Editore"s Note
Tilting at Windmills

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April 30, 2007
By: Kevin Drum

MISDIAGNOSIS?....In our current issue, Phil Longman reviews Sick, Jon Cohn's new book about the dysfunctional American healthcare system. But he thinks Cohn has misdiagnosed the disease. Money can't really be our core problem, he says, since the evidence indicates that the more you spend, the worse your treatment is likely to be:

According to a recent RAND study published in the New England Journal of Medicine, uninsured patients receive only 53.7 percent of the care experts believe they should get — that is, appropriate, evidence-based treatment. But according to the same study, patients with private, fee-for-service insurance are even less likely to receive the proper care. Indeed, among Americans receiving acute care, those who lack insurance stand a slightly better chance of receiving proper treatment than patients covered by Medicaid, Medicare, or any form of private insurance.

....[Dr. Elliot Fisher] found that in America's highest-spending hospitals, only 74.8 percent of heart attack victims receive aspirin upon discharge from the hospital, as opposed to 83.5 percent in lower-budget competitors. This may be one reason why survival rates for heart attack victims are actually higher in low-spending hospitals than in high-spending hospitals.

What's more, these spendthrift hospitals often skip other routine preventative care such as flu vaccines, Pap smears, and mammograms. This general lack of attention to prevention and follow-up care in high-spending hospitals helps to explain why not only heart attack victims but also patients suffering from colon cancer and hip fractures stand a better chance of living longer if they stay away from "elite" hospitals and choose a lower-cost provider instead. Given this reality, it is perhaps not surprising that patient satisfaction also declines as a hospital's spending per patient rises.

So what does Longman think the answer is? Click the link to find out. Or buy his new book. Or buy 'em both.

Kevin Drum 2:09 AM Permalink | Trackbacks | Comments (44)

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Posted by: Donald from Hawaii on April 30, 2007 at 2:33 AM | PERMALINK

This is a little disturbing. For 20 years of treatment for a chronic ailment, I've always gone out of my way to seek health care at the nation's premiere research hospitals. Now they claim that I would be better off going to some small town clinics instead?

Posted by: N on April 30, 2007 at 3:41 AM | PERMALINK

Maybe we can achieve full employment by expanding our health sector! Would our health system be better or worse as a result?

Posted by: parrot on April 30, 2007 at 3:49 AM | PERMALINK

Clearly this is proof that throwing money at a problem is never a good idea. That's why socialistic health care systems like France and Canada are such failures.

Posted by: Al on April 30, 2007 at 6:17 AM | PERMALINK

Al, How would we know if throwing money at a social problem works, since we have never done it? We throw lots of money at the Pentagon, and that sure doesn't work, does it?

Michael Moore's new movie, Sicko, explores this same territory.

Posted by: The Conservative Deflator on April 30, 2007 at 6:43 AM | PERMALINK

My experience bears out what is in the book. If you go to a premiere research hospital, they don't care about patients--they care about research and major projects. As a consequence, the patients don't do very well. Unless you need some fancy treatment that's never been tried before or some rare surgery that's only done on 10 patients a year, find a functional neighborhood hospital.

Posted by: reino on April 30, 2007 at 6:54 AM | PERMALINK

One more reason to go to a fancy research hospital--the local hospital tells you to do so because they cannot diagnose you.

After those exceptions are taken into account, go to a local hospital that is not ranked in the US News.

Posted by: reino on April 30, 2007 at 7:03 AM | PERMALINK

the VA system has lower wait times, lower costs, better outcomes and is actually *run* by the government (and note they don't make these numbers by having a clientele that is mostly healthy young people). I guess by GOP logic those are all good reasons to dismantle and privatize it so a few cronies can make money while the consumers spend more to get less and worse.

Posted by: supersaurus on April 30, 2007 at 7:23 AM | PERMALINK

You have to be contrarian to get buzz, but you also end up setting up the Als of the world. We'll be hearing about this piece forever.

I wish that the Washington Monthly would change their template. I don't doubt this story at all, but you still have people dying because they postpone care for financial reasons. Obviously there's an ideal middle somewhere between luxury care and no care, and for a lot of reasons, that's what the story should have been written about. But debunking liberal pieties is what the WaMo is about.

