Right Wing Health Care Lie Of The Day: Ban On Asthma Inhalers

Many conservative sites are spreading a false claim today that the Obama administration is banning over-the-counter asthma inhaler over environmental concerns. In actuality, the ban on chlorofluorocarbon in inhalers was passed in 2008 when George Bush was president. Since that time the manufacturers of virtually all inhalers have switched to the more environmentally-friendly hydrofluoroalkane as the propellant. Epinephrine inhalers using chlorofluorocarbon have been an exception.

On the one hand, these ephedrine inhalers are less expensive than prescription inhalers. On the other hand, these over-the-counter inhalers are universally considered to be extremely poor choices for asthma treatment, being both less effective than prescription medications and having far more side effects. While the safer and more effective prescription bronchodilators are more expensive, their use should be minimized by asthma patients with the use of prophylactic medications such as inhaled steroids.  Regardless of their legal status, I had strongly advised my asthma patients not to use these products even well before the ban (which, once again, was passed under George Bush).

Update: The real problem is that many asthmatics have resorted to this type of treatment because of lack of health care coverage. Obama does deserve credit for addressing this problem.

Questioning Simplistic Answers In Health Care Policy

We often hear simplistic explanations as to why health care is so expensive. Conservatives dwell on malpractice which, while reform would be desirable, is only responsible for a small portion of health care costs. Others argue that the problem is with unnecessary procedures. While I don’t doubt that there are some unnecessary procedures performed, I doubt this is the real answer. I see far more examples of under-utilization as many people either do not have access to care or their physician fails to provide all recommended care for chronic diseases.

Mike the Mad Biologist shares this view, questioning the study upon the belief that the problem is unnecessary procedures in some areas:

First, unnecessary procedures do not appear to be driving cost differences. What is driving cost differences? Price gouging. That is, certain hospital systems and medical practices have de facto monopolies, either through consumer loyality or market share. For instance, in 2000, Tufts Health Insurance (this is not associated with the university), in response to Partners HealthCare’ (which includes the Harvard hospitals) demands for much higher reimbursement rates, announced they would no longer include these hospitals. After a day, Tufts backed down. This wasn’t about unnecessary care: Partners simply wanted to charge more for the same care. This type of thing is still happening: now Tufts Hospitals is butting heads with Blue Cross.

The second problem, as I’ve discussed before, is that the claims of unnecessary procedures, to a considerable extent, are overhyped, at least in terms of costs*. That assumption is based on an analysis that conflated high-income low-need patients with low-income high-need patients. In other words, the supposed evidence that regional disparities in costs reflect unnecessary procedures didn’t take into account the role of poverty.

Sure, we should not provide unnecessary care. But much of the problem seems to revolve around anti-trust and poverty. We need to fix those things.

Insurance and Mortality

I cannot believe that Ezra Klein had to even waste time arguing over the fact that lack of insurance leads to increased mortality. He’s been engaged in such a debate in the blogosphere for the last few days and provides what might be his “closing argument” here.

There certainly is no argument with the opposing view that those who are at immediate threat of loss of life will receive emergency care even if uninsured.  However, while such people will not be turned away from an emergency room, the care they receive afterward can still differ from those who are insured and this has been demonstrated to affect mortality.

To deny the effects on mortality of lack of insurance is also to deny that both preventative medicine and long term care of chronic disease have an effect on mortality. Both claims are absurd, and Klein does provide evidence to support what we would think.

While there is no question that lack of insurance does increase mortality, there is a legitimate question as to the actual numbers. Klein cites a number of 18,000 people dying a year due to lack of health insurance. There are other numbers floating around but, regardless of the exact number, in terms of mortality we have the equivalent of multiple 9/11 attacks every year due to lack of health care coverage.

Republican Ideas on Health Care

The main strategy of Republicans is to block any meaningful health care reform. Their overall plans would do little if anything to help the uninsured, increase the ability of insurance companies to avoid consumer protection laws by operating out of the states with the weakest regulations, and would increase out of pocket expenses for most people. However, when Republicans have made suggestions which could be considered as part of an overall health care reform measure many Republican ideas have already been included.

