Category: Health Care Quality

The Patient Care Quarterback

The New England Journal of Medicine recently published an article by Matthew J. Press, MD, about the need for patients to have a quarterback to coordinate the team of care-givers. Dr. Press writes –

Care coordination is now a high priority in health care and is the backbone of new models of care, such as accountable care organizations, that aim to improve quality and reduce costs. But it remains an abstract concept to many people who are not on the front lines of clinical care, as well as to some on the front lines who lack (or don’t want to have) the quarterback’s view of the field. In replaying the highlights, we can learn some important lessons about care coordination.

The CON of Certificate of Need Laws

I once heard Dr. Roy Cordato of the John Locke Foundation in North Carolina describe an unusual metaphor. Imagine that you wanted to open an Italian restaurant. In the town where you want to open it, you need to apply to the municipal authorities for a Certificate of Need. That is, before you put any of your capital or reputation into actually opening and operating the restaurant, you have to prove to bureaucrats and politicians that the town “needs” it. So, even though no taxpayers’ dollars are invested in your business, you are not allowed to take this risk before writing applications and participating in hearings to prove the unprovable: That potential customers “need” your Italian restaurant.

Who else is monitoring your application and participating in hearings? Owners of Italian restaurants that already exist. They have reams of data that prove that they fully satisfy the demand for Italian cuisine in the town. You have none. They have effective veto power over the entry of new competitors. You do not need a PhD in economics to predict that such a town would have a shortage of Italian restaurants with very high prices.

Yet, this unacceptable situation exists for hospitals or other healthcare facilities in 36 states and the District of Columbia. Thomas Stratmann and Jake Russ of the Mercatus Center have used a newly compiled database of these laws to examine their consequences. Their key findings are:

Switching Cholesterol Drugs to Over-the-Counter Could Prevent 250,000 Coronary Events

Lipid-lowering statins have been life-savers for many years now. They are so well understood that many now believe that they should be sold over-the-counter (OTC), that is, without a physician’s prescription. The proposal is certainly controversial. After all, how do you know you have high cholesterol without a physician telling you? It’s not like you are coughing or sneezing and just trot off to the pharmacy to get some cough suppressant or antihistamine or whatever you need.

Nevertheless, many medicines we consume OTC — even children’s Advil — were once available by prescription only. There is no doubt that when a medicine switches from prescription to OTC that more people will take it. New research by Christopher Stomberg and colleagues suggests that switching statins to OTC would reduce the number of coronary events by a quarter million annually. Manufacturers would like to switch their statins, but the FDA is not allowing it.

Let me open a bag of worms…

Does the U.S. Over Diagnose Cancer?

Ezra Klein challenges the notion that patients in the U.S. get better cancer treatment than patients in other developed countries. Klein was writing in response to the Commonwealth Fund’s comparison of health systems in eleven developed countries. As I noted previously, one problem with this survey is that there is no apparent relationship between ranking on the survey and health outcomes. Although the U.S. does poorly in the survey, it does well in health outcomes, especially cancer outcomes.

Or maybe not, according to Klein:

Most of the studies that highlight America’s skill in treating cancer do so by measuring survival rates  — that is to say, they measure how many people survive for a certain number of years after the cancer is diagnosed. So if a certain cancer kills 50 percent of people within five years, then the five-year survival rate is 50 percent.

The problem here is simple: survival rates don’t necessarily measure when people die. They also measure when they’re diagnosed — and sometimes, that’s all they measure.

Ignoring the Obvious? Choosing Suitable Metrics in Evaluating Health Care

One of the biggest problems in health policy is choosing the appropriate metrics to evaluate a complex good like health care. Value is in the eye of the beholder. All too often, the beholder is not the consumer, which leads to an affinity for numeric measures said to be more “rigorous” or “precise.”

As a result, many Medicaid evaluations use population health measures that have as much or more to do with individual behaviors as they do with the action of any part of the healthcare system. Things like number of primary care visits, BMI, cholesterol levels, and blood pressure, are easy to measure provided someone first decides to visit the doctor. And outcomes based on those measures depend upon whether someone decides to diet, exercise, and take the prescribed medications.

Because simple metrics abound, we have a lot of studies evaluating the health “system” that only observe changes in relatively simple and inexpensive treatments that are behaviorally dependent and are provided to a lot of people. Many policy makers are satisfied with this. It accords well with the views of U.S. health care reform advocates who favor more centralized gatekeeping and approve of policies that force people to consume more primary care as a condition of being allowed access to specialists. If people got more primary care, the mantra goes, they wouldn’t need to see specialists.

