Editore"s Note
Tilting at Windmills

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August 15, 2007
By: Kevin Drum

HEALTHCARE SPENDING....Does higher healthcare spending actually provide better healthcare? Maybe not. Phil Longman provides one side of the argument:

Dr. Elliot S. Fisher, a Dartmouth Medical School researcher, estimates that 30 percent of all Medicare spending goes for unnecessary operations and procedures. For instance, under Medicare, the per capita cost of treating terminally ill patients in Miami is $50,000 more than the per capita cost of treating equally old terminal patients in Minneapolis, yet the patients in Miami don't live any longer. The explanation is simply that Miami's high concentration of specialists and hospitals is overtreating the city's patients.

But maybe there's a difference between the elderly populations of Miami and Minneapolis that accounts for this. Perhaps Miami has a reputation for providing great healthcare and tends to attract sicker patients. That might explain the higher average cost.

So how do you eliminate this possible geographical bias and study only the effect of spending itself? Tyler Cowen points to a new paper that tries to do this by comparing outcomes only for people who get sick away from home and therefore receive care at a random location:

Visitors who become ill in high-spending areas have significantly lower mortality rates compared to similar visitors in lower-spending areas. The results are robust across different types of patients and within groups of destinations that appear to be close demand substitutes.

Interesting! It's not conclusive, of course, since this study looks at a wide range of illnesses while Longman focuses solely on terminal care for elderly patients. It's entirely possible that higher spending is largely wasted in terminal care but highly effective elsewhere. More study is needed!

On a (marginally) related note, though, one thing that always bugs me about these discussions is their focus on mortality. In the great scheme of things that might be worth focusing on since a large portion of our healthcare dollars are spent in the last year or two of life. But extending life is hardly the only — or even the primary — purpose of healthcare. I tore a meniscus in my knee a few years ago and ended up getting $10,000 worth of arthroscopic surgery on it. It didn't extend my life by a single minute, but it sure did improve my life. Ditto for things like dental care, antidepressives, athsma inhalers, cortisone shots, and all those infamous hip replacements. They cost a lot of money, but they don't really have much of an effect on mortality at all. Still pretty nice to have around, though.

Kevin Drum 3:04 PM Permalink | Trackbacks | Comments (52)

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Along these lines, Colorado Public Radio had an interesting interview with our former governor, Dick Lamm about his new book Condition Critical: A New Moral Vision for Health Care.

Lamm is known for his "duty-to-die" comments years ago. In this interview, he makes some interesting observations about health care priorities and how health care is rationed in different systems, including our own.

Posted by: Quaker in a Basement on August 15, 2007 at 3:17 PM | PERMALINK

No expert here but there seem to be two questions we shouldn't confuse. First, do higher expenditures at the margin increase quality of care, across all levels of health care spending? Second, do areas with higher expenditures yield higher quality?

The answer to the first could be no; the answer to the second could be yes.

No?

Posted by: Econobuzz on August 15, 2007 at 3:18 PM | PERMALINK

Actually, expenditures for things like dental care, antidepressives, asthma inhalers, cortisone shots and your knee surgery do extend life. Maybe not immediately, but the knee surgery means you are more likely to remain active and physically fit, thereby extending your life. People who have good access to dental care wind up with much better nutritional status, and also avoid gum disease which is linked to heart disease and premature labor. Untreated asthma can have fatal outcomes, as can untreated depression. Maybe they don't affect mortality this week, but they certainly effect lifespan.

Posted by: MPH on August 15, 2007 at 3:22 PM | PERMALINK

My wife the psychiatric nurse practitioner would tell you that antidepressives absolutely do extend life. Suicide caused by depression is a significant cause of death.

Posted by: Karl Weber on August 15, 2007 at 3:24 PM | PERMALINK

I would actually think that Minneapolis (with the Mayo Clinic in its orbit attracting patients such as King Hussein) would affect the results the other way, drawing people seeking good care.

Posted by: George on August 15, 2007 at 3:24 PM | PERMALINK

Antidepressants certainly reduce mortality. The depressed tend to die earlier, if not of suicide. When you die from suicide, it doesn't say "depression" under cause of death, but it should.