Newt Gingrich and John C. Goodman list several suggestions in an op-ed in The Wall Street Journal. This hardly represents a meaningful health care reform proposal but many of the Republican ideas are already included in the current health care legislation. The Wonk Room goes through many of these suggestions noting how many are now in the bill. I’ll just add comments on a few of the topics.

The Republicans are trying to portray themselves as the defenders of Medicare  after years of trying to destroy the program. The Medicare cuts being proposed are not serious cuts to the program. Most of the cuts would be to Medicare Advantage programs which use the bulk of the subsidies they receive to increase profits for insurance companies and sometimes use a small amount to provide extra benefits to entice customers. In addition, if there is near-universal health care it will not be necessary to fund as much money for Medicare to pay for added expenses due to cost shifting because of the uninsured.

The article is misleading when it says Medicare pays doctors by the task but  doctors “do not get paid to advise patients on how to lower their drug costs.” No, there is not a CPT code for advising patients on lowering drug costs but Medicare does pay for office calls in which such matters can be discussed, and does pay more when more time is spent counseling patients.

They also write that “Under Medicare, doctors are not paid if they communicate with their patients by phone or e-mail.” True, but the same is true of most private payers. This is an area which is just starting to be considered. It could either be added to health care reform legislation or could be added in the future.

Gingrich and Goodman advocate meeting the needs of the chronically ill but one of their key recommendations for doing this will not have this result. They write that “Having the ability to obtain and manage more health dollars in Health Savings Accounts is a start.” The problem is that when people with chronic diseases have to pay for more expenses out of money in their own account they tend to avoid many necessary tests and office visits to save money. In the long run this leads to poorer outcomes and higher costs. There is also the danger of these accounts being depleted leaving patients with chronic medical conditions without sufficient coverage.

They also advocate eliminating junk lawsuits. I agree, but Republicans tend to greatly exaggerate the effect of this. Malpractice suits and the resultant defensive medicine do result in wasted money we should attempt to recover but this is a small part of overall health care costs. The health care legislation does provide for state demonstration tests regarding tort reform. I would be happy to see some actual solutions included in the bill. Perhaps if the Republicans took an attitude of compromising to get their ideas included, as opposed to all deciding early on to vote against health care reform, they might have been successful in having more concrete solutions for tort reform included.

Opposition to Medicare Lab Fees Proposed By Senate Finance Committee

Republicans have been trying to scare seniors with misinformation on health care reform, falsely claiming they will be subjected to loss of care due to Medicare cuts. While in general this is false, there is one health care reform proposal which actually does cut benefits to Medicare beneficiaries. This is in the bipartisan Senate Finance Committee proposal which I have previously stated should not be passed.

The Wall Street Journal reviews just one negative aspect of the proposal. Fortunately this comes in the business section and is worth reading, as opposed to the tremendous amount of misinformation which has been published in their opinion section.  The proposal is to charge a co-payment for laboratory tests. Currently Medicare has a deductible for most out-patient services and a 20% co-pay, but does not charge this on laboratory tests.

One major reason for not charging this is that the charges to collect this copay will often exceed the actual amounts which can be collected. Medicare approved charges for many laboratory studies are often under ten dollars. Billing for such small amounts can easily cost more than is collected. Further adding to the complications of collecting this is the problem that patients tend to be less likely to pay bills for services provided by outside billers  as opposed to the physician they are actually seeing.

While the added out of pocked expenses will generally be small, they can add up to be meaningful for seniors on a fixed income, leading AARP to oppose this measure.  One goal of the health reform legislation is to reduce out of pocket costs to encourage patients to obtain preventive care, as well as to receive routine monitoring of chronic diseases. It is contradictory to eliminate the co-pay on the office call for preventive services and then to charge more than in the past for laboratory studies.

It is possible that having to pay something out of pocket will lead to lower costs by reducing the amount of laboratory studies performed. This might turn out to be counterproductive for overall cost savings. Several years ago the  local Medicare intermediary became very restrictive on paying for drug levels for patients on digitalis. I wound up ordering far less of the levels, potentially saving Medicare some money. I also had a couple of patients hospitalized due to elevated levels of the medication which would have been picked up in out patient laboratory studies if not for the restrictions. In the end I bet that the restrictions cost Medicare far more than it saved due to increased hospitalizations, along with an increased number of EKG’s done to make up for the difficulties in obtaining the drug level. This laboratory restriction has subsequently been dropped.

