The Cost Control trilemna

From Brad Delong:

My healthcare costs are already going to skyrocket, but being responsible for 100% of the premiums just isn’t realistic on my salary. I know I’m not the only staffer looking for a job off the Hill, because I knew this was a possibility…

From the Journal of the American Medical Association via Incidental Economist:

Most of the overall study population opposed a government CER [cost effectiveness research] agency. About 56% of respondents would oppose such an agency []. Democrats and Independents were about evenly split on the issue, while a significantly smaller percentage of Republicans would support such an agency (26.9%). Younger respondents, aged 18 to 29 years, were significantly more likely to support an agency (64.7%) than respondents 65 years or older (31.2%). […]

Also from the Incidental Economist and JAMA:

First, we observed a significant increase in the frequency of treatments that are considered discordant with current guidelines, including use of advanced imaging (ie, CT or MRI), referrals to other physicians (presumably for procedures or surgery), and use of narcotics. Second, we also observed a decrease in use of first-line medications, such as NSAIDs or acetaminophen, but no change in referrals to physical therapy. […]

Recent meta-analyses and research of lumbar fusion surgery have not revealed improvement in patient outcomes and demonstrate that these procedures lead to significant adverse consequences, including 5.6% with life-threatening complications and 0.4% mortality….

Our findings also confirm an inappropriate increase in advanced diagnostic imaging that has been seen previously, with use of CT or MRI increasing by 56.9% in our study sample. Six randomized controlled trials have found that imaging in the acute care setting provides neither clinical nor psychological benefit to patients with routine back pain, and multiple prospective studies have found the lack of serious disease in the absence of red-flag symptoms….

This is a trilemna of cost control.  Our health care costs too much, no wants wants an outside entity to say no, and systemically, we do too  many expensive things that don’t actually help people.

Benefit design of insurance plans is an attempt to say no or at least to say “really, really, think about this some more….” for procedures of minimal medical value.  For instance, my health plan does not cover leeching of blood.  My personal benefit package also has a variable co-pay for imaging services.  Basic services such as X-Ray and ultrasound have a $25 co-pay while MRI, PET, DEXA, CT and other advanced scanning systems have co-pays of $150 for the first five and then $25 after that as the actuaries figure that MRI #6 is probably medically useful by then.  But this is a rough and crude steering method as an MRI is perfectly appropriate when initial physical manipulation indicates a high probability of an ACL tear but inappropriate for non-specific back pain complaints. 

Finer steering methods of moving people to more cost effective treatments as the first course of action could theoretically work.  If an insurance company said that it would only pay for back surgery after fifteen PT visits and anti-inflamatory drugs have been used, that would reduce back surgery.  However, since it is saying no, consumers would bitch about faceless bureaucrats wearing Mickey Mouse ties getting between them and their doctors who are effectively practicing folk ways at this time.  And the company would lose members to another firm that charges a little more but does not say no. 

System reform changes like the Accountable Care Organizations and capitation models where the doctors are strongly encouraged by profit motives to refer patients to higher effectiveness and efficiency treatments may be the only way to get a politically viable means of saying no in place in the United States.






47 replies
  1. 1
    Punchy says:

    Anyone else notice that the House’s likely biggest alcoholic–Boehner– is listed as “R-OH”? Hoo-ah.

  2. 2
    The Red Pen says:

    Somewhat OT: There’s been a lot of noise on the RW blogs about Obamacare sign-ups being pitiful. I’ve heard that the federal HIX site is finally behaving. Are we still looking for a signup spike on Oct 30?

  3. 3
    dmsilev says:

    @The Red Pen: I’d imagine that sign-up spikes would be in mid-late December (coverage under those plans starts 1 Jan) and then again once the open enrollment period nears its end (March 1st, I think).

  4. 4
    Richard Mayhew says:

    @The Red Pen: My company is modeling a trickle through November 15th, a big spike right after Thanksgiving and a bigger spike between Dec. 10 and Dec. 15 and then a decline until Jan. 12 th or so, Feb 12th and Mar. 12 and a final spike in the last three to five days of March

  5. 5
    catclub says:

    “For instance, my health plan does not cover leeching of blood.”
    Although men often have excess iron and blood donation ameliorates that.

