Cutting Care Key to Health Reforms

Among those of us who've abandoned our search for the health-care fairy, there's a realization that the only way to cap costs is to limit care. An unkind and provocative word to characterize that policy is rationing.

In fact, rationing is already pervasive. The challenge lies in doing it better. In a system where experts agree that three dollars of each ten spent pay for services that do no good, that doesn't seem like an impossibly cruel goal. But squeezing out the waste won't be easy or painless.

Convincing patients to do without services they've become comfortable with and providers to do without the resulting fees that have financed comfortable lifestyles is a daunting task.

Our president tries to artfully move things along by promising that all will get the care that they need, not mentioning that some are already getting much more than that. When reformers hint that better care could actually involve less care, their inability to specify who won't get what when inevitably fans public apprehension.

We have a goal -- providing an optimal amount of care -- but lack a reliable roadmap to get us there. We know that some areas -- like Santa Fe -- spend less that half as much per Medicare patient than others -- like Miami -- do without yielding any improvement in health status.

But we don't know how to bring Santa Fe style medicine to Miami, however much we'd like to.

We know there are similar disparities between elite institutions like the Mayo Clinic in Minnesota and Mt. Sinai Hospital in New York City, but lack a strategy to translate this knowledge into policy.

Politicians writing reform legislation are trying to create an infrastructure that would definitively tell us precisely what works and an atmosphere where providers would gravitate toward this standard, even if it cost them money. This has never been done successfully on a large scale, making it difficult to rank proposals to get us there.

In the meantime, people are getting nervous about the realization that Washington would like to cut care and Washington's faint reassurance that doing what's best might be wiser than doing whatever a physician suggests is a good idea.

I personally have no problem with cutting insurer profits or eliminating needless paperwork, but neither of these satisfying changes would be adequate to fund a program that provides adequate care for all.

Drew Altman of the Kaiser Family Fund outlined the problem when he noted that while experts believe that 30 percent of care delivered today is unneeded, 67 percent of those polled think Americans are being denied the care they need. That tension underlies today's frustration.

Comments

[Rivercs]

Every time I see someone saying that we need to get less care, I get nervous. If I get less care, I get less life. I am 49 and on dialysis.

The most expensive care that I get is the dialysis I do at home on a daily basis. I cannot dialyze less frequently; indeed, it would be much better for me to move from daily peritoneal dialysis to nightly hemodialysis, also at home. It has been clinically proven, however, that nightly hemodialysis is as good as a transplant where the patient's health and vitality are concerned.

I am diabetic and hypertensive; both are well-controlled. In the case of the hypertension, the medications are generic; in the case of the diabetes, they aren't. I cannot take the generic medications available for diabetes. I see my GP at least every 3 months and my nephrologist once a month; the latter is a Medicare requirement.

I don't think I get unnecessary care, but I get a lot of care. Any less is more or less guaranteed to shorten my life. I have a good quality of life despite the dialysis; I don't think it needs to be taken from me yet. If I were more elderly, I probably wouldn't have started dialysis at all. I'd have said no voluntarily and then gone on hospice. I don't think it's unreasonable to keep middle-aged, younger and sturdier elderly people alive while they have a good quality of life.

[PlaceboStudman]

Care doesn't need to be cut, it needs to be stream lined and redistributed

And, yes I know that that is an evil Socialist concept, but it's true. We need to train doctors to better diagnose illness and disease, and put more money into medical R&D to find the best treatment possible, and get rid of the older less effective treatments. While the older less effective treatments are cheaper, they are less effective, and as such may require repeat procedures, which will make them more costly

For example, someone with a heart issue may have a bypass, or stints put in. Conventional wisdom says put in stints becuase it is less invasive. However, the success/failure rate of stints makes them a prime candidate for failure, and need for replacement. Usually multiple times, and by the time a patient has had multiple stints replaced, they would spend just as much money as the bypass surgery which only needs to be done once.

And that isn't even discussing how poor our medicine actually is. 15,000 people a year ending up in the ER, 500 of whom die, for accidental overdose of the daily recommended dosage of "safe, harmless" tylenol

[Jim Jaffe - Huffpost Blogger]

well, the jury seems to still be out on stents and whether we should invest more time and effort in perfecting them. that's typical of the problem when you try to determine what's optimal.

and yes, care needs to be cut. with due respect streamlining is diplomatic language for doing less. redistribution suggests doing less for some and more for others, but the overconsumption category appears larger at the moment.

and if care isn't cut, how do you keep medical costs from gobbling up a growing share of our dollars and our government's budget?

[PlaceboStudman]

and if care isn't cut, how do you keep medical costs from gobbling up a growing share of our dollars and our government's budget?