Paying Doctors

There’s been a lot of talk lately about changing how physicians are paid as a part of health care reform. Many have recommended that pay for primary care physicians be increased, arguing that this will increase the number of doctors practicing primary care, leading to higher quality care along with lower costs. As a primary care physician I totally agree with this. There have also been bad ideas raised, such as returning to capitation despite how badly this idea has failed in the past. Today The New York Times has a round table on physician reimbursement.

Elliott S. Fisher, a professor of medicine and director of the Center for Health Policy Research at Dartmouth Medical School, recommends:

One approach that has shown some early promise is to combine the fee-for-service with “quality bonuses” and “shared savings” payments when they reduce spending growth for all of their patients. Doctors, hospitals and society should realize that slowing spending growth would not require dramatic cuts in income under a system where providers would be rewarded for better care, not just more care.

In general that is what some are now trying, but so far such ideas have been poorly implemented. One major problem is that it is hard to measure quality and tell what is really going on in all the offices around the country. At present incentive payments are so low that it often isn’t worth the administrative expenses to submit the data to qualify. General measures of quality often do not apply in specific cases. While practice guidelines are often written for a specific disease, in the real world patients have multiple problems and sometimes the recommended care for any specific condition is not the appropriate care for the individual patient.

Sometimes insurance companies will try to analyze whether a patient is receiving all the appropriate medications based upon diagnoses submitted. The entire concept is flawed as often diagnosis codes are used for suspected ailments to justify testing, and sometimes one person seeing a patient enters a diagnosis into the system which is simply incorrect. Even if they have the correct diagnosis, particular medications might be not be tolerated by certain patients, or a patient might simply refuse to take them. Sometimes the actions of doctors to help patients turns out to be counterproductive with regards to quality measurements. We might give a patient samples, or switch the patient to a generic medication they can receive for less than their insurance co-pay at certain pharmacies. To the insurance company it appears that the patient is not receiving a needed medication.

Steffie Woolhandler and David Himmelstein, associate professors of medicine at Harvard Medical, note that every system has its flaws:

There are a variety of bad ways of paying doctors, but no particularly good ones. Fee-for-service health care rewards the overprovision of care; capitation (a set monthly fee per patient) rewards underprovision; and salaries reward just showing up. The minority of physicians (and hospital administrators) who are motivated mostly by money will find a way to game an incentive system rather than do the hard work of providing excellent care.

Even paying doctors based on quality measures (using data from medical records that the doctors themselves create) can be fudged.

They support a single payer system, noting the tremendous cost savings on administrative expenses, but that still leaves the question of how to pay doctors unanswered.

Liam Yore, an emergency room physician, points out a serious problem with the current system:

The underlying cause, however, is a bias within the physician compensation system that extravagantly rewards surgical procedures performed compared to “cognitive” services like diagnosis and medical management. In the E.R., for example, sewing a facial laceration pays far better than accurately diagnosing a heart attack. The same principle applies to any procedure — from angiograms to colonoscopies.

The predictable consequence is that physicians gravitate toward lucrative procedural specialties. They perform more and more procedures, using expensive new technologies, driving costs ever higher.

Meanwhile, office-based primary care doctors struggle. The compensation for an office visit is a tiny fraction of that for the simplest procedures. The family physician must rush from patient to patient just to keep pace with static or diminishing reimbursement. Fewer and fewer medical students are going into primary care.

What we need to do is rebalance physician compensation away from procedures and toward primary care. Surgeons can easily earn three to five times the average salary of a family doctor. The compensation for surgical procedures should be reduced, and the savings realized should be applied toward increasing pay for primary care physicians.

Better-compensated primary care specialties would attract more doctors who would be able to spend more time with their patients. They would require fewer expensive diagnostic tests like M.R.I.’s and rely less on specialists. Accordingly, the use of expensive and invasive procedures would decline. Prevention, wellness and chronic disease management would be encouraged: enhancing quality and patient satisfaction, but at a far lower cost.

Primary care is the linchpin to successful health care reform. Ignore it, and reform will fail. Make it an appealing career choice, and the odds of success increase greatly.