  6. 6
    maximiliano furtive, formerly known as dr. bloor says:

    capitation models where the doctors are strongly encouraged by profit motives to refer patients to higher effectiveness and efficiency treatments

    Is there some evidence suggesting that this would actually happen this time around? Last time this wheel was reinvented (in the 90’s) it just led to substandard care and treatment up to the limits of the policy.

  7. 7
    maximiliano furtive, formerly known as dr. bloor says:

    capitation models where the doctors are strongly encouraged by profit motives to refer patients to higher effectiveness and efficiency treatments

    Is there some evidence suggesting that this would actually happen this time around? Last time this wheel was reinvented (in the 90’s) it just led to substandard care and treatment up to the limits of the policy.

  8. 8
    catclub says:

    You did not include the most important and cogent budget arguments in Brad Delong’s post:

    “Tea Party Constituent #1:

    You can start with foreign aid. Cut that out. You can cut, you know, federal arts.

    Tea Party Constituent #2:

    There are a lot of grants.

    Tea Party Constituent #1:

    Grants. There are a lot of grants.

    Tea Party Constituent #2:

    It’s a big problem.

    Tea Party Constituent #1:

    It is. It is.”

    On the other hand, the congressional staff coverage is a microscopic issue ( although it illustrates how important the employer provided health insurance still is).

  9. 9
    The Red Pen says:

    @Richard Mayhew: Thanks.

    Now, on topic: Didn’t Deval Pattrick get providers and payers in a room to hash some of the cost problems out — or wasn’t it planned? I never heard the outcome of that and I can’t find anything with Google.

    If that succeeded, it would suggest that the ACA might give the FedGov some leverage to get some of these “no you lower prices” logjams cleared.

  10. 10
    Scott S. says:

    Anyone who identifies as a Tea Party Constituent should have any benefits the receive classified as Foreign Aid, since they sure as hell ain’t Americans.

  11. 11
    gelfling545 says:

    @catclub: So leeching for free, plus, you get a cookie.

  12. 12
    PurpleGirl says:

    In the mid-1990s I developed an acute back problem — but it wasn’t my back that hurt. Rather, my left leg was on fire. It felt as if there was a tiny man inside my leg, holding a blow torch and running up and down my leg. My activity levels decreased to the point where I could be up, maybe 7 hours a day, then I had to lie down, and lie perfectly still or the pain continued. X-rays of my back, thigh and hip did not reveal any fractures that could account for the leg pain. The orthopedist ordered the MRIs. Bingo, herniated discs, one in particular that was quite severely bulging. We tried some conservative treatment but the condition worsened. Six months after the pain first presented itself, I had surgery.

    I get antsy when anyone talks about restrictions on MRIs. In my case, they clearly showed where the damage was and how extensive it was. They were a clear map for the surgery. Maybe the key is that I had the tests within six months of when the pain began; it was acute and not chronic. But an X-ray of my lower back would not have showed the damage — X-rays are good for hard tissue (bone) images but MRIs show the soft tissue damage. Herniated discs are classified as soft-tissue. (To show the disc damage on a X-ray, they would have to use dangerous dyes. An MRI is a superior image and a safer way to get the image.) I become concerned that TPTB will simply restrict MRI use too much and subject patients who would benefit from their use that benefit. (Rant over)

  13. 13
    Richard Mayhew says:

    @PurpleGirl: But they went through the cheap and high probability methods first. Most back pain/dwarves with fire hammer problems won’t be better resolved with MRIs.

  14. 14
    catclub says:

    @gelfling545: … and pineapple juice!

    I consider donating blood pretty useful. I really do not want to learn that donated blood supplies are horribly managed.

  15. 15
    PurpleGirl says:

    @Richard Mayhew: Sorry, I don’t understand what you are saying here.

    We tried pain medication, I stayed home from work for close to two weeks (luckily I worked for a non-profit that closed between Christmas and New Year’s so I didn’t lose salary for the time off) and the pain subsided for about a week and then it returned with a vengence. Without the MRI, they would not have known about the herniation or the stenosis or any of what was in the Radiologist’s report. Without the surgery, I would have become completely disabled.

