Where’s the outrage over our failed health care system?
Posted Aug. 15, 2013, at 11:05 a.m.
For the next few months we’ll be bombarded by messages from the Obama administration urging people, especially young, healthy people, to sign up for insurance provided under the Affordable Care Act. Without them, premiums for that insurance will soon climb to unaffordable levels.
We’ll also hear plenty of noise from the ACA’s opponents. It will be hard to get any other health policy messages across during the upcoming PR blitz.
But there are some other important and noteworthy things going on in the policy world. Perhaps the most important is the growing interest in the origins of the high costs of medical care in the U.S., now about double that of other wealthy countries.
That interest has been fueled by the ACA. By requiring many Americans to buy private health insurance, the federal government is now obliged to see to it that insurance remains affordable. Whether they are actually able to do so remains to be seen.
Because of that, both government and the lay media have now joined academicians in paying a lot more attention to the costs of medical care in the U.S. and how they compare to those in other countries. That attention was jump-started last March by a Time Magazine article titled “Bitter Pill” by journalist Stephen Brill, who looked at hospital charges and their causes. He concluded that while many of those paying the bills suffered badly from the high costs, those selling health care products and services were prospering, helping to create an island of affluence for themselves and a sea of poverty for everybody else.
That was followed by Medicare’s public release of the prices it was being charged in various regions throughout the country, revealing huge variations without any persuasive explanation as to why these variations should exist.
More recently, the New York Times has published an ongoing series by Elizabeth Rosenthal examining the costs of medical care for various procedures throughout the U.S., and comparing them with those in other countries. So far she has examined three common types of care: colonoscopy, pregnancy and hip replacement. In each case, she found prices in the U.S. were both variable and extremely high by international standards, some up to 10 times the prices for comparable care in other countries. When asked why, one expert commented, “They’re charging these prices because they can.”
In other words, as economist George Akerlof predicted in his Nobel Prize-winning paper “Selling Lemons,” in a market where the sellers have a great deal of information (and therefore power) and the buyers have little or none, the buyers (most of us) are being ripped off big time.
In most countries that have enacted programs of universal health care, two things have taken place. First, health care prices were restrained so as to keep their national programs affordable. Profiteeringfrom illness is not allowed.
Second, the importance of medical care in maintaining a healthy population was put in perspective. Medical care can be very effective in fixing what’s already broken, but not very effective in preventing the breakage in the first place.
End the Healthcare-For-Profit Marketplace
Kathleen Sebelius, Secretary of Health & Human Services, The Washington State House, The Washington State Senate, Governor Jay Inslee, The United States House of Representatives and 2 other targets (click here to see more) “The United States is the only nation that lets insurance companies extract a profit from basic health coverage” (T.R. Reid)*I have been paying for healthcare insurance for decades, and yet now that I need medical care, I am swamped with medical bills, deductibles to fulfill, co-pays and co-insurance costs, and limited in-network provider choices. I am being billed by out-of-network pathology labs for more than four times the amount that my insurance company or Medicare would have to pay, and I am being threatened with collections if I don’t pay the full amount. (*Laurie S., Licensed Counselor and Filmmaker)
Sen. Reid: Obamacare ‘Absolutely’ A Step Toward A Single-Payer System
By Avik Roy for Forbes –When I speak to conservatives about health care policy, I’m often asked the question: “Do you think that Obamacare is secretly a step toward single-payer health care?” I always explain that, while progressives may want single-payer, I don’t think that Obamacare is deliberately designed to bring about that outcome. Well, yesterday on PBS’ Nevada Week In Review, Senate Majority Leader Harry Reid (D., Nev.) was asked whether his goal was to move Obamacare to a single-payer system. His answer? “Yes, yes. Absolutely, yes.”
In one sense, this isn’t shocking. Reid and many other Democrats, including President Obama, have often stated that their ideal health-care system is one in which the government abolishes the private insurance market. Video of the PBS discussion isn’t yet online, but here’s how Karoun Demirjian of the Las Vegas Sun described it:
Reid said he thinks the country has to “work our way past” insurance-based health care during a Friday night appearance on Vegas PBS’ program “Nevada Week in Review.”