More Bad Ideas From Conservatives On Health Care Reform

Another article demonstrates how little conservatives understand health care as they try to come up with arguments against health care reform. This is from the American Enterprise Institute (hat tip to Patrick Appel):

Health insurance should not cover basic or routine medical services, but instead should cover major illnesses, surgeries, etc. Moreover, the government should require that healthcare providers charge all patients the same fees for out-of-pocket medical procedures (insurance companies and the government should be free to negotiate discounted prices for the services for which they directly pay, but these preferred rates would not apply to the services paid out-of-pocket by their members). This would bring normal, competitive market forces to bear on the provision of routine medical services. Insurance would then provide (as it is properly intended) coverage against significant and expensive maladies. This helps the poor in two ways. First, routine services would be much cheaper, and so the poor and uninsured would be able to afford (out-of-pocket) basic services. Second, the price of catastrophic medical insurance would be within reach of many more Americans. While high-deductible insurance plans already exist (in which the insured pays the first $1,500 to $2,000 in medical expenses and the insurer pays everything above this amount), what is really needed is for Medicare and Medicaid along with most employer-provided plans to adopt this high-deductible model. Although the current system epitomizes the overuse or misuse of insurance, the Obama plan fails to recognize this, and instead seeks to expand the size and scope of this distorted system.

The major problem here is that a tremendous amount of health care costs do come from routine medical services which become major expenses for those with chronic diseases. Many people can now afford what is essentially catastrophic insurance, but it does them little good as they cannot afford the high deductibles and co-pays should they require medical care.

If people have to pay out of pocket, they will be less likely to pay for routine treatment diseases which are generally asymptomatic such as diabetes, hypertension, and hyperlipidemia. This will create a greater amount of “major illnesses” and surgery. It is far more cost effective to provide routine care to people with diabetes and hypertension than to perform coronary artery bypass surgery or dialysis, or to provide post-stroke care. Eliminating coverage for routine medical services will also reduce the likelihood that people will receive tests such as mammograms, pap smears, and colon cancer screening, increasing health care costs in the long run.

As I mentioned yesterday, an article in this week’s issue of The New England Journal of Medicine has also noted how such market-based approaches to health care reform are not likely to be successful. This type of market-based argument, which we also heard from Republican candidates such as John McCain last year, will wind up increasing the cost of health care and do noting to achieve the goal of making health care coverage available to those who do not currently have it.  The arguments really make no sense if you have any concept of how health care works. They are just empty arguments to try to block actual reform.

Paying For Medical Care Which Is Not Cost Effective

Yesterday I discussed the question of whether preventive care will reduce or increase health care costs. Tobacco cessation was one example which had been given in which the life style change could wind up costing more if this leads to people living longer and consuming health care services for a longer number of years. I also noted that this might not be the case as it costs more to care for people with chronic diseases, even if they don’t live as long, due to higher annual expenses when they are alive.

In general I think that the right preventive programs will save money, but only in the long run. This is also not the key issue as preventive care is still beneficial if it leads to a healthier population without saving money. I have thought of a perfect example of a case where preventive care clearly costs more money is still worthwhile.

People with congestive heart failure are at an increased risk of serious ventricular arrhythmias which can cause sudden death. Because of this, implantable defibrillators are placed in many heart failure patients. This costs a fair amount of money for the procedure. This also increases health care expenses because it leads to people with congestive heart failure living longer, which requires more money to treat them.

In some cases failure to provide preventive care can lead to greater expenses, such as if an inadequately treated diabetic requires dialysis or bypass surgery. In this case, failure to insert the implantable pacemaker will lead to sudden death in a certain number of heart failure patients.

If a heart failure patient dies of sudden death from a ventricular arrhythmia there are no medical expenses for treatment and there is one less person with heart failure requiring medical care. In this case an analysis based purely upon cost would show that implantable defibrillators are not cost effective, but this is still something we would want a health care system to pay for.

Preventive Care And Saving Money

During the last presidential campaign I criticized both Hillary Clinton (back in 2007 when she appeared to be the inevitable Democratic nominee) and Barck Obama (when it was clear that he really would be the nominee) for claiming that savings from preventive care would help finance their health care plans. The question of savings from preventive care and life style changes came up in the blogosphere in an exchange between Paul Campos, Matthew Yglesias, and Ezra Klein.