  16. 16
    April says:

    I spent a summer getting unnecessary treatments. I suppose I could have said “No”, but I thought “What if…”

    It started with X-ray after I came in with whooping cough and pneumonia.

    They saw something that looked to be maybe on my colon.

    So I got a radium enema. Inconclusive.

    So I got a CAT scan.

    I felt like I was getting a tour of technological treatments. There may have been a stop for an MRI along the way, but I can’t remember.

    In the end they decided it was nothing.

  17. 17
    PurpleGirl says:

    @PurpleGirl: I guess what I’m saying is, I’m concerned that some people might be denied the diagnoses method that finds the root cause before it’s too late for the treatment to be effective. And this needs to be determined on a case by case basis, they (the doctors and payment agent) need the time to do a full study.

  18. 18
    PurpleGirl says:

    @April: If I may ask, what was the problem that began the string of tests?

    In my case, I told the internist that I was having pain in my leg and it was becoming hard to walk. She sent me to an orthopedist and a neurologist. Orthopedist had X-rays done, neurologist and I talked and he was for a conservative course of action to see what happened in the next six months. It was the orthopedist who ordered the MRIs when the X-rays showed no causes for the pain. At the time I had healthcare through HIP, and it was their policy that when a radiologist saw the conditions I was presenting, the patient was sent to a neurosurgeon.

  19. 19
    maximiliano furtive, formerly known as dr. bloor says:

    @April:

    I suppose I could have said “No”, but I thought “What if…”

    You seem to overlook the possibility that your doctors shared this mindset.

    “Did not yield findings” does not equal “unnecessary.” Next time, you can comfortably adopt a “let’s wait and see” approach to that shadow on the X-ray that might be a malignancy.

  20. 20

    @Richard Mayhew:

    My company is modeling a trickle through November 15th, a big spike right after Thanksgiving and a bigger spike between Dec. 10 and Dec. 15 and then a decline until Jan. 12 th or so, Feb 12th and Mar. 12 and a final spike in the last three to five days of March

    The co-op executive I know is expecting something very similar to that. He said Nov 15 is when it’ll start to really happen and then in the last 2 weeks of Dec.

  21. 21
    Gypsy Howell says:

    Dear congressional staffer,
    Welcome to the wonderful world of the individual insurance market. Maybe if more of you had been subjected to it like I have been for lo these many years, you would have urged your bosses to do something about our wretched health insurance system a little sooner.

    Call me cold-hearted, but I’m having a hard time feeling bad for these folks.

  22. 22

    @catclub:

    Leeches have made a major comeback in medicine since they’re very useful in healing after microsurgery.  A specific kind of maggot is also now used as a “medical device” to clear necrotic tissue before gangrene sets in.  Gross, but more efficient and less dangerous than the methods that were used before.

  23. 23
    TriassicSands says:

    But this is a rough and crude steering method as an MRI is perfectly appropriate when initial physical manipulation indicates a high probability of an ACL tear but inappropriate for non-specific back pain complaints.

    In a way, it seems like this has it backwards. I tore my ACL (along with my medial collateral ligament and my medial meniscus and it was obvious from physical manipulation that that is what had happened (this was many years before the existence of MRIs). On the other hand, the back is an area of mystery where mere manipulation seems unlikely to reveal much. I suppose it is possible that MRIs just don’t give us much useful information about back injuries, in which case doing them is likely to be a waste. But in the case of torn ACLs, at least completely severed ligaments, one doesn’t need an MRI to determine the damage. Again, I suppose an MRI might reveal a partially torn ACL and that could be useful information.

    In the case of a torn ACL, repair can be done immediately or later — even many years later. In my case, 19 years went by before it was repaired, and although the damage done from years of having an unstable joint was not reparable, the instability was eliminated by the later surgery. (The reason for the delay was to allow the creation of reconstructive surgery.) We can never expect high profile athletes to wait to see how things turn out — they’re going to get every expensive test and diagnostic imaging procedure immediately, regardless of cost. But there is no reason why all of medicine has to follow the wasteful and too expensive model of high profile athletes.