Posted by: John Emerson on April 30, 2007 at 7:56 AM | PERMALINK

Dear Political Animal Comments Censor:

Please do not delete my post before you read it. You give folks like Al prime real estate because he's not a real challenge to your position, but I get shoved down the memory hole...

General readers;

I agree with the comment above that says the VA has a successful formula that should be looked at; maybe a gradual expansion to the general population of VA services as the WWII vets pass on would be the path of least resistance for fundemental health care reform. Perhaps Waxman can have hearings to publicise how much the VA spends per patient and how satisfactory the patients evaluate their care, in comparison to GM workers or other plans.

Posted by: minion on April 30, 2007 at 8:16 AM | PERMALINK

Interesting bit of a parallel.

Much like the current healthcare system in the US as a whole, it seems more money spent sadly does not equal better care. It's about how it's spent rather than how much.

Posted by: Kryptik on April 30, 2007 at 8:37 AM | PERMALINK

In order to make a profit, private health insurance must bring in more revenue than it spends on treatment for its beneficiaries. This is the reason why it refuses to cover "experimental" treatments and why it refuses coverage to individuals with "pre-existing" conditions. Its incentives are to skim off the healthiest individuals least likely to use their benefits and to refuse coverage to the sickest individuals most in need of their benefits.

This has been the case for many years. The problem is compounded by the way insurance rates its customers---it assesses risk based on the pool of individuals to be insured. You don't have to be a rocket scientist to realize that this approach puts small companies at a disadvantage over large corporations. One case of cancer and you throw off the average in a big way.

Why should insurance be tied to employment? Why are we not entitled to health care just as a fact of being a U.S. citizen? Provide everyone with a basic level of care and let the wealthy pay out of pocket for premium services.

Under the current system, many people who go without insurance end up costing the rest of us through our taxes -- which support the public hospitals that eventually will treat them, often too late in their illness -- at a point when the cost of care is now astronomical. Early detection in many cases would mean a better outcome all around -- health restored to the sick at a much lower cost.

Why this has not happened yet is a testament to the influence of the AMA and the medical/insurance industry, which has billions in profits riding on the inefficiency and unfairness of our current system. It also says a great deal about the American obsession with "free market solutions." The free market worshippers refuse to concede that in health care, the free market model is irrelevant. Consumers can't shop around and reduce prices through competition -- the same way they can't shop for cheaper electricity.

There is such a thing as a natural monopoly -- and health care falls into this metric.

Posted by: Harpo on April 30, 2007 at 8:55 AM | PERMALINK

Al: " That's why socialistic health care systems like France and Canada are such failures."

The Canadian system works for me just fine. I don't understand US right-wingers at the most minute level. Even when they meet someone and ask, "How are you?", they can't really be expressing true human sympathy, for their philosophy seems to be "Hey, Bud, you look after yourself and I will look after me." Kind of uncivilized, not to say personally hypocritical.

I like the Canadian/French system simply because you know all sorts of poor people at least don't have to worry about something as basic as their bodies. Life is hard enough even for those better off.

But it will be nice to see good old American know-how put to figuring out how to make this type of system even better.

Posted by: Bob M on April 30, 2007 at 9:00 AM | PERMALINK

I think you're measuring health wrong. There's no reference to erections or breast size.

Posted by: Albot on April 30, 2007 at 9:00 AM | PERMALINK

I call shenanigans.

Posted by: Garrett on April 30, 2007 at 9:03 AM | PERMALINK

Yes, indeed. When my father was dying of cancer he was given strong palliative care and told very directly that nothing could be done. There were no tubes and useless treatments.
He died at home without spending a day in the hospital. His diagnosis was grim but uncomplicated -- and his quality of life was as good as it could be under the circumstances. Hospice nurses figured prominently in making it so.

However, not all of the blame for the abundance of excessive care cannot be laid at the door step of doctors -- plenty of patients are in a state of denial over the limits of medical care, and their doctors go along because it's hard not to and the financial incentives make it painless to do so.

Posted by: Barbara on April 30, 2007 at 9:08 AM | PERMALINK

Strange, even paradoxical, to say, the way to achieve the best possible outcomes in the aggregate in health care is to handle patients in certain key respects as if they're industrial product.