Posted by: Carl K on August 15, 2007 at 3:27 PM | PERMALINK

Did Mayo relocate? Last I heard it was in Rochester, MN, approx 50 miles from the Twin Cities.

Posted by: Chocolate Thunder on August 15, 2007 at 3:29 PM | PERMALINK

Oh, come on. The bias is obvious. The elderly who choose to live in Minneapolis, and brave the winters, clearly have something called "blood" in their veins. Otherwise they would bring new meaning to the word "POPsicle" (or Granmdasicle).

New medical research has shown that "blood" in your veins can be of considerable benefit. People often move to Miami because they lack this substance.

Posted by: alex on August 15, 2007 at 3:30 PM | PERMALINK

Of course Rochester is 50 miles from the Twin Cities, but when Twin Citians have serious medical problems, that's where they go. And by today's standards that practically qualifies as the same metro area. Does the study account for that? Are Twin Citians actually getting all their unnecessary surgeries down there, thereby excluding such procedures from the study?

Posted by: George on August 15, 2007 at 3:32 PM | PERMALINK

I apologize for not following the links, but I am familiar with the Dartmouth Atlas team's line of research. The critique you describe about good reasons for regional variation is not new, not particularly valid, and in any case applies only to the very earliest Dartmouth studies by Wennberg.

Other Dartmouth studies looked at practice variation within the same region or city. One study found wildly varying rates of knee replacement surgery in three different Florida cities. Another found extreme differences in physician intensity and ICU stays for patients in Los Angeles, and yet another found the same phenomenon in New York City.

Also, the point of the focus on mortality is not that it's more important than quality of life, but that it's more measurable.

Posted by: TomH on August 15, 2007 at 3:43 PM | PERMALINK

Kevin - you are correct about other outcomes being useful. The problem is that something like "quality of life" is difficult to quantify and expensive to measure (surveys or interviews). Mortality, on the other hand, is straightforward and can be applied to administrative data.

Posted by: Dan on August 15, 2007 at 3:45 PM | PERMALINK

Not to mention that the University of Minnesota also has excellent healthcare facilities w/ the highly qualified docs characteristic of teaching hospitals. And Minnesota has passed legislation aimed at assessing and improving the quality of care.

Posted by: THS on August 15, 2007 at 3:50 PM | PERMALINK

Actually dental care does prolong life. An untreated cavity can get infected and lead to lethal complications, like in the recent case of that poor kid in Baltimore. Before the wide availibilty of modern dentistry it wasn't an unusual way to die.

Posted by: heckblazer on August 15, 2007 at 4:00 PM | PERMALINK

Actually, I would argue that your arthroscopic surgery might well extend your life. With a healthy, robust knee, you will walk more, you will get out of the house more, you will see more people.

All of these things are important to extending lifespan.

Posted by: Doctor Jay on August 15, 2007 at 4:12 PM | PERMALINK

Yes, yes, but I said my examples don't have "much of an effect" on mortality, not "no effect." And I'll stand by that. Sure, they all make small differences on mortality, but for the most part they're rounding errors in the overall numbers.

Posted by: Kevin Drum on August 15, 2007 at 4:13 PM | PERMALINK

My point being, of course, that even things that have only a small effect on mortality can be pretty important. This occasionally gets lost when we focus heavily just on the stuff that keeps you breathing.

Posted by: Kevin Drum on August 15, 2007 at 4:14 PM | PERMALINK

High price is either indicative of higher quality, or a captive market. In the case of health care - unless you're a Free Market Fundamentalist in total denial of reality (lest you suffer a crisis of faith) - which do you think it is. Do you think that a 90 year old blind diabetic with high blood pressure and osteroporosis is going to travel to 20 different medical centers across the country to find the best price for her hip replacement surgery?

Posted by: osama_been_forgotten on August 15, 2007 at 4:18 PM | PERMALINK

With regard to dental care:

It has been shown that there is a relationship (correlation - causation has not been established) between periodontal disease (plaque, gum disease) and arterial plaque and blockage, including blockage known to cause heart attacks. The theory is that, in persons who suffer gum disease, the bacteria enter the blood stream through the gums, if left untreated, and live in the blood stream, causing plaque to accumulate in the arteries, eventually contributing to heart disease.

So floss, dammit. Floss.