The main argument from Campos is that improving health does not save money because people will live longer. If someone does not die of cigarette smoking they will live longer and consume greater health care costs. This very well could be true but there are problems with this line of thought.

Not all health care expenses are equal. Chronic diseases such as diabetes and complications of tobacco use can be very expensive to treat. While success is questionable, if Americans could really be convinced to lead healthier life styles this could reduce the incidence of diabetes. People can live a far longer time without diabetes and require less health care costs than someone receiving treatment for diabetes for thirty or more years. If life styles could not be changed to prevent diabetes, then changes once someone is diagnosed with diabetes can still greatly affect health care costs. Intensive treatment of diabetes to achieve good control costs far less than renal dialysis or coronary artery bypass surgery.

I don’t think it is possible to answer the question of whether life style changes and preventive medicine will lead to greater or lesser costs in the long run. There are just too many variables. Different types of preventive medicine and life style changes will vary tremendously in both cost and efficacy. If looking purely at the cost, then the ultimate fate of the person saved from dying of complications of cigarette smoking can lead to different outcomes. Treatment of heart disease, lung disease, and cancer from tobacco use can be expensive, especially if this leads to bypass surgery or if the patient winds up on a ventilator several times (which often happens with COPD).  If someone is kept from smoking they might live longer, but they could also wind up consuming a lot less in health care costs despite a longer life. The right preventive programs will probably save money in the long run, but this is not the main reason for such treatment.

The more important point here is that if measures lead to a longer life span, especially in which people are healthier during this time, this is a major benefit in itself even if we do not save money. As Ezra concluded, “If the end point of health reform is not that we spend fewer dollars, but that we get a lot more health for the dollars we do spend, that’ll be a good outcome.”

While  it is not possible to answer with certainty whether encouraging healthier life styles and practicing preventive medicine will save money in the long run, one thing is certain. This will cost more in the short run. It costs money to provide preventive care and it can take many years to see the benefits. While we should concentrate a larger share of our health care dollars on preventive care, this cannot be done with the expectation that we will save money in the short run or will help pay for health care reform.

Update: I have thought of a good example in this post in which preventive care is clearly not cost effective, but we should still spend the money.

US Ranks Poorly in Treatment of Chronic Disease

The Commonwealth Club has reported on a study in Health Affairs regarding care of chronic conditions in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. The results find that more patients in the United States fail to receive recommended care due to cost than other countries. While conservatives often claim that universal care will lead to rationing and excessive waiting time for appointments, the study found that the United States, as well as Canada, did more poorly than the other countries with regards to waiting time.

Problems were also found to be greater in the care of chronic medical conditions, backing up the inclusion of improved disease management in Barack Obama’s health care plan.  I suspect that this is also related to our problems with dealing with such a poor system of reimbursement which takes up an exorbitant amount of time in medical offices.

A summary of their findings follows:

  • More than half (54%) of U.S. patients did not get recommended care, fill prescriptions, or see a doctor when sick because of costs, versus 7 percent to 36 percent in the other countries.
  • About one-third of U.S. patients—the highest proportion in the survey—experienced medical errors, including delays in learning about abnormal lab test results.
  • Similarly, one-third of U.S. patients encountered poorly coordinated care, including medical records not available during an appointment or duplicated tests.
  • The U.S. stands out for patient costs, with 41 percent reporting they spent more than $1,000 on out-of-pocket costs in the past year. U.K. and Dutch patients were most protected against such costs.
  • Only one-quarter (26%) of U.S. and Canadian patients reported same-day access to doctors when sick, and one-fourth or more reported long waits. About half or more of Dutch (60%), New Zealand, (54%), and U.K. (48%) patients were able to get same-day appointments.
  • A majority of respondents across the eight countries saw room for improvement. Chronically ill adults in the U.S. were the most negative; one-third said the health care system needs a complete overhaul.
  • In the past two years, 59 percent of U.S. patients visited an emergency room (ER); only Canada had a higher rate (64%). In both countries, one of five patients said they went to the ER for a condition that could have been treated by a regular doctor if one had been available.