What this means is that quality control should be a dominant factor in hospital care. We need to employ it the way the Japanese brought quality control processes to their manufacturing processes for cars. We need to approach "zero defect" in the handling of our patients, just as the Japanese (and now, finally, the American manufacturers) strive to achieve with their cars. This means, for example, bar coding at all stages, checklists that are rigidly employed (flu shots, mammograms, etc.), and doctors who are disciplined if they do not follow the protocols. (Prima Donnas = Deaths).

Posted by: frankly0 on April 30, 2007 at 9:10 AM | PERMALINK

The VA system has a cost incentive to keep patients well. The healthier their patients are, the more money they save. In the fee for treatment system, the sicker you are the more money goes into the system.

Harpo says "Under the current system, many people who go without insurance end up costing the rest of us through our taxes" -- It's great that people are starting to understand cost shifting, but the simple fact is, the cost shift is done through price hikes for every other patient, which shows up in your skyrocketing insurance rates. The more uninsured, the more your insurance co. or you pays for treatment.

Posted by: underseige on April 30, 2007 at 9:33 AM | PERMALINK

Kevin, there is something disingenuous about the premise here.
Think about all the unpleasant and unsatisfactory experiences we have every day with imperfect or inattentive or incompetent employees at the grocery store, the bank, the telephone or electric company, the city inspections office, the public schools, the contractor repairing our homes, the colleges... you name it.
Why do we suppose that medical care providers, even the superior research hospitals, should be uniquely able to avoid making mistakes in performance, or in designing systems of delivering care?
We each have to look out for ourselves in dealing with the store, bank, utilities, school, etc. Doesn't the same apply with our health care? Who is so foolish as to rely on "experts" to unfailingly pursue the best possible outcome for one's personal health?

Posted by: Tyrone on April 30, 2007 at 9:40 AM | PERMALINK

Tyrone, when the consequences of failure are a matter of life and death, we expect higher standards, and often we expect governments to enforce them. That's why people rarely die in plane crashes, for instance.

The health system, however, has not learned the lessons of the air transport industry and other safety-critical industries in reducing mistakes. Nobody expects absolute perfection, but the health system is so far away from perfection at the moment that there is plenty to be achieved.

As to looking out for ourselves, it's pretty hard to do that when you're lying unconscious in the ER.

Posted by: Robert Merkel on April 30, 2007 at 10:13 AM | PERMALINK

The factor you don't take into account is the selection bias of patients between "expensive" academic hospitals and "inexpensive" community hospitals for some conditions. I'll be the first one to say that academic docs are MORE resistant to basic quality measures (like aspirin for heart attack patients) than other docs, but it is also true that academic centers get very complicated, very sick patients transferred to them by the community hospitals.

Posted by: rdb on April 30, 2007 at 10:17 AM | PERMALINK

Teaching / academic hospitals are probably not the best. You'll often be treated by inexperienced, exhausted residents and you might get ineffective experimental treatments. In the best hospitals experienced doctors provide up-to-date (but not ahead-of-the-times) state-of-the-art treatment.

Posted by: John Emerson on April 30, 2007 at 10:28 AM | PERMALINK

N said: This is a little disturbing. For 20 years of treatment for a chronic ailment, I've always gone out of my way to seek health care at the nation's premiere research hospitals. Now they claim that I would be better off going to some small town clinics instead?

Actually, I have found it to be generally the other way around. The premiere research hospitals are often state hospitals which take on the most indigent care and are cost-controllers, whereas a great number of small hospitals are privately owned and will send you for an MRI at the drop of a hat. "Higher spending" does not necessarily mean "research hospital."

As for the care without consideration of the element of cost, I think questions have to be asked about the studies that the author points to (e.g. heart attack patients): what were the profiles of the patients being treated at the "higher spending" hospitals vs. the "lower spending" hospitals? Do the more difficult cases end up at the "higher spending" hospitals thus predisposing them to worse outcomes? This is akin to studies I read comparing the outcomes of operations performed primarily by a resident vs. an attending... often, the resident will have better outcomes, but that's because they get the easier cases in order to learn and develop their skills, while the attendings take on the crappy cases because they are more skilled than the resident. It is comparing apples to oranges.