    In the case of MRIs, it seems like the first thing to do, even before reducing the number of unnecessary images, is to reduce the absurd, inflated cost of such images. MRIs in the US cost much more than they do in other countries and at least one reason for this is obvious. No competition. A number of years ago I heard a report that said that there were more MRI machines in LA than in all of Canada. The problem is that everybody (quotes) has their own machine in the US and everyone sends their own patients to their own machines. And they charge whatever they want. If a patient were deemed to be a candidate for an MRI and could have a list of MRI machines available — and doctors and hospitals were restrained from guiding patients to their own machines — that might help. But maybe the
    resulting image wouldn’t be exactly what the ordering doctor wanted. In that case, I’m not sure I see a way to avoid simply putting limits on what facilities can charge for MRIs. Otherwise, we’ll continue to have the current ridiculous situation.

    Other suggestions for reducing the ridiculous cost of MRIs?

  24. 24
    Adolphus says:

    @gelfling545:

    You can buy your own leeches so cheaply it would likely be well below a co-pay and/or deductible. Leeches are probably not covered for the same reason band-aids aren’t. Too cheap.

    On the other hand a band-aid would likely be covered if subsumed within a much larger bill for a hospital stay or dr. visit. And in this sense, I suspect leeches would be covered if used to help remove congested blood from a wound, help reattach a lost finger, toe, or other extremity or to remove necrotic tissue. Maggots are good for that last purpose, too, and probably covered, though I’ll bet they don’t use words like “maggot” and “leech” on the paperwork.

    ETA: Mnemosyne typed faster than me. I was not frist.

  25. 25
    liberal says:

    @PurpleGirl:

    I get antsy when anyone talks about restrictions on MRIs.

    Look…while plainly what tests and procedures are used will depend on the underlying condition, if we don’t start restricting utilization (based on scientific analysis) and just leave everything up to the sacred “patient and her doctor,” we’re going to be bankrupt.

    In the case of back issues, while I’m sure there are legitimate uses of advanced methods, I’ve read time and time again that we’re spending tens of billions of dollars annually on unnecessary spinal fusion surgery.

    Give me the British NHS system. Their end results are broadly similar to ours, and it’s like 1/3 the cost.

    Though even there they’re having problems with things like denying cancer medication to people where the quality of life benefit is clearly not worth the cost.

  26. 26
    Pongo says:

    The pharma lobby is adamantly opposed to CER and their congressional lackeys have done a great job of supporting them in this. The National Center for the Advancement of Translational Medicine (NCATS) and the Patient-Centered Outcomes Research Institute (PCORI) are just two examples of how Congress can gut best efforts at controlling costs. NCATS goal was to make use of the reams of basic research data that has been generated from multiple sources, but sits unused if it doesn’t fit the specific business goal or model of individual pharma or academic sites. The idea was to use what is already known to ‘de-risk’ future development. Pharma and academics rose up in protest–they don’t want to use their data for anything, but they don’t want anyone else to, either–so Congress has put so many restrictions on NCATS operational capability, it is difficult for them to do anything. Pharma didn’t want NCATS and argued it was not necessary. Congress kowtows to pharma and renders NCATS virtually useless and ‘unnecessary’ becomes a self-fulfilling prophecy.

    PCORI is even worse. Pharma’s antipathy to CER meant that there could be no official NIH office devoted to it. In response, a private entity (funded by federal dollars, however) was devised specifically to look at CER to better inform patients about treatment options. Except Congress specifically mandated that PCORI can’t do CER–so the agency created to do CER is legally banned from doing CER. The reason for this is that (as one congressman helpfully pointed out) CER can effectively put companies out of business if their drug doesn’t perform well (‘free market,’ indeed). Yes. It can. That is the entire point. If you are pushing a shitty drug that is expensive and not as effective as cheaper options, you should be put out of business. That is the role of the ‘invisible hand’ of the free market, which can’t protect us from snake oil salesmen if Congress allows them to hide the reality of their snake oil.