Posted by: osama_been_forgotten on August 15, 2007 at 4:24 PM | PERMALINK

Kevin - you're right about the importance of quality of life. But it really hasn't been forgotten by researchers. In fact, it's one of the ominous holes in the motherhood-and-apple-pie talk about preventive care. For years, the progressive argument was that investing in preventive care would save money on the back end, e.g., high-cost hospital and specialty care. And it still may.

But we're finding out that the picture is more complicated, especially in areas where quality of life has little to do with mortality or even future cost of care: pain medication and mental health are two prominent examples of this. There are obviously anecdotal exceptions, but the data is compelling. So what happens when our medical establishment puts its money where its ideals are, and costs keep going up?

Btw, that Tyler Cowen column is silly piffle. See above.

Posted by: tomH on August 15, 2007 at 4:29 PM | PERMALINK

Alex nails it. Minnesota is FUCKING COLD. Miami is WARM.

No one lives in MN who doesn't have to. People CHOOSE to live in Miami ... including a lot of sickly old people.

I mean, when you hear of people moving "for their health," how many move to freakin' North Dakota?

Posted by: Anderson on August 15, 2007 at 4:41 PM | PERMALINK

just off hand, comparing miami and minneapolis doesn't make much sense because of differences in population. my guess is that miami has a much higher proportion of immigrants than minneapolis and a huge disparity in income among its population. both could affect spending and outcomes.

Posted by: mudwall jackson on August 15, 2007 at 4:42 PM | PERMALINK

The case is that there are simply cost differences as well that having nothing to do with the care provided. Florida and California are high cost states. Minnesota is, and has been historically, a low cost state.

Conversely, Minnesota is also one of the states that always ranks very high (often #1) for overall health and longevity.

It should also be noted that Minnesota is a primarily not-for-profit state for healthcare (all the hospitals are non-profit) as are the major insurers (Blue Cross, for example). Florida is a for profit environment.

Posted by: Doug on August 15, 2007 at 4:52 PM | PERMALINK

"Ditto for things like dental care, antidepressives, athsma inhalers, cortisone shots, and all those infamous hip replacements. They cost a lot of money, but they don't really have much of an effect on mortality at all. "

(1) They cost a lot of money RELATIVE to the healthcare budget? Are you sure about this? My understanding was that most money was actually spent in about the last year of life, desperately attempting to stave off the inevitable.

(2) A major problem in this respect is American morality. There is a strand in American culture that thinks suffering is great, especially other people's suffering. cf the idea that war gives the society energy and purpose. I personally have little problem with cosmetic medicine, whether it is braces or breast implants, but a large fraction of America seems to think it unacceptable that anyone undertake a medical procedure just to improve their lives. It's an affront against god just to undergo the thing, insurance damn well shouldn't cover it, and that goes ten times for the government covering it.

I really don't know how you escape this sort of petty-mindedness. What we have now is the same sort of dodge as we have with federal industrial policy. We sneak in federal industrial policy by calling it "defence related" and getting DARPA to oversee it. We sneak in quality-of-life issues by pretending that they have some sort of outcome effect on the measures that are acceptable to uptight America, eg it saves money or it (somewhere far down the road) improves mortality.
Both of these are problematic strategies. By hiding some large aspect of the situation, they solve the immediate problem, but allow the larger public attitude problem to fester; people can continue to pretend that the federal government is not involved in industrial policy, or that quality of life should not be a goal of medicine, because 80% of the problem is dealt with in this sneaky fashion.
But it's not great to build a society on lies, it's a real problem when the lies are exposed (part of the arguments in the comments above and your point), and it sucks for the 20% that can't be squeezed into the framework of the lies.

Posted by: Maynard Handley on August 15, 2007 at 4:57 PM | PERMALINK

Anderson: No one lives in MN who doesn't have to. People CHOOSE to live in Miami

Well, that wasn't exactly my point. Here in NY, my father, who's pushing 80, complains about the heat but doesn't mind the cold. If he had to make a choice between Miami and Minneapolis, I bet that he'd become a Twins fan.

Nevertheless, most elderly people seem to be the other way around. I wonder if sicker people are more inclined to move to the heat.

when you hear of people moving "for their health," how many move to freakin' North Dakota?