I have a lot of similar questions about the studies he mentions, but one thing I will take whole-cloth is regarding the VA: patient continuity and preventative care is obviously very important. However, that makes the author's assertion that there is more than enough money in the system a bit strange... the poor and uninsured don't get that kind of care precisely because they don't have insurance or money (e.g. Cohn's example of a breast cancer that the patient sits on). Sure, once they finally bring themselves to coming to the emergency room, they might get comparable care to the insured, but their overall health and outcomes are always going to be crappy because the ER isn't your model of preventative medicine.

Posted by: medstudent on April 30, 2007 at 10:32 AM | PERMALINK

rdb's point is what makes me distrust Longman's article (which is probably unfortunate). Unless we know the average severity of illness for patients going to different hospitals, the raw survival rate is meaningless. (Hospitals do indeed keep track of adjusted-mortality rates, and for all I know that's what the article is referring to, but without that extra bit of explanation, I tend to wonder whether the stats are being cherry-picked to support the article's thesis.) Same thing with low-dose aspirin: are the patients coming out of the high-tech hospitals on other drugs, either more efficacious or conflicting?

In addition to those quibbles, I'm also put off by the implicit assumption (particularly in the section on balloons and stents) that the only thing that counts is mortality figures. Much of the argument for invasive treatment vs drugs has been on the basis of quality of life -- if I had a choice between living for a year of slow decline with barely-managed pain before dying and living for 10 months of relatively normal activity, just for a hypothetical, I know which I would choose.

So although the argument for care that isn't so linked to the supply curves of the local physician population is an important one to make, I'm not sure this article is making it well.

Posted by: paul on April 30, 2007 at 10:36 AM | PERMALINK

One area where this is increasingly evident is our rising c/section rate; despite many studies proving that less interventions=better birth outcomes (including 2 last year that showed *triple* mortality rates for mother and child in an "uncomplicated" (during the procedure) but unnecessary c/sec). OBs are under tremendous pressure to make as many births surgical as possible, and also lash out at alternative providers like midwives, who provide equally successful but less-interventive care, because they are the competition. Something like 80% of adult women will give birth at some point in their lives; that's far too big a market to let slip away, no matter what the women themselves may think or feel about it.

Posted by: emjaybee on April 30, 2007 at 10:38 AM | PERMALINK

More anecdotal evidence;

Twenty years ago my wife went to one of the country's most prestigious Eye and Ear hospitals and was basically experimented on by some residents. It didn't solve the original problem, and she still deals with the unintended consequences. We were fortunate enough to have decent insurance but I saw the bills, and holy crap!

About a year later the problem grew acute again. At our local hospital (which was, it must be said, probably a bot better better than the average community hospital) she was seen by a competent but not world-famous surgeon, had a more conventional surgery, and the problem was resolved.

Posted by: thersites on April 30, 2007 at 10:47 AM | PERMALINK

This seems to be such a mess that in order to fix it, there ought to be more than enough "slapping" to go around.

1. Everyone needs healthcare, even and especially the very sick "uninsurable" people. If money grubbing insurers won't cover them, they still need a place to go. That's the model we should be operating from, not strictly financial.
2. Healthcare should be much more about prevention. Doctors may not be the most effective, and they certainly aren't the cheapest way to get across prevention, however. More community workers/nurses/etc. would help. Doctors=angioplasty; community workers=aspirin. Let's get into more of an aspirin frame of mind...all of us. I suspect that some patients brush off some of the prevention stuff as well because they don't believe in it or don't feel like anyone else is doing it.
3. Healthcare isn't just about doctors and hospitals. Many many more low cost alternatives to ERs that don't involve insurance at all might be nice...
4. People with complicated health issues should have "care coordinators". Right now that's expected to be one's internist, but internists are not really set up to handle that task and often don't have the right mindset for it. People (who don't have to be doctors) who have training and experience coordinating specialists, medications, etc, would be helpful. Read a story in the NYer about geriatricians (speaking of unglamorous underfilled specialties) and that was a big part of their role.
5. Patients should stop expecting that A) they can't die B) more and fancier treatments will automatically stave off death. I don't know how common that sort of thing actually is, but if it's contributing to the problem at all, people need to knock it off.

