Medical waste (18 June 2009)

The Obama administration, thankfully, is making a serious push to reform the absurdly inefficient U.S. health care system, which is currently and pointlessly tied to employment status. And private insurers have every incentive not to insure individuals who may perhaps have the effrontery to become sick in the future, leaving those who get laid off doubly screwed over. In America, private nsurance appears like a racket whereby the companies collect premiums and then seek to deny coverage when the opportunity arises. If you don't already hate health insurers, read these posts about recission and see what you think. Recission is when insurance companies respond to a customer needing health-care services by trumping up some error they made in filing paperwork as fraud, which then justifies the insurers in denying claims and dropping their coverage. And when questioned about the practice in Congress, the CEOs of several health insurers refused to consent to limiting the practice to, in the Los Angeles Times's words, "only policyholders who intentionally lie or commit fraud to obtain coverage."

As any sane person would point out in response to this, the U.S. needs a public option -- an insurance plan offered by the state that doesn't seek to profit at the expense of the sick, one that is reasonably affordable and doesn't rule people out entirely based on the risk they represent. Of course, in order for such a program not to explode the budget, health care costs would need to be brought under control. On that point, Atul Gawande's recent article in the New Yorker about wasteful Medicare spending in McAllen, Texas, offers a lot to consider. It turns out that doctors' overprescription of expensive tests leads to worse outcomes for patients.

. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.

Gawande shows how hospitals and physicians, caught up in a for-profit medical world, have metrics that show them only whether they are making money, not whether their practices are making their community any healthier.

Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.

This dynamic, along with a prevalent ideology that holds that what markets provide for is best, leads some doctors to conclude that maximizing profits is in some way guaranteeing that the appropriate amount of health care being administered. To do anything else would be socialistic "rationing."

David Leonhardt, writing in the New York Times, punctures that conservative talking point: "The noise about rationing is not really a courageous stand against less medical care. It’s a utopian stand against better medical care." He notes that we are always already rationing (nobody gets their medical care without sacrificing something, even if it's only a couple bucks), only we don't call it that when richer people reap its benefits.

The high cost of care means that some employers can’t afford to offer health insurance and still pay a competitive wage. Those high costs mean that individuals can’t buy insurance on their own.
The uninsured still receive some health care, obviously. But they get less care, and worse care, than they need. The Institute of Medicine has estimated that 18,000 people died in 2000 because they lacked insurance. By 2006, the number had risen to 22,000, according to the Urban Institute.
The final form of rationing is ... the failure to provide certain types of care, even to people with health insurance. Doctors are generally not paid to do the blocking and tackling of medicine: collaboration, probing conversations with patients, small steps that avoid medical errors. Many doctors still do such things, out of professional pride. But the full medical system doesn’t do nearly enough.

Professional pride is a thin thread from which to hang the health of a country, particularly one as enamored with "rational self-interest" as the U.S. is. And the AMA -- which boos Obama and decries the public option because it might deprive them of the opportunity of bilking insurance companies -- does not give me much faith in the "professional pride" of doctors, though as one doctor notes here, the AMA is losing membership quickly. (It not represents less than a quarter of practicing physicians.) Clearly, the legal and social framework should be changed to align incentives with that professional pride, to make it easy for doctors to do the right things, help patients and overall healthfulness, rather than make it easy for them to rationalize doing the wrong thing and buy an extra Lexus or two. Gawande recommends that communities adopt a Mayo Clinic model in which doctors are paid a salary, rather than charging per visit and procedure, and work together to determine the course of a particular patient's care, serving as a check on one another for unnecessary tests and such. I suspect the AMA does not concur.