A Glut of Antidepressants
By RONI CARYN RABIN
Over the past two decades, the use of antidepressants has skyrocketed. One in 10 Americans now takes an antidepressant medication; among women in their 40s and 50s, the figure is one in four.
Experts have offered numerous reasons. Depression is common, and economic struggles have added to our stress and anxiety. Television ads promote antidepressants, and insurance plans usually cover them, even while limiting talk therapy. But a recent study suggests another explanation: that the condition is being overdiagnosed on a remarkable scale.
The study, published in April in the journal Psychotherapy and Psychosomatics, found that nearly two-thirds of a sample of more than 5,000 patients who had been given a diagnosis of depression within the previous 12 months did not meet the criteria for major depressive episode as described by the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (or D.S.M.).
The study is not the first to find that patients frequently get “false positive” diagnoses for depression. Several earlier review studies have reported that diagnostic accuracy is low in general practice offices, in large part because serious depression is so rare in that setting.
Elderly patients were most likely to be misdiagnosed, the latest study found. Six out of seven patients age 65 and older who had been given a diagnosis of depression did not fit the criteria. More educated patients and those in poor health were less likely to receive an inaccurate diagnosis.
The vast majority of individuals diagnosed with depression, rightly or wrongly, were given medication, said the paper’s lead author, Dr. Ramin Mojtabai, an associate professor at the Johns Hopkins Bloomberg School of Public Health.
http://well.blogs.nytimes.com/2013/08/12/a-glut-of-antidepressants/?emc=edit_tnt_20130812&tntemail0=y&_r=0&pagewanted=print
The Calculus of Primary Care
By ABIGAIL ZUGER, M.D.
My patient Kevin developed a terrible rash. By the time he showed up, a few weeks into his new life as human scratching post, he was red and flaky from scalp to ankles. I asked a few basic questions and knew in less than 30 seconds exactly what to do for him.
Which was to get rid of him as quickly as possible.
As I explained to Kevin at some length, I have the ability to address basic, garden-variety itches, but he clearly needed more than I was ever likely to learn about skin disease; what he needed was a dermatologist.
And so off he went, with some ad-hoc creams and a dermatology referral in hand.
Two weeks later, he was back. He had missed the appointment and used up all the creams. “Doc, you’ve got to do something,” he pleaded, scratching his shoulder blade against the back of the chair. “I’m dying here.”
And so off he went, with more educated pharmaceutical guesswork and another dermatology appointment.
And then, incredibly, he was back. He had made it to the dermatologist’s crowded office, found the wait intolerably long, and left, scratching, to come back to me.
We looked at each other. “Why are you here?” I asked. “Because you’re my doctor,” said he. Check and mate. Now what?
The calculus of primary care demands a certain amount of blind faith. Not unlike various biblical concepts — the loaves, the fishes, the burning bush — it conflates finite and infinite, arguing that an entity can be endlessly consumed yet remain whole.
Riley defends Obama health-care law
Posted Jan. 21, 2011, at 6:52 a.m.
LEWISTON, Maine – Health care costs are too high, but Americans aren’t healthier for it, according to the former director of the Governor’s Office of Health Policy and Finance.
She told a crowd at the Great Falls Forum Thursday that the federal government’s controversial health care reform law is the best way to change that.
“It’s taken a lifetime to pass health reform in this country,” Trish Riley said. “It is not perfect, no law ever is. But one choice would be, let’s take it — it doesn’t (fully) go into effect until 2014 — let’s take it as it goes, let’s see how it works, let’s fix what needs to be fixed as we go.”
Her comments came one day after the House of Representatives voted to repeal the health care reform law. The repeal effort is not expected to last through the Democrat-controlled Senate.