So what do I think? If doctors are too expensive, don't make them (or let them) do things non-doctors can handle perfectly well (and more cheaply). Change the mindset around "healthcare" toward prevention, not procedures. Barack Obama was derided for his grand healthcare plan of computerized records, but that's not such a bad idea (that is, it's symbolic of needing to get the system's administrative processes under control). Don't just mouth "evidence-based" medicine--any expensive procedure or medication should be examined closely to see if something simpler and cheaper would work just as well. Look at the system as a whole, not just each piece of turf. And accept that at times, if the evidence shows that a simple cheap intervention is as good as a fancy one, it may be the limitation of the human body, not the procedure.

Posted by: JMS on April 30, 2007 at 10:56 AM | PERMALINK

In order to make a profit, private health insurance must bring in more revenue than it spends on treatment for its beneficiaries.

Which is why I am opposed to for-profit insurance for health. I believe that ALL health insurance should be required to be non-profit in some form - more of a health cooperative in which the insurance company is subscriber-owned and profits are not a factor. At worst, health insurance should follow the Credit Union model rather than the Bank of America model.

It is the WRONG motive, profit, to use in providing required medical treatment to people. The motive should ONLY be on health.

Posted by: Praedor Atrebates on April 30, 2007 at 11:21 AM | PERMALINK

I have to take issue with the characterization of teaching hospitals as somehow unsafe. Firstly, it needs to be said that attending physicians at academic medical centers are often on salary, meaning that their is little to no financial incentive for them to order unnecessary tests to benefit the hospital financially. Their salary is fixed regardless of the profit the hospital pulls down. Secondly, academic medical centers often get patients that are SICKER than the patient population inhabiting your local community hospital, the patients that your regional medical center simply cannot handle. Because they are sicker, their health outcomes will be worse, regardless of the quality of care they receive. Thirdly, although I haven't read the study mentioned, it doesn't necessarily follow that academic medical centers are the "highest spending" hospital. I can think of several private hospitals, not affiliated with a university, that may fit this bill (Cedars Sinai in LA, Beaumont in the Detroit Burbs). Finally, and this may sound arrogant, but as someone who has worked in both academic and community hospitals, their is a large disparity between the comparative medical capacities of the physicians at such centers. If you think this doesn't make a difference, I can assure you it does.

Posted by: Sean on April 30, 2007 at 11:26 AM | PERMALINK

One could argue that the current farm subsidy program originated as program to address rural poverty in the 30s. And we're certainly throwing money at it that's for sure.

As for the issue at hand. My wife recently finished her medical residency and I, for one, have no interest in ever being treated in a giant teaching/research hospital no matter what the circumstances.

Posted by: Kent on April 30, 2007 at 11:30 AM | PERMALINK

So what does Longman think the answer is?

I hope impeaching Bush and Cheney is part of it.

Posted by: craigie on April 30, 2007 at 11:34 AM | PERMALINK

Interestingly, the New Yorker has an article which, while not specifically about this, points out that great results are possible without spending money - and that that's why insurance companies hate geriatric doctors. Worth reading.

Posted by: craigie on April 30, 2007 at 11:40 AM | PERMALINK

This is similar to the recent study comparing British and American health outcomes.
...The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer. Within each country, there exists a pronounced negative socioeconomic status (SES) gradient with self-reported disease so that health disparities are largest at the bottom of the education or income variants of the SES hierarchy....Based on self-reported illnesses and biological markers of disease, US residents are much less healthy than their English counterparts and these differences exist at all points of the SES distribution....
The US pays twice as much as the British for less effective healthcare.

... suffering Americans to Cuba to delight in Fidel Castro's universal health coverage...mhr at 11:29 AM

Why don't you inquire about their mental health coverage?

Posted by: Mike on April 30, 2007 at 12:04 PM | PERMALINK

What, you're telling me that restricting citizens' ability to sue for malpractice won't solve this problem?

The insurance industry lied to me.