  27. 27
    Pongo says:

    The pharma lobby is adamantly opposed to CER and their congressional lackeys have done a great job of supporting them in this. The National Center for the Advancement of Translational Medicine (NCATS) and the Patient-Centered Outcomes Research Institute (PCORI) are just two examples of how Congress can gut best efforts at controlling costs. NCATS goal was to make use of the reams of basic research data that has been generated from multiple sources, but sits unused if it doesn’t fit the specific business goal or model of individual pharma or academic sites. The idea was to use what is already known to ‘de-risk’ future development. Pharma and academics rose up in protest–they don’t want to use their data for anything, but they don’t want anyone else to, either–so Congress has put so many restrictions on NCATS operational capability, it is difficult for them to do anything. Pharma didn’t want NCATS and argued it was not necessary. Congress kowtows to pharma and renders NCATS virtually useless and ‘unnecessary’ becomes a self-fulfilling prophecy.

    PCORI is even worse. Pharma’s antipathy to CER meant that there could be no official NIH office devoted to it. In response, a private entity (funded by federal dollars, however) was devised specifically to look at CER to better inform patients about treatment options. Except Congress specifically mandated that PCORI can’t do CER–so the agency created to do CER is legally banned from doing CER. The reason for this is that (as one congressman helpfully pointed out) CER can effectively put companies out of business if their drug doesn’t perform well (‘free market,’ indeed). Yes. It can. That is the entire point. If you are pushing a shitty drug that is expensive and not as effective as cheaper options, you should be put out of business. That is the role of the ‘invisible hand’ of the free market, which can’t protect us from snake oil salesmen if Congress allows them to hide the reality of their snake oil.

  28. 28
    liberal says:

    @TriassicSands:
    Socialize medicine—all of it, not just the insurance. Market-based incentives cannot work. Ideally, what you really want to provide is long-term health care outcomes. I’ve never seen a convincing regime of market-based incentives that could get that right.

  29. 29
    liberal says:

    @Pongo:
    Agreed.

  30. 30
    PurpleGirl says:

    @TriassicSands: When I had my lower back MRIs, HIP sent me to an outside imaging center. The films were read by HIP’s radiology department. During the whole course of treatment I had three sets of MRIs, each at a different imaging center.

  31. 31
    PurpleGirl says:

    @liberal: I did not have a spinal fusion, I had a hemilaminectomy. But again, I state, without the MRI, the doctors would not have known what was happening in my lower back. And the pain was not in my lower back, it was referred pain and all in my leg. So, they shouldn’t have done the MRIs on me and I should have ended up in a wheelchair and unable to work because I couldn’t think from the pain.

  32. 32
    April says:

    @maximiliano furtive, formerly known as dr. bloor:

    Actually I’m sure that the doctors thought it was probably nothing, but “What if…” And that’s why people get “unnecessary” expensive procedures: because what if it turns out to have been necessary? I think that it is inevitable that one of the costs of medical care will be procedures that turn out in hindsight to have been unnecessary, but couldn’t see seen that way ahead of time without risking the patient’s health. Uncertainty is baked in the cake.

  33. 33
    PurpleGirl says:

    @liberal: Maybe the problem isn’t the MRIs but the spinal fusions.

  34. 34
    April says:

    @PurpleGirl: They saw a shadow that looked to be near or on my colon while x-raying me for pneumonia. I had whooping cough.

    Actually I appreciate the thoroughness of the team. It just got to be almost funny. I went in for one test, the results were inconclusive, so I went back for another…it took all summer. I got the grand tour.

  35. 35
    jl says:

    @TriassicSands:
    @Pongo:

    I think you folks have a point. Relative to other countries, the U.S. does not have an overall over-supply of health care personnel and equipment.

    Japan has a higher rate of MRI per capita than the the U.S. Most countries have a higher rate of total health care personnel per capita (when you count people like physician assistants, nurses, pharmacists, etc, in addition to docs). In some countries like New Zealand there is a special type of nurse that has more or less taken over primary care for prenatal and post-natal and early pediatrics care after mom and kids get home (there was initial resistance from docs, but the system works fine).

    Health care resources in the U.S. are simply, on average, priced much higher than other high income industrial countries. There are a few exceptions: specialists in the Netherlands have incomes comparable to U.S. specialists, but those are exceptions, and excellent primary care, and its ‘hidden single payer’ system channeled through private insurance and providers provides cost savings in other areas.