None, but that may be because they didn't realize the "true story" claim in the movie Fargo was just a joke.

Posted by: alex on August 15, 2007 at 5:14 PM | PERMALINK

Did I misread Kevin's original statement? Did it not say they were comparing EQUALLY OLD, TERMINAL patients in Minnesota and Florida?

I think this narrows down the study set pretty well, unless the old terminal patients in Min always seem to come up with a terminal condition that costs a lot less money.

Doug offers a valid suggestion addressing the issue, Min has higher costs than Fla, but really, $50,000 more? Only if the costs he is alluding to are in the area of doctor/hospital billings.

Then Doug nails it, in Florida, healthcare is a major profit center.

Posted by: says you on August 15, 2007 at 5:18 PM | PERMALINK

I can't quote the source, but I remeber reading about a study that showed that blacks were turned away from emergency wards more frequently than whites. However, even with the data adjusted for the nature and severity of the illness/injury their fatality rate was significantly LOWER.

Medical intervention sometimes kills people.

Posted by: memyself on August 15, 2007 at 5:18 PM | PERMALINK

Simple simple simple,The health exec. makes more in Miami.How much do we have to spend to get these execs. there billion dollar paychecks.

Posted by: john john on August 15, 2007 at 5:21 PM | PERMALINK

Mental health care is yet another example where you can pay some now, or pay more later. People untreated for mental health problems get worse. People with worse mental health problems cost more money whether it is treatment, supporting those unable to function, or dealing with follow on problems (eg crime).

I don't know about short term vs long term costs on pain management specifically, however, regular universal preventative care will reduce the amount of pain management treatment required. If your diabetes is treated earlier and more regularly you are less likely to need pain management for diabetic neuropathy. Long term pain management is a good example of the kind of cost that earlier preventative care reduces and that our current system increases.

"There are obviously anecdotal exceptions, but the data is compelling."

No, cases where preventative care isn't more efficient than skipping it are the anecdotal exceptions. The data shows quite clearly that regular universal preventative care produces better results for less money compared with the relatively poor provision of preventative care from the US health care system. Even inside the US systems (like the VA) which can and do provide better preventative care over long periods of time are significantly more efficient than those which don't.

"So what happens when our medical establishment puts its money where its ideals are, and costs keep going up?"

Our medical establishment's money is already where its ideals are but its ideal is that it get as much money as possible so its money is in advertising and buying politicians (especially republicans). Oh, and costs are already going up faster than anywhere in the world.

Over the long term our costs probably will still go up, there are other drivers besides poor provision of preventative care. Other wealthy nations have increasing health care costs as well, their are simply increasing quite a bit slower while their populations are healthier.

A continued increase in costs would not refute the claim that better preventative care would more than pay for itself, it would only refute a far more optimistic claim that better preventative care would reduce costs by enough to counteract the aging population, increasingly sedentary lifestyles, increasingly unhealthy food, increasing stress, etc. But I have never heard anyone make that claim outside the imagination of a person constructing a straw man argument.

Now, to really stop health care increases?
Universal health care emphasizing early preventative care.
Automobiles illegal.
Dramatically increase spending on free public athletic facilities and youth programs.
End all subsidization of corn, soybeans, etc in favor of fresh fruits and vegetables.

I don't know. All of that might come close. We might not even need crystals in our hands that turn black at 30.

Posted by: jefff on August 15, 2007 at 5:32 PM | PERMALINK

*

Posted by: mhr on August 15, 2007 at 5:33 PM | PERMALINK

perhaps in miami there's a difference, but on the whole people in the US are no "sicker" than people in other countries, yet we pay more for health care and the health care system delivers worse outcomes.

the definitive study on this, which i think i've cited a few times in comments on this blog, was done by McKinsey & Co. not so long ago. sorry to sound like a broken record, but anybody who reads it will be well-served.

http://www.mckinsey.com/mgi/reports/pdfs/healthcare/MGI_US_HC_fullreport.pdf

Are there any clever little econ-experiments that contradict the overall trend? then perhaps "more study" will actually be needed.

Posted by: lewis on August 15, 2007 at 5:51 PM | PERMALINK

Flash- Government spends too much! That's news?

You will observe which party controlled the relevant governments . . .