The government spends FAR FAR FAR less on health care than they do on wars and other completely unnecessary BS like the Office of Faith Based Initiaitives ( aka "soup and a sermon"). No, Mr Jaffe, redistributing is NOT cutting. The same amount of money coming out of the government for wars and F.B.I. can be redistributed to Medicare, Medicaid, Disability Social Security, and allow those people to live good decent livings that allow them to retain their dignity and self respect when they are unable to be a "productive member of (capitalist) society". And, even more importantly, the government is far far far more effective in curing disease, and finding sustainable treatments for diseases that do not yet have a cure, via NIH. Sure, stints need to be improved, but just like every other treatment for a certain ailment, not every treatment works for every patient. We need to have the freedom and ability to choose what treatments that are available that work for our individual needs, and not be relegated down to some number on some doctor's chart

[swift goat pet for truth]

I noticed the use of comparative effectiveness is not mentioned.

Begin with practices and treatments that are shown to be more effective first, then try the less effective ones. Or trying effective generics before new name brands.

Seems to me that would "limit treatment", yet save money.

Of course, I am no health care specialist.

[HST]

I think you are putting forth false choice. It is both true that Americans are being denied treatment by greedy insurance companies and that a lot of the care approved by those companies is not needed. In a system where almost all of the costs are for treament in the final years of life, the challenge is not to cut care but to redirect vital services and treaments to where they will do the most good. Open heart surgery to correct a congenital condition in a child good. The same surgery to treat heart disease in a 90 year old who may not survive the surgery bad. Of course the exception to this rule is money. The rich are always going to be able to afford the best at any age in any situation. The trick is for the rest of us to have access to affordable care when we need it.

[classicalgeek]

Not only that, but as the saying goes, "An ounce of prevention is worth a pound of cure." While the ratio may not be exactly 16-1, a $50 session on how to take care of your teeth properly is probably saving 16 times as much as a mouthful of cavities, even if you provided toothbrushes for free. The same goes for avoiding dehydration, warming up before exercise, proper nutrition and eating fewer processed and prepared foods, and many, many other preventative measures. (A local police officer became dehydrated on training and his hospital care has cost thousands of dollars.) Therefore, more focus on prevention will more than pay for itself and significant savings can be realized in the medium term.

[Jim Jaffe - Huffpost Blogger]

this is a sensible theory, but is terribly difficult to put into practice. if you do a class of 10 people at $50 each on how to care for teeth and none of them change behavior, the money is wasted. if only one complies, it isn't a terribly good investment. if we could get all to eat better and exercise more, that would probably help, but there's little evidence we know how to accomplish that. if we could wish away obesity, many problems would be solved, but we can't.

[mobetta]

Jim, you and Classicalgeek are both correct: The biggest healthcare savings opportunity in America is to cut care by investing in systems and culture that promotes prevention.
The biggest opportunity to cut care is through Americans making better health choices AND the biggest opportunity to achieve that is to reward right choices and to change the culture in America that health is primarily their responsibility, not the government's or insurance companys.
Safeway's healthcare costs, by rewarding good choices, HAS controlled their costs through prevention and individuals' having an incentive program to take steps to correct or control their health issues.

[classicalgeek]

If one person complies, and nets a savings of four cavities not acquired, then the $500 was well-spent, or you haven't been to the dentist lately.

Another savings where accurate information would have helped: I went to the doctor with a symptom. He took a quick look at me and referred me to a well-regarded specialist, who took a quick look at me, and gave me a medication. However, the underlying cause was never diagnosed, resulting in seventeen more visits to the doctor (not all the same doctor as I moved a lot for work), seventeen more referrals to specialists, and seventeen more medications.

Some years later, I was living in France, went to my local doctor, who took a look at the list of the medications I was taking, asked what each one was for, and after the third, correctly diagnosed the underlying cause of the symptoms. Result: I am off all medications and have not needed to go to the doctor since. I just eat three ounces of a certain food every week (I was already getting a healthy and highly varied diet so it was not a case of eating processed or fast foods.) If I had gone to that French doctor first, I could have saved myself (and my insurance company) thousands of dollars.

[WDStannard]

A trillion dollars over 10 years for universal health care means around $3000 a year per person, if my math is correct.

Either a lot of people need extraordinary healthy care or my idea of routine care is way different than that of a lot of people.

My namesake great-grandfather was a Civil War surgeon. He once saved the life of a farm boy by stitching up a wound that usually resulted in a preacher performing his services. Health care in 1865 and until around 40-50 years ago was limited by what physicians could do, not much.