Posted by: Ringo on April 30, 2007 at 12:18 PM | PERMALINK

Excellent article Kevin. I sent it on to Tammy Duckworth the Illinois Department of Veterans' Affairs. I figured she could use it.

In Oct. 2005 my mother was admitted to our local hospital for a kidney infection. With 17 specialists she was given all kinds of conflicting if not contra-indicated meds, a triple bypass she was in no condition to receive, and they ran up over a half million in bills to Medicare and BCBS.

She wound up being passed off between 3 hospitals, one nursing home and 6 months later she was dead.

Posted by: markg8 on April 30, 2007 at 12:40 PM | PERMALINK

There's a problem with arguments like these. They are evidence that money is being spent unwisely, but they create a political case for simply decreasing spending, which does nothing to force the remaining funds to be spent more wisely.

Doctors and hospitals are bombarded with advertising from drug companies and medical equipment companies to buy the latest and greatest. No one's hammering them to make sure the heart patients get aspirin; that's boring and the profit is insignifant.

Posted by: Joe Buck on April 30, 2007 at 12:47 PM | PERMALINK

Longman did not say in his article that teaching hospitals were the big spenders with poor outcomes. Nor did he say that local hospitals were the small spenders with good outcomes.

In fact, many local or "community" hospitals will not accept Medicare-Medicaid patients. In contrast, most teaching hospitals, and almost certainly any owned by universities, are obligated to accept Medicare-Medicaid patients.

Thus, it appears likely that for-profits are the big spenders, as they accept only people who will pay their rates, while the teaching hospitals have a lower average cost because Medicare pays much less for anything than is charged to private-pay patients.

If your condition is not too serious and you have good insurance, you'll probably survive your stay at a community hospital. You might even meet a good doctor there. Having worked in the business for a number of years, and been a patient, I think most community hospitals stink, but YMMV.

The average person would do well to hire a Registered Nurse for an hour or two each year to assess their health and plan how to maintain or improve it over the coming year. Any nurse with a BSN from a state university would be qualified, even if they'd never done that before or thought about doing it. (They actually did it before in school but just weren't ever called on to use it.)

It's just like your car, really- if you want it to be dependable you take it to a mechanic once a year and ask him to look for stuff that's just about to break. You get 80% of your results from 20% of your effort.

Posted by: serial catowner on April 30, 2007 at 2:39 PM | PERMALINK

I love how aspirin statistics are always used to compare health care across different sites, as if somehow you should just look at tires when deciding what new care to buy. Aspirin after an MI just isn't a reasonable proxy for quality health care. I've never seen a reasonable proxy statistics for quality health care, actually, and until some measures that can control for the differences in populations treated at different sites, efforts to "teach to the test" simply aren't going to do much to improve health care.

Posted by: Garrett on April 30, 2007 at 2:44 PM | PERMALINK

Something is fishy here:
these spendthrift hospitals often skip other routine preventative care such as flu vaccines, Pap smears, and mammograms

In the U.S. hospitals don't generally provide preventive care measures like vaccines, Pap smears, and mammograms. Hospitals that perform indigent care generally have associated clinics that are performing Pap smears, etc. I suspect this finding is mostly an artifact.

Posted by: J Bean on April 30, 2007 at 3:46 PM | PERMALINK

J Bean may be right about the statistic being an artifact (or he may be wrong- reading the actual study may tell whether it is or not) but he is definitely wrong to associate care for the indigent with expensive hospitals.

I provided care for my disabled wife for 12 years with Medicaid coverage, and I can assure you that no unnecessary expense was suggested or incurred.

Hospitals and doctors are simply not going to do anything at Medicare rates of reimbursement without a d*mn good reason. It's just that simple.

Posted by: serial catowner on April 30, 2007 at 4:05 PM | PERMALINK

That hospital and the surgeon were more than happy to give my mother a triple bypass for Medicare rates. But then they're running TV ads now bragging about how fast they get you under the knife when you walk in the door with chest pains. They are a heart surgery mill and thanks to folks like my mother they've now opened their new wing.

Posted by: markg8 on April 30, 2007 at 5:38 PM | PERMALINK

As an RN for many, many years, I can assure you that the only thing that will kill you faster than a doctor is a doctor working in conjunction with a hospital.

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