The Ten Contradictions of American Health Care

Uwe Reinhardt at the Health Affairs Blog points out the contradictory wishes of most Americans with regard to health care.

[A]s the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:

1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
2. Limits their families’ out-of-pocket payments for health care to make it “affordable.”
3. Keeps insurance premiums and taxes for health care low.
4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
5. Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
7. On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).

That’s all.

How should patients decide which hospitals are best for them?

Johns Hopkins Hospital is consistently named one of the best in the country. I can’t disagree with that; after all, I just started working there as an internist in September. Coincidentally, in the midst of the raging debate around health care reform, the past few months have seen increasing discussion of a small but crucial question: why do some of the best hospitals spend more money than others? If other hospitals named to the best-of lists consistently spend less money than my employer, shouldn’t we be emulating them instead? And how should an individual patient go about deciding which hospitals are the best for them?

Read more at KevinMD.

Evidence-Based Lobbying

Leaders of the medical-industrial complex wonder if the Dartmouth research findings might be a touch overblown. I dunno - maybe. But don't we doctors do a lot else based on much less evidence? What fraction of hallowed medical practice is based on no more than class IIb recommendations?

Heck, I'm ready for New York to get less medical money. I don't think the kinds of places I'd rather practice are the ones that are overspending.

Does Massachusetts's health care reform work?

As Massachusetts’ Secretary of Health and Human Services, JudyAnn Bigby, MD, is charged with overseeing the health-care program which covers nearly all of the Commonwealth’s residents (nearly 98%) while costing more than anyone expected (about 800 million dollars in 2008). On February 4th, Dr. Bigby spoke at NYU’s Medicine Grand Rounds, where she summarized the approach and accomplishments of Title 58, the health care legislation passed in 2006. The program had several goals: improving access, reforming the insurance market, and (it was hoped) improving outcomes. Bigby gave clear and convincing evidence for the first two goals, while the jury is still out on the third.

More in Clinical Correlations.

Can health care act as an economic stimulus?

I'm scholar Googling and can't find anything. I don't know what the Obama Administration's argument is supporting their inclusion of comparative effectiveness research in the stimulus bill. Obviously I think CER is great a priori, as are EHRs, but neither save money in the short run. Do they stimulate the economy? Beats me - not my field - but I suppose in the sense of creating jobs, sure. (Funding research supports researchers, who buy bread, gasoline, and electricity just like everyone else.)

Note that this is separate from whether prevention and CER give good value for the dollar. Stephen Woolf claims unsurprisingly that they do, writing recently in JAMA. But the real point of his article is this: if you're going to ask whether prevention is worth the cost, you have to ask also whether (say) CTs, MRIs, and the whole whizz-bangery of technologized medicine is worth the cost too:

Throughout health care, the spending crisis requires a comprehensive search for ways to shift spending from services of dubious economic value to those with high cost-effectiveness or net savings. Whether those services are preventive or otherwise is not the point; what matters is prioritizing services that produce the greatest health benefits for the dollars spent. ... As a matter of economic security and ethics, it is inappropriate to debate the economic value of prevention while excusing the rest of medical care from such scrutiny.