    Uwe Reinhardt ar Princeton, a rare health economist who is also an expert in finance, has done research on the problem of the high cost of resources in U.S. health care, and concluded that much of it consists of various types of rental income due to restrictions imposed by AMA, and government assisted restraint of trade that is preferential to large pharma and medical equipment and supply companies.

    And I will repeat my complaints about lax regulations on self dealing between medical groups and labs and examination providers. This is a source of hidden self-referral that increases costs.

    So, I agree, saying no to that is just as important as saying no to inefficient use of resources.

    Also, despite overall lower supply of health care resources in the U.S., there is an imbalance, too much supply in affluent areas that have a lot of private specialty clinics and hospitals that are playing games with average costs and reimbursement rates, too little in poorer areas.

    Important to say no to certain doctors, medical groups and corporations, as well as the overworked primary care doc and average patient.

  36. 36
    jl says:

    Also, IMHO, problem of duplicate tests is related to messed up incentives that produce high coss, in addition to very inefficient and old-fashioned medical record system in the U.S, compared to other comparable countries.

  37. 37
    Chris J says:

    I’ve been in the doctoring business for 35 years in a pretty high-cost specialty and see this kind of thing every day.

    I think the root cause is fee for service — the more you do, the more money you make. I’ve always been a straight salaried physician and prefer that.

    Most estimates are that around a third of medical interventions are useless or worse. If there were no financial incentive to do them, physicians would be much more willing to pay attention to effectiveness research, although there are other things driving the excess care.

    One of them is that Americans are inclined to think doing something, anything, is always better than not. What’s needed is more of what an old teacher of mine would yell: “Don’t just do something — stand there!”

  38. 38
    jl says:

    @PurpleGirl:

    ” Sorry, I don’t understand what you are saying here.

    We tried pain medication, I stayed home from work for close to two weeks (luckily I worked for a non-profit that closed between Christmas and New Year’s so I didn’t lose salary for the time off) and the pain subsided for about a week and then it returned with a vengence. ”

    I think RM is saying that you got reasonable appropriate care. He is not saying that MRIs are bad and should not be used, rather that cheaper methods that carry less risk of serious side effects should be used first when the exact diagnosis is difficult.

    Cost-efffectiveness research (CER) and that amorphous thing called ‘evidence based medicine’ has gotten a bad reputation, some it deserved when it is used to push every case into a one size fits all protocol based on estimates for average effective size in the the average patient, because no patient is completely average and few come with a completely average case.

    It should be used as a way to prioritize cheaper more effective and safer treatments as the first to be used, except in cases where there is a clear indication that the patient should be moved to more expensive, on average less effective, and riskier tests and treatments because that clear indication suggests that a specific course of tests and treatments would be best.

    Companies in the U.S. have a strong incentive to push whatever makes them the most profit. Many people in these industries rationalize this, but it works with existing financial incentives of the health care industry, and current institutional features of the system to first use riskier tests and procedures, that most importantly, make a good buck from the doctors and suppliers.

    Some the problem has been fixed by different professions battling for control over parts of the medical system. I know there have been epic battles in medical groups between docs and pharmacists. The pharmacists want to keep the drug reps from talking alone with the docs, and keep free samples out of the doctors supply cabinets. I know some places where they put down a big yellow line in the suite of doctors offices, and the drug reps cannot cross that line! Often that happens after a bigshot doc in a group has been egregious burned by a drug company misrepresenting a new expensive product. But stuff like that is penny ante compared to the haphazard approach to establishing and finding a way to intelligently enforce standards of care across the country that are affordable, based on good evidence, and flexible enough to accommodate special cases.

    THe U.S. health care system suffers from many serious diseases, and I think a mistake of focus to much on just one fix.

  39. 39
    Another Holocene Human says:

    @Chris J: Your comment vs the rest of the thread shows why this will be a problem for some time–most laypeople have no idea how the determination is made that a procedure is necessary (NNT and so on) and just want the “best” chance, the “best” care even though there’s quite a lot of evidence that “heroic” measures can reduce quality of life and even lifespan in some cases. There’s little respect for hospice care, for example, as Americans just associate that with death. (I’m picturing Harry Mudd stuttering over that word–I think that’s how most Americans feel about it.)

