attack, that means... 3 in 300. The statin treatment reduces risk by 30%, or about one-third.
Let's apply that benefit to a group of 300 women like Susan, where three would have a heart attack without taking statins. If we treat them all, we would prevent one heart attack—because we protect one-third of those three. The other two women would still have a heart attack despite taking the medicine. The remaining 297 would not have had a heart attack even without the medication, so they wouldn't benefit from taking it.
This statistic comes as a surprise to many people. When you hear that a statin lowers Susan's risk by 30%, it sounds as if she is at a 100% risk of suffering a heart attack if she doesn't take the medication.
Another component of health literacy is understanding the risks of a therapy. Statins cause muscle pain in 1% to 10% of people who take them. However, if we "flip" the frame, the number without any side effects is 90 to 99 out of 100, a much more reassuring statistic.
Advertisements for drugs ...are designed to communicate a compelling tale. ...In 2007, a team of researchers from the UCLA Medical Center and other medical centers studied prescription drug ads broadcast on national networks. They found that the average American TV viewer sees over 1,000 prescription drug ads in the space of a year. That's 16 hours all told—much more time than the average person spends with his or her primary-care physician.
The study concluded that the large majority of TV ads fail to fulfill an educational purpose. But they clearly work, ...: Every $1,000 spent on advertising translated into 24 new prescriptions...
Another illuminating study ...examined the impact of printed drug ads on patient preferences. One group was given actual ads. A second group received the same ads, except that the brief summary at the end of the text was replaced by a "drug-facts box." [like the nutritional facts box on packaged foods] The box presented information in a clear, accessible fashion, similar to the ...the benefits and risks of a statin for Susan [presented above].
The results of the Dartmouth research are impressive. Nearly two-thirds of the group that saw the original ads overestimated the benefits... They believed it was 10 times more effective than it actually was. But nearly three-quarters of the participants who saw the information in the drug-facts box correctly assessed the actual benefits...
Even more striking was another finding. When people were given readily understandable information about the statin's actual benefit in preventing future heart disease, nearly twice as many said they wouldn't take the drug in light of its side effects. When given clearer information, the patients weighed the risks and benefits differently ...and were less likely to take the medication.

Should car dealers be forced to post the prices that they charge each customer for new cars?  Why should health care be any different?  Yglesias:

Josh Barro at National Review writes in favor of the idea that the law ought to require "hospitals and medical practices to disclose their full price lists—both the inflated list prices and the rates negotiated with each insurer that the practice accepts."

To my way of thinking, this is a moderately good idea. I remarked on twitter, however, that it didn't strike me as a particularly free markety idea. That's fine by me. Sometimes heavy-handed regulation is what you need. But others seemed to push back and say that anything aiming at providing more information about prices is per se a pro-market intervention. I don't think that's correct. Opaque pricing is a pretty common feature of the economy. Cable companies, for example, will often offer pretty steep discounts to customers who threaten to cancel service. The marginal cost of providing cable to an additional household is very low, so it's worth knuckling under to pressure. But obviously cable companies don't want to disclose how low they're willing to go, since if they did that would strengthen everyone's else's hand in bargaining. In general, full disclosure of how much you pay/charge your employees/clients/suppliers/customers would be pretty poor negotiating strategy in a wide variety of contexts so it doesn't exist in a market equilibrium. Rules banning price secrecy across the board would, whether you like them or not, be a very drastic regulatory intervention into the marketplace.

Waiting In America

Aaron Carroll:

Some days it’s hard to be a blogger. Yesterday, I told a story about how the local Minute Clinic filled a niche by providing timely care on off hours for a simple acute issue. Nevertheless, I got a lot of email accusing me of being a shill for Walmart and selling out the medical profession. Please.
Look, I clearly said at the end of my piece that I don’t think retail clinics are good for everything. I think longitudinal care through a medical home is proper for primary care. But there are limits. There are times when you need to see a health care professional early in the morning, or later at night. Have you tried to get an appointment lately when you’re sick? It’s hard! That’s not all. You often have to wait a while:

So almost 20% of people need to wait at least a week to see a doctor when they are sick. Try getting a same day appointment if you can. Or, even better, try getting an appointment before or after work. Or on a weekend:

Yeah, we beat Canada. But we lose to almost every other country. Almost two thirds of Americans have trouble getting care on nights, weekends, and holidays. You know what? A significant amount of the week is filled with nights, weekends, and holidays. Especially if you don’t want to miss work.
It’s fine to believe that people should try and see the doctor in the office. But if you want that to happen, then you need the office to be available. If retail clinics do a much better job in that respect, you can’t complain when people make use of them. In my example, my kids could be seen at 8AM, before school, without an appointment. That’s useful. If physician offices want that business, they should do the same.