Posted by: rea on August 15, 2007 at 6:00 PM | PERMALINK

I'm not really seeing the relevance of patients receiving care in random areas study to the question of whether the terminal elderly are over or undertreated in some geographic areas. These are people who are acutely dying (as opposed to the chronically dying we are all in the midst of). If you spend lots more money, and they don't live longer, well, how does spending lots more money on someone who isn't dying who does get a better outcome related to that? Intervening apparently helps when it can help, which is a great argument for better healthcare for the non-dying, I suppose. But there does come a time when intervening, other than palliative comfort care, needs to stop. This often isn't recognized by the patient or family members. And lots of docs, especially specialists are interventionists by nature, so they sure as h-e-double hockey sticks aren't going to say "it's time to stop this".

Posted by: bluewave on August 15, 2007 at 6:15 PM | PERMALINK

Does higher healthcare spending actually provide better healthcare? Maybe not

Then Democrats won't mind if we slash Medicare spending, right?

Posted by: Al on August 15, 2007 at 6:28 PM | PERMALINK

As an elderperson who just moved away fom Miami after 30 years there, I can report that heathcare is indeed a major industry in Miami.

However, it's major by reason of being a black hole for Medicare and Medicaid dollars that disappear with a trace of service to those who need care.

Same thing applies to other kinds of federal aid--like housing and transportation, just to pick a couple. HUD just took control of Miami-Dade Conty's housing authority--too corrupt, even by Current Administration standards.

Posted by: wileycat on August 15, 2007 at 6:37 PM | PERMALINK

Al: Then Democrats won't mind if we slash Medicare spending, right?

Oh, come on Al, what's with the halfway measures? We want to slash all health care spending, by about 1/3! The only way to do it is UHC (the fact that we'll get equally good health care and cover everyone in the country is just gravy).

Posted by: alex on August 15, 2007 at 6:45 PM | PERMALINK

I saw Dr. Fischer speak one time. I thought he was very good. Speaking to the differences Kevin mentioned between Miami and Minni, they probably do have different populations. Hence his looking at terminally ill patients and not just everyone over 65. The feeling here is that the levels of sickness are about the same between two populations of terminally ill patients.

Posted by: Jason on August 15, 2007 at 6:50 PM | PERMALINK

Hip replacements reduce pneumonia, less pneumonia means less death.

...But that's kinda a weak point.

Posted by: Crissa on August 15, 2007 at 7:21 PM | PERMALINK

The whole terminal-patient thing is really a bunch of baloney, because it's assessed retrospectively. Unless you decide at the outset that anyone with a possibly-terminal condition isn't going to get care, a bunch of them are going to die and you can then turn around and say, "Look! this treatment cost money and didn't extend their lives." Tens of thousands of dollars are spent on trauma patients in the last hours of their lives, but typically that's not used as a call to not treat trauma.

(Yes, there are plenty of cases where obviously futile care is lavished on the dying, but that's not going to be addressed until we adjust the whole system to have a decent mix of care other than physician practices and high-intensity hospitals.)

Posted by: paul on August 15, 2007 at 7:41 PM | PERMALINK

It's entirely possible that higher spending is largely wasted in terminal care but highly effective elsewhere.

As you point out, this is kind of a "duh!"

On a (marginally) related note, though, one thing that always bugs me about these discussions is their focus on mortality.

Also true. Maybe we can start to look a little deeper than life-expectancy figures when discussing health-care numbers between the U.S. and other countries? People make fun of the "hip replacement" anecdotes, but maybe there's something there.

The other lesson here is that maybe health care is a very complex issue that isn't going to be handled all that well by a highly-centralized government system.

Posted by: harry on August 15, 2007 at 8:07 PM | PERMALINK

This is an unusually insightful post on healthcare especially for Kevin (sorry!) Mortality in the US is probably more affected by obesity, sedentary lifestyles, poverty and urban violence than by a true failing of the healthcare system.

Posted by: Brian MD on August 15, 2007 at 8:16 PM | PERMALINK

Fisher's et al's work is very compelling. If you delve into the Dartmouth Atlas Study (http://www.dartmouthatlas.org) and his other research, it consistently points to patterns of overspending on procedures that do not correlate with measurable benefits for patients.