Let’s Talk about a Real Healthcare System (And, No, I Don't Mean "Obamacare")
Let’s talk about healthcare. I don’t mean debating the Affordable Care Act. I mean healthcare, as in: If everyone needs healthcare, guarantee that everybody gets it.
I know, when it comes to healthcare, it’s easy to get into a debate for or against Obamacare. But we nurses see the world through a different lens: our patients.
Good healthcare is a fundamental resource that keeps America’s big engine running. Every day, as we do our best to care for our patients, nurses see people with chronic disease like asthma or diabetes who can’t afford insurance costs or medication. Maybe they’re absent from work, tired, and distracted from trying to manage their health on a shoestring. They run the risk of hospitalization. They struggle for a distant unreachable shore hoping something will help. They can’t get ahead because their health keeps dragging them down.
And yet the answer isn’t on the horizon, the answer is in our pockets, in our hands. It’s our taxes. We pay them and we ought to benefit from them.
There’s one thing that every American does. Every working American (ok, except the Wall Street crowd) pays taxes. But what do we pay taxes for? Increasingly, we wonder where our money is going, how our money is serving our communities, and how our tax money is helping us and our families.
Controlling Health Care Spending, Revisited
By UWE E. REINHARDT
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
A hotly debated question among health policy wonks is whether the decline in the year-to-year growth in health spending in the United States, which started in 2002 (see Figure 1), will leave that growth rate at a permanently lower level.
I had a blog post on this question in January 2012, drawing no conclusion but noting that over the longer term the growth rate just had to come down closer to the level of growth in gross domestic product.
An intriguing question is what drives the fluctuations in the growth of health spending clearly visible in Figure 1. It was a topic at a recent symposium convened by the Altarum Center for Sustainable Health Spending.
In a joint effort, Thomas Getzen, professor emeritus of economics at Temple University; Gary Claxton and Larry Levitt, senior vice presidents of the Henry J. Kaiser Family Foundation, and Charles Roehrig, vice president of the Altarum Institute, developed a statistical model in which the annual growth rate in nominal national health spending (not adjusted for inflation) in any given year over the long period 1965-2012 is assumed to be driven primarily by two macroeconomic variables: (1) the inflation rate in the current and the previous two years, measured by the G.D.P. deflator, and (2) the growth rate in real G.D.P. in the current year, as well as in the previous five years. The approach is called “lagged regression analysis.”
In a joint effort, Thomas Getzen, professor emeritus of economics at Temple University; Gary Claxton and Larry Levitt, senior vice presidents of the Henry J. Kaiser Family Foundation, and Charles Roehrig, vice president of the Altarum Institute, developed a statistical model in which the annual growth rate in nominal national health spending (not adjusted for inflation) in any given year over the long period 1965-2012 is assumed to be driven primarily by two macroeconomic variables: (1) the inflation rate in the current and the previous two years, measured by the G.D.P. deflator, and (2) the growth rate in real G.D.P. in the current year, as well as in the previous five years. The approach is called “lagged regression analysis.”
The model was able to explain 85 percent of the observed variation in the annual growth of national health spending, as is illustrated in the authors’ chart, which depicts the actual and the predicted growth rate in nominal health spending.
One concludes from this analysis that both year-to-year fluctuations in national health spending and the longer-term trend in that growth rate are driven primarily by current and prior-year changes in macroeconomic conditions.
One also infers from the model that if either inflation or the growth in real G.D.P. in the United States should pick up again, then the growth of national health spending should be expected to pick up again as well.
There is an emerging consensus among health economists, however, that other factors within United States health care itself have contributed to the decline in health spending growth and will prevent that growth rate from returning to levels observed in previous decades.
A Limit on Consumer Costs Is Delayed in Health Care Law
By ROBERT PEAR
WASHINGTON — In another setback for President Obama’s health care initiative, the administration has delayed until 2015 a significant consumer protection in the law that limits how much people may have to spend on their own health care.
The limit on out-of-pocket costs, including deductibles and co-payments, was not supposed to exceed $6,350 for an individual and $12,700 for a family. But under a little-noticed ruling, federal officials have granted a one-year grace period to some insurers, allowing them to set higher limits, or no limit at all on some costs, in 2014.