    When told their options under conventional care some turn to woo procedures, such as the woo for pancreatic cancer which leads to a quicker death and more misery before death, but, hey, how many Americans can look up a paper in PubMed and understand it, either?

    Look at the controversy over reducing mammagrams–some take it as some sort of conspiracy against women. Also the total lack of nuance that many have, that they can’t understand that in a population as diverse as ours that risk factors are going to differ between individuals and populations. Your parent and grandparent had this kind of genetically linked cancer, you need to get screened too. But if not, probably not.

    Look at the overuse of narcotics… gah… it’s terrible.

    It’s not just access to medical care that needs reform, it’s medical care itself.

    Finally, and I know doctors may not want to hear this, but the problem is not just outside the medical profession–beancounters, woo, big pharma. It’s also “self-policing”. It’s not working and good doctors pay the price for bad ones. There needs to be some real discipline applied where bad doctors lose their license instead of continuing to rack up malpractice claims. So-called tort reform is a bandaid over a sucking chest wound–not only ineffective but positively immoral. And independent board with legal teeth and qualified medical advisory members but not MD control needs to be set up in each state to reduce medical malpractice. And hospitals need to be forced kicking and screaming into the 20th century with published procedures and checklists and enforcement of cleaning/containment procedures. It’s great that some of have voluntarily done this but it’s high time the rest do what works instead of endangering patients.

    Oh, and let’s not let nurses off the hook–you work in a hospital with children or the elderly or immune compromised patients? No current jabs, no job. Buh-bye.

    The health dept doesn’t let restaurants continue to infect patrons with gastro-intestinal bugs because of lousy handwashing or try to kill patrons with bad fish/meat because of improper storage temperatures–they get shut down. (And if they go out of business as a result, too damn bad.) Why nurses get away with not being immunized and getting sloppy about handwashing/sanitizing is utterly beyond me.

  40. 40
    jl says:

    @PurpleGirl:

    WP detected naughty words in my comment, so I try again.

    Sorry, I don’t understand what you are saying here.

    We tried pain medication, I stayed home from work for close to two weeks (luckily I worked for a non-profit that closed between Christmas and New Year’s so I didn’t lose salary for the time off) and the pain subsided for about a week and then it returned with a vengence. ”

    I think RM is saying that you got reasonable appropriate care. He is not saying that MRIs are bad and should not be used, rather that cheaper methods that carry less risk of serious side effects should be used first when the exact diagnosis is difficult.

    Cost-efffectiveness research (CER) and that amorphous thing called ‘evidence based medicine’ has gotten a bad reputation, some it deserved when it is used to push every case into a one size fits all protocol based on estimates for average effective size in the the average patient, because no patient is completely average and few come with a completely average case.

    It should be used as a way to prioritize cheaper more effective and safer treatments as the first to be used, except in cases where there is a clear indication that the patient should be moved to more expensive, on average less effective, and riskier tests and treatments because that clear indication suggests that a specific course of tests and treatments would be best.

    Companies in the U.S. have a strong incentive to push whatever makes them the most profit. Many people in these industries rationalize this, but it works with existing financial incentives of the health care industry, and current institutional features of the system to first use riskier tests and procedures, that most importantly, make a good buck from the doctors and suppliers.

    THe U.S. health care system suffers from many serious diseases, and I think a mistake of focus to much on just one fix.

  41. 41
    Richard Mayhew says:

    @Pongo: PCORI is allowed to do cost and effectiveness research it just can not use a cost per quality adjusted life year comparison. However, the data that it generates allows a freshman in high school to perform that calculation once you point them to the correct reference table.

  42. 42
    TriassicSands says:

    @liberal:

    Of course. I was referring to fixing one problem of a hopeless system, since we won’t be ready for socialized medicine in the US until we figure out how to get Democrats holding overwhelming majorities in both houses and the presidency. Sixty senators will never be enough (see Manchin, et al.). The Dems will need close to seventy Senate seats to be able to pull off a single payer, universal care system. Given the irrational and ignorant resistance to Obamacare, I’d expect much worse with Medicare for All. Until people get used to having insurance.