The current payment structure for health care in the US disincentivizes use of the most critical diagnostic tool - a robust medical history developed by taking time talking with a patient - as well taking time to make sure that patients and/or their caregivers understand a diagnosis, the side effects of medications and needed follow up, and answering patient questions by phone or email instead of with a (billable) office visit. The countries with the best overall quality of care (like Norway, based on Commonwealth Fund studies) incentivize care for the health of patients through strong emphasis on primary care structures. In the US, primary care and coordination of care is becoming less common as the providers receive ever less reimbursement (translating in a need to see more patients per hour in order to keep up with overhead).

I recently saw a financial analysis of the cost of care for (non-terminal) patients who received palliative care while receiving other care for their conditions. These were not people in hospice in the last months of life with care being withheld. Within 48 hours there was an appreciable and ongoing decline in the per patient spending for these patients. However, palliative care providers are not compensated for spending more time with patients. Providers spending adequate time with their patients does not have to be in conflict with patients receiving high-cost procedures, as long as there is a balance between the two. In today's system, the clear choice is to pay for the procedure, not the provider's time.

How can universal health care become a reality when Medicare is The "stealth" financial crisis? The system is perfectly designed to produce the result it produces.

Posted by: Kathy on August 15, 2007 at 8:21 PM | PERMALINK

harry writes "The other lesson here is that maybe health care is a very complex issue that isn't going to be handled all that well by a highly-centralized government system."

Gee, if only we had empirical data on this; you know, perhaps a large set of countries that had dealt with this issue in different ways, and we then had specialists who evaluated the results.
Do you think the results of such empirical research might change the minds of ideological twits? I guess it's as likely as these same people believing the research regarding global warming or evolution.

Posted by: Maynard Handley on August 15, 2007 at 9:15 PM | PERMALINK

"Visitors who become ill in high-spending areas have significantly lower mortality rates compared to similar visitors in lower-spending areas."

I can't say I find it very interesting to conclude that, when everything else is held constant, spending more money to care for individuals obtains better health outcomes than spending less money. Well, duh!

After eight months in France, I have been startled by three things upon returning to Minnesota for a visit. The first is that Americans appear less healthy than the French (obesity is part of that); The second is the level of anxiety that Americans experience over obtaining basic health care. The third is how many Americans have no health insurance or inadequate coverage and how this distorts lives. (I am not referring to the poorest Americans, either. My observations have been made among a privileged, college-educated population.)

Why do Americans choose to live with such endemic anxiety and inequality?

Posted by: PTate in FR on August 15, 2007 at 9:26 PM | PERMALINK

This seems like such a terrible waste of space. You see, in America, the issue of health care is a simple one.

In Europe, and throughout the rest of the world, the health of a citizen is influenced by many factors: environment, genetics, the country's health care system, etc.

But in America, only thing influences health: God.

You see America is the one nation on the face of the Earth where God determines who is sick and who is well, who shall live and who shall die. One nation under God and all that.

So stop wasting valuable pixels discussing this issue. If God wanted Americans to live longer, healthier lives, he would have told George Bush to institute universal health care. Instead, he told George to start a war in Iraq, and he told my master to tell Leahy to go fuck himself.

Posted by: Dicksknee on August 15, 2007 at 9:36 PM | PERMALINK

As a person with severe asthma, I am appalled at your designation of asthma inhalers as a "quality of life" treatment. In the last 3 years, I have had two complete airway collapses remedied by an asthma inhaler. I would be long dead without mine.

Asthma is a fatal illness without treatment. In fact, I was diagnosed with emphysema and put on oxygen for a year. (Medicare, $100 a week) Midway through the year, we moved to a small town with much less air pollution. 6 months later, my diagnosis was changed back to asthma and the hated oxygen machine vanished!

If the true cost of fast food, air pollution, pesticide contamination, etc. was reflected in the cost of the products we are forced to consume, market forces would insist on healthier products and a healthier environment. Health care would no longer be the proxy argument for wingnut welfare sustaining corporations selling poisonous products at the cost of our health.

Posted by: Street Smart on August 15, 2007 at 10:01 PM | PERMALINK

Ditto for things like dental care, antidepressives, athsma inhalers, cortisone shots, and all those infamous hip replacements. They cost a lot of money, but they don't really have much of an effect on mortality at all. Still pretty nice to have around, though.