The grace period has been outlined on the Labor Department’s Web site since February, but was obscured in a maze of legal and bureaucratic language that went largely unnoticed. When asked in recent days about the language — which appeared as an answer to one of 137 “frequently asked questions about Affordable Care Act implementation” — department officials confirmed the policy.
The discovery is likely to fuel continuing Republican efforts this fall to discredit the president’s health care law.
Under the policy, many group health plans will be able to maintain separate out-of-pocket limits for benefits in 2014. As a result, a consumer may be required to pay $6,350 for doctors’ services and hospital care, and an additional $6,350 for prescription drugs under a plan administered by a pharmacy benefit manager.
Some consumers may have to pay even more, as some group health plans will not be required to impose any limit on a patient’s out-of-pocket costs for drugs next year. If a drug plan does not currently have a limit on out-of-pocket costs, it will not have to impose one for 2014, federal officials said Monday.
The health law, signed more than three years ago by Mr. Obama, clearly established a single overall limit on out-of-pocket costs for each individual or family. But federal officials said that many insurers and employers needed more time to comply because they used separate companies to help administer major medical coverage and drug benefits, with separate limits on out-of-pocket costs.
In many cases, the companies have separate computer systems that cannot communicate with one another.
A senior administration official, speaking on condition of anonymity to discuss internal deliberations, said: “We knew this was an important issue. We had to balance the interests of consumers with the concerns of health plan sponsors and carriers, which told us that their computer systems were not set up to aggregate all of a person’s out-of-pocket costs. They asked for more time to comply.”
Health plans are free to set out-of-pocket limits lower than the levels allowed by the administration. But many employers and health plans sought the grace period, saying they needed time to upgrade their computer systems. “Benefit managers using different computer systems often cannot keep track of all the out-of-pocket costs incurred by a particular individual,” said Kathryn Wilber, a lawyer at the American Benefits Council, which represents many Fortune 500 companies that provide coverage to employees.
A Powerful Tool in the Doctor’s Toolkit
By DANIELLE OFRI, M.D.
It was well past midnight and most of the patients had settled in. The hospital ward was quiet, except for “the howler.”
The howler was a patient in his 30s who earned his nickname for his nightly bouts of yelling. This was in the early 1990s, during the peak of the AIDS epidemic. I was a second-year medical resident at Bellevue Hospital, in charge of the sprawling AIDS ward that night. Admissions were rolling in, one after another, each more feverish and emaciated than the previous.
This patient was already receiving hefty doses of pain medication, yet he kept screaming to the nurses about his pain. This went on, night after night, despite extensive medical evaluations to see if there were any missed explanations for his pain.
Nothing seemed to help, and the nightly yowling was agitating the other patients and driving the nursing staff to distraction. The head nurse paged me at 3 a.m. “You have to do something,” she said.
I went to the patient’s room. It was my fourth visit of the night, and the patient and I were both pretty exasperated with each other. He was sullen and cranky; I was exhausted and at my wits’ end.
I pulled out a syringe and carefully drew up one c.c. of plain saline. “You know about Tylenol,” I said, showing him the liquid-filled syringe. “You’ve heard of Tylenol #3. There’s even a Tylenol #4. This” — and here I paused for dramatic effect— “this is Tylenol #5.”
The patient stopped howling and gave me an interested look. Then he lowered his pajamas and allowed me to inject his gluteus maximus. Afterward, I pulled up a chair to his bedside and we waited together, allowing the minutes to tick unhurriedly by.
After what seemed like a mutually agreeable time, I stood up and bid him goodnight. The patient put his head to the pillow and promptly fell asleep. The ward was silent for the rest of the night.
I felt terribly guilty that I had committed an outright deception with this patient — something that is a true no-no. But on the other hand, it was the first night he got a full night of sleep, to say nothing of all the other patients on the ward and the rest of the staff.
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