My 89-year-old father's final 10 days cost over $100,000 a few years back. He was kept alive by machines even Jules Verne didn't imagine.

Medical technology today makes routine what was miracle treatment not too long ago.
However, what is technologically possible should not determine what is routine.

Advertising and the media promote popular demand for high tech medical procedures and for expensive drugs. Patients believe they are as knowledgeable as physicians about issues medical and routinely demand extraordinarily treatment, brainwashed to believe the treatment routine. Patients have become salesmen and saleswomen for corporations that manufacturer marvelous machines and drugs which promise the likes of a four-hour erection.

Routine health care needs to be clearly defined and there should be guidelines for beyond routine treatment so a physician doesn’t have to choose between agreeing with a patient’s demand for unnecessary treatment and a lawsuit.

[WASanford]

In a little less than two weeks, I'll be 75 years old. I have a knee that was badly damaged in a motorcycle accident, but that doesn't keep me from running 2.9 miles at least 5 times a week. I'm a KP member who hasn't seen my primary care doctor for more than 2 years. I watch my diet and keep my weight (BMI) within the range of most athletes. In short, I take care of myself. Nevertheless, my monthly premium will be $280.16 per month on top of my medicare. So just how do you intend to define routine health care? If I'm the model you'd better buy yourself a good pair of running shoes, I always buy New Balance, they're made here in the US.

[WDStannard]

I too am a KP member and, though I haven't run 2.9 miles in over 40 years, I've only seen my primary a half-dozen or so times in the past 10 years. My knees hurt because I played football, also a reason my BMI is outside the range of most athletes.

We are obviously paying for other people's care or for care when we get truly old. I pay more than you because I'm younger.

Routine is, for me, care that a physician must or should provide for body maintenance and damage repair enabling people to go about normal lives. It is probably the kind of care associated with socialized health care, the care I had when I lived in England and Germany that I found more than OK. No body is perfect and spending money to make any body perfect is not routine.

KP care is a health care model. I participate in preventive programs and, more or less, follow my primary's advice. If less, the consequences are on me.

When my knee joints stop working, I'll have them replaced with artificial ones. Until then, I'll put up with the pain because a little pain isn't a reason to replace them.

There is a just so much money that can be spent on anything. I would rather endure some discomfort than have money spent on me better spent on a child or young person with many more years to live than I have to live.

[Jim Jaffe - Huffpost Blogger]

hard to keep the decimals straight with such big numbers, but it appears that the cost per person per year is a tad under $350 -- call it $1 a day. when you figure that nearly 20 percent are now uninsured, that means the cost per uninsured person is significantly less than what most of us are paying (or having paid for us now).

agree we need to squeeze out unneeded costly care, but experience suggests it is more likely to be suggested by the doctor than the patient.

[johnashman]

Don't you mean by the patient, rather than the doctor?

Well, there's a whole lot of profit and paperwork in healthcare that doesn't need to be. We need to send a whole lot of accountants, secretaries, business managers, salesmen and bureaucrats to the unemployment lines.

[dpavsek]

$3,000 per person per year??? WOW!!! I wish I could get health coverage that cheaply. I retired at age 62 and in order to keep my employer-provided health care package I have had to pay $618 per month for health insurance - $7,416 per year. That is more than twice as much as your calulation. And I am continuing in my group plan which brings with it certain economies of scale. What would my premium have been had I tried to change groups and got slapped with "pre-existing conditions?" I move to medicare in January and will realize a pay increase because my medicare/s­upplementa­l premiums will probably not exceed $218 a month. We need reform and we need it NOW.

[nellyb stl]

It all rests with Medicare (MedPAC) and doctors - there is where the dollars can be saved. And patients could be given an incentive to request that certain tests not be performed. A catscan equals the same as getting three years of radiation from the sun and if people knew this they would opt for just the plain old doctor's exam and/or ultrasound.

[nellyb stl]

FISCAL REASONS demand we rein in the Explosive Rise in Medical Costs – Pay for only
Quality of Care not Quantity of Care; need MedPAC reform; Insist on Single-payer cost cutting; Say NO to mandated health insurance with the insurance industry the only winner. In my case three months and thousand of dollars in unnecessary tests only to find problem through doctor's exam...

[suegar]

This is why new funds should come from reducing the 30% that corporate insurance companies skim off in administatrative costs and profits.

Today we ration care by ability to pay a monthly fee for insurance. Maybe tomorrow we will be rationing care according to efficacy and need.

Doctors and hospitals will have to adjust their expectations of profits somewhat but will gain relief from overwhelming amounts of beaurocratic crap and relief from the moral dilemmas they face when confronted by ill people who have no insurance.