  43. 43
    TriassicSands says:

    @PurpleGirl:

    Was there any reason for three sets? That sounds grossly wasteful.

    @jl:

    He is not saying that MRIs are bad and should not be used, rather that cheaper methods that carry less risk of serious side effects should be used first when the exact diagnosis is difficult.

    This confuses me — there are no known harmful or serious side effects to MRIs (unless you swallow a hunk of iron before the test). There are certainly cheaper diagnostic tools, but to limit the number of unnecessary MRIs, we probably have to take the profit out of giving MRIs in the first place. As is frequently the case in American medicine, the proliferation of MRI machines was due to everyone wanting to get their own slice of the pie, not to a need for so many machines.

    Orthopedist A has no MRI machine and may or may not decide to send his/her patients for MR imaging. — it depends on sound medical practice.

    Orthopedist B has an MRI machine and sends all of his/her patients down the hall for MR imaging — it depends on sound early retirement planning.

    (Orthopedist C has no MRI machine, but gets kickbacks for sending his/her patients to Biff’s Quickie MRI. In the short run he/she does better than both A and B; in the long run, B probably comes out ahead. In the long run everyone else gets screwd.)

  44. 44
    Older says:

    @catclub: It’s not “an excess of Iron” and doesn’t occur only in men. What you’re talking about is hemochromatosis, an inherited condition which may or may not cause a person who is homozygous (has two genes) for the condition. Whether they are male or female. And it is not a problem of “too much iron” but rather of how the body deals with iron.

    I, for instance, am female and I had at one time considerable problems associated with hemochromatosis. Several of my children were also homozygous for the gene, but none of them has had any symptoms, including my son.

    The treatment is not “leeches”. Leeches can remove only a small amount of blood, and only from limited areas of the body. Treatment for hemochromatosis is to be drained of a pint of blood at a time. The blood is not “tainted” and could be used, but the laws in some states prohibit it.

    I’d address the medical use of leeches, but I see it’s been done already.

  45. 45
    Dan says:

    Managed Care?

  46. 46
    Carl W says:

    Opposition to cost-effectiveness research seems like a remarkably irrational position. As I understand it, the total cost of medical treatments paid for by insurance is essentially fixed (it’s required to be at least 85% of premiums, so for-profits will pay out almost exactly 85%, non-profits might be a bit higher). Both from a good-of-society and a personal-selfishness point of view, why wouldn’t you want that money all spent on effective treatments, instead of a mixture of effective and ineffective treatments? (For purely selfish reasons, I don’t want my insurance company spending money on ineffective treatments for other people that they could be spending on effective treatments for me.)

    I suppose people who make their money selling medical treatments that they know or suspect are ineffective could have a rational (although very selfish) reason to oppose CER, but surely that can’t account for all the opposition.

  47. 47
    Josh G. says:

    Finer steering methods of moving people to more cost effective treatments as the first course of action could theoretically work. If an insurance company said that it would only pay for back surgery after fifteen PT visits and anti-inflamatory drugs have been used, that would reduce back surgery. However, since it is saying no, consumers would bitch about faceless bureaucrats wearing Mickey Mouse ties getting between them and their doctors who are effectively practicing folk ways at this time. And the company would lose members to another firm that charges a little more but does not say no.

    The fundamental problem is that insurance companies have a conflict of interest. It is to their benefit to deny payments for expensive procedures, whether the procedures are effective or not. As a result, the public does not and will not trust insurance companies on these matters; they don’t have the moral credibility to make these decisions.
    It’s true that doctors in the U.S. have far too much autonomy and are bound by scientific evidence in their decision-making far too little. (There are also way too few general practitioners being trained and licensed, too many specialists, and too many restrictions on which procedures must be done by doctors as opposed to registered nurses.) But if it comes down to a choice between doctors and insurance companies, the public will side with the doctors every time. I believe that if we want efficient, science-based medicine in the U.S., only single-payer can get us there.

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