Saturday, February 13, 2010

"What's Worse Than?"

What's worse than health care overhaul? No changes

Health care spending hit $2.5 trillion last year, growing faster as a share of the economy than at any time in a half century, yet with results that compare poorly with other advanced countries spending less. Government programs — mainly Medicare and Medicaid — will soon cover more than half the nation's health care tab, a staggering burden for federal and state budgets.

For those with private insurance, the recently announced double-digit premium increases for people purchasing their own coverage with Anthem in California could be a harbinger. Medical costs are rising in a weak economy, causing healthy people to drop coverage and raising costs for those left behind, with no limit in sight.

Now this is supposed to be the fear that pushes us to seek health care reform from DC.  And of course the legislation will "contain costs" right?

Both Democratic bills would begin experiments aimed at providing quality care at lower cost for Medicare recipients, particularly those with chronic conditions such as heart failure and diabetes. Copayments for preventive care would be eliminated. The House bill gradually would close the "doughnut hole" prescription coverage gap, now growing wider and deeper because of inflation.

Experiments at providing quality care at lower costs?  Actually,  they were starting this a couple years ago with Medicare.  Called it a pilot program or some such.  We had to check a box on every fee ticket stating whether we used an electronic prescription deal to prescribe medications.  Medicare was going to give us 1% extra or something like that for using electronic prescribing.  Well at the end of the year they decided they wouldn't.  IF the feds figured out something that was doing more harm than good,  what kind of uproar would there be if they cut reimbursement for that service?  So far Medicare has demonstrated zero ability to incentivize so called quality care.  How much extra would it cost to manage the data gathering and processing to figure out who is following the incentives?  

And what happens if the feds end up incentivizing medical practices that do more harm than good?  Medicare and several insurance companies have been proposing lists of "standards" and "benchmarks" for years for different chronic conditions.  Like if someone has diabetes,  if that patient has a A1C (a blood test monitoring how well blood sugar is controlled) below 9 then the doc's office gets paid more.  If the A1C is over 9,  the doc gets paid less.  The problem is a level of 9 isn't a goal with diabetes.  We want the level around or just under 7.  And a couple years ago we thought we wanted the level as low as possible ,  like closer to 6.  Of course then we learn that pushing sugars that low probably harms those folks who are on insulin by making their sugars dip too low off and on during the day and at night.  Medicare is very poorly equipped to deal with the rapidly changing targets in medicine.  Additionally,  when you pin physician reimbursement on how well a patient takes care of their diabetes you end up mucking up the whole relationship between doctor and patient.  If a patient chooses to not control their diabetes,  because say they can't afford their 100 dollar insulin this month or they were just diagnosed with terminal cancer and it's just not a priority,  well Medicare doesn't have a box to check marked "life is complicated, we're doing the best we can".

And look how barriers to preventive services are touted once again in this article.  Preventive services like screening mammography.  Did you know that the equipment used for screening mammograms has changed?  We're switching over to digital mammograms.  Which cost 3-4 times the cost of the older machines and films.  You can read about them indirectly here:

They harp on whether the extra cost is worth it but they don't address whether these more crisp, detailed images result in better outcomes.  The fact is with screening mammograms we did a great job picking out cancers that are benign.  Over the past 30 years we have been able to find a huge number of cancers,  most of which never needed to be found OR when found early didn't change whether individual was cured.  Now with more detailed images,  are we going to find even more benign cancers that we couldn't see previously?   Are we going to tell even more healthy women never destined to die from breast cancer that we saved their life with screening followed by surgery/radiation/chemo?   Are we just going to run yet another mass experiment and see what happens later?

So what's my point?

Our health care system is a public health menace.  We have been sold services, meds, and tests which offer little benefit and significant harm and we have been made financially destitute picking up the tab.  The poor health delivered by the health care system is applied systematically systemically based on demographics such as gender, race and age.  The medical knowledge base,  made up mostly of clinical trials,  has been built by the organizations marketing the drugs to treat diseases they helped characterize.  The government regulatory institutions are corrupted beyond recognition.  Most the funding for the FDA comes from the pharmaceutical industry through the user fee acts dating back to the 80s and the push for new HIV meds.  

Finding ways to inject 30 million more customers into the system by mandating health insurance and shifting more of the bill to the collective pockets of tax payers is the goal of the proposed health care reform.  People can not afford the price of health care now.  Adding more demand will only drive up costs.  Costs have to go up to pay for all the new equipment and construction that goes into the perpetual expansion of health care.  Hospitals build new parking garages and purchase digital mammogram equipment;  where do you think the money comes from to pay for those projects in the end?  

What's the solution?  

Starve it.  The health care system has continued to expand during the great recession and it is inconceivable for the corporations profiting from this marketing of poor health to budget for anything else.  As people choose to do what's best for themselves and their families,  they will naturally decrease their interactions with the health care system.  People are already overwhelmingly seeking understanding for free online and bypassing the harmful system.  This trend can only continue as costs soar.  

The solution has always been the same all these years.  

Learn about every item the system tries to sell you.  Ask yourself and the employees of the system "what are my risks to begin with,  how much does this med/test/procedure lower those risks, and what are the possible harms of that test/med/procedure".  Treat every interaction with the system like purchasing an item in a pawn shop.  Buyer beware;  our track record is pretty poor overall and almost all of the new fads in treatment and diagnostics end up being abandoned as we learn yet another experiment failed to deliver to goods.  

And understand this is not bad news.  We have a staggering amount of resources available to improve society.  If you pile up all the money wasted on harmful or useless treatments and tests,  we'd have trouble spending it all.  

Can our economy survive the coming collapse of the health care system?  I don't see how.  If a few banks failing causes the gears of the financial system to grind to a halt,  then when 18% GNP goes poof..... 

But one thing I do know.  The health care system like the financial system exists because of the people and not the other way around.  The health care system depends on a progressively enlarging stream of customers.  It has betrayed trust repeatedly and grown incredibly wealthy in the process.   

But we can trust the average person to do what's best for themselves and their family when given the chance.  And information is free.  Sure we're still figuring out how not to drown in all the excessive information now available to us but it's just a matter of time now.  The system has set up a network of incentives which encourage people to bypass the system as much as possible.  

Information is free,  understanding take some work and trial and error.

Understanding is freedom