Broken Mirror on the Wall: On the Commonwealth Fund’s Increasingly Frustrating Comparison of International Health Systems

The Commonwealth Fund has released another edition of its Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. Following tradition, it concludes that the American health “system” is the worst of eleven developed countries. This time, it prompted the editorialists at the New York Times to conclude:

 electronic-medical-recordBritain and Switzerland were top scorers in a study examining the quality and efficiency of health care systems in 11 advanced nations by a leading American research organization. As usual, the United States finished last overall and last on several important measures of cost and health outcomes, despite having the most costly system in the world.

The poor results for the United States reflect the high cost of its medical care and the absence of universal health insurance, a situation being addressed by the Affordable Care Act.

Other advanced nations are far ahead in the game because they have long had universal health coverage and promoted strong ties between patients and doctors.

The VA Scandal and Cheap Government Medicine

The VA waiting list scandal is a strong piece of evidence that governments running monopoly health systems have few incentives to provide quality health care. The easiest way to cut costs is to deny access to prompt care, advanced treatments, and new drugs. As far back as 2007, the VA Inspector General reported that some of its facilities keep poor records and had long waits for care. It has never accurately estimated the size of its waiting lists, or been able to say exactly how it spends its budget.

VA care looks better than it is because a lot of veterans have Medicare or other private insurance. They can switch to private care when the VA fails. And VA care does fail. Even if they make it to the top of the waiting list, people stuck in the VA are 35 percent less likely to receive kidney transplants or effective modern drugs than people with private insurance.

Like most government entities, the VA often seems more concerned about the people who work for it than the patients it is supposed to serve. In 1995, he GAO reported that the VA shields “its physicians from the professional accountability that is required of private sector practitioners,” and it is not clear whether all of its hospitals have formal processes to report incidences of serious injury, death, or potential legal liability. In 2003, its electronic records were found to contain numerous errors, and did not include some important adverse events. As of 2007, its electronic patient records could be edited by unauthorized people.

Quiz of the Day: Define Overtreatment

Now that government is paying the health care bills we are hearing a lot about overtreatment. As always, where one stands on it depends upon how one defines it.

Here is what the National Cancer Institute says about mammograms and overtreatment:

Screening mammograms can find cancers and cases of ductal carcinoma in situ (DCIS, a noninvasive tumor in which abnormal cells that may become cancerous build up in the lining of breast ducts) that need to be treated. However, they can also find cancers and cases of DCIS that will never cause symptoms or threaten a woman’s life, leading to “overdiagnosis” of breast cancer. Treatment of these latter cancers and cases of DCIS is not needed and leads to “overtreatment.” Overtreatment exposes women unnecessarily to the adverse effects associated with cancer therapy

Why not leave the harmless DCIS tumors alone?

Oops! Paul Krugman, Uwe Reinhardt, Nicholas Kristof, RAND Corporation All Praised the Veterans Health Administration

Ben Shapiro (Truth Revolt) has posted a list of recent quotations from leading public intellectuals cheerleading the VHA as a model of a well-functioning health system. Here’s former Enron adviser Paul Krugman in 2011:

Multiple surveys have found the VHA providing better care than most Americans receive, even as the agency has held cost increases well below those facing Medicare and private insurers…the VHA is an integrated system, which provides health care as well as paying for it. So it’s free from the perverse incentives created when doctors and hospitals profit from expensive tests and procedures, whether or not those procedures actually make medical sense.

Should Taxpayers Spend $250,000 to Give an Uninsured Person 16 Days of Healthy Life?

ObamaCare spends a lot of money that could be better spent elsewhere:

money-crossroadsSo, even when we combine the most optimistic estimates of gains in mortality and morbidity, the average uninsured person would gain about 16 healthy days a year…As a comparison, 75-year-olds with foot problems prior to chiropody treatment rate their quality of life at .956. For the average uninsured person, having health insurance coverage provides health benefits that are roughly equivalent to averting the foot problems experienced by typical 75-year-olds.

More importantly, even using the most optimistic assumptions, ObamaCare does not appear to be very cost-effective in relative terms. That is, we could attain the equivalent gains in health status for only 4% of the trillions that will be spent on ObamaCare. Conversely, for the same massive expenditure, we could attain up to 27 times as much improvement in health status. In light of this rather egregious squandering of other people’s money, it’s little surprise that opposition to ObamaCare has been so persistent and widespread.

From: Christopher Conover at Forbes.