Good point, Kevin. I've always thought the same thing, which is one reason I've never had a problem with commercial advertising by drug companies. I mean, if you've got a product that will improve somebody's quality of life, why shouldn't you be able to market it? For the same reason, if we ever get everybody covered with medical insurance in this country, we all ought to take a chill pill over the issue of medical spending. Sure it's likely to increase as a percentage of GDP for the foreseeable future. But if that spending is enhancing quality of life, why is that a bad thing?

Posted by: Jasper on August 15, 2007 at 10:08 PM | PERMALINK

Jasper: I've never had a problem with commercial advertising by drug companies. I mean, if you've got a product that will improve somebody's quality of life, why shouldn't you be able to market it?

Or for that matter, why require an Rx for it? If patients can intelligently evaluate a drug on the basis of TV ads, why do they need a middleman doctor? And the charming thing about such advertising is that it's the still-on-patent (hence $$$) drugs being pushed, and drowning out the message about off-patent and non-drug therapies.

For the same reason, if we ever get everybody covered with medical insurance in this country, we all ought to take a chill pill over the issue of medical spending.

You mean unlike every other developed country? I'm all for UHC, and have been for over 20 years. It has the potential to cover all Americans and reduce costs. But even in the best UHC countries, 10%/GDP ain't hay, and costs are rising, and for good reason they spend plenty of time worrying about it.

But if that spending is enhancing quality of life, why is that a bad thing?

"If" is a small word with a big meaning. How much of the increase in medical care is enhancing quality of life? How much is misdirected or just wasted? That's what this whole thread is about.

Posted by: alex on August 15, 2007 at 10:23 PM | PERMALINK

Dr. Elliot S. Fisher, a Dartmouth Medical School researcher, estimates that 30 percent of all Medicare spending goes for unnecessary operations and procedures.

Oh for fuck's sake. Define unnecessary. If it's a 20/20 hindsight thing, then only wasting 30% of your money is doing pretty well, I'd say.

Posted by: craigie on August 15, 2007 at 10:36 PM | PERMALINK

Or for that matter, why require an Rx for it? If patients can intelligently evaluate a drug on the basis of TV ads, why do they need a middleman doctor?

Being told that there's a drug for a situation that is causing one a problem hardly renders one capable of self-diagnosis, or self-treatment. For this reason a physician is critical. Nonetheless, if I were suffering from a particular ailment, and were unaware that a therapy had been developed capable of treating it, I'd certainly want to be let in on the secret. Wouldn't you?

You mean unlike every other developed country? I'm all for UHC, and have been for over 20 years. It has the potential to cover all Americans and reduce costs.

I don't follow you. I'm well aware America isn't the only country grappling with healthcare costs. What I'm saying is, provided we could get everybody covered with robust insurance, I'd reckon the continued rise in healthcare's portion of the economy wouldn't be such a problem, but, to a substantial degree, the inevitable byproduct of very welcome advances in medicine. Sure, we spent a lot less of GDP on healthcare in 1950. We also saved a lot fewer lives from cancer.

How much of the increase in medical care is enhancing quality of life?

I reckon a great deal of it. I doubt I'd get very many takers on an offer to be transported back to the (cheaper!) hospitals of the 1970s.

Posted by: Jasper on August 15, 2007 at 10:56 PM | PERMALINK

People do occasionally try to put together quality of life metrics, but the trouble is that it's incredibly difficult to quantify, especially based on claims data. Length of life is a easy number, and it isn't a terrible stand-in.

But having worked in Medicare fraud and on a quality pilot program, it's painfully clear that they just shovel money out the door. There are all sorts of programs that would have paid for themselves in savings, either quality initiatives, or fraud investigations, that just don't get funded because money saved doesn't get booked as revenue. It's incredibly frustrating, and it's why I whimper whenever I see numbers about how low Medicare overhead is. It would be even lower if they just handed the money out at AMA meetings and stopped with all this red tape of processing claims.

Posted by: Boring Commenter on August 16, 2007 at 9:15 AM | PERMALINK

The only thing inevitable in life is death. For this reason, while health care may be important, freedom is even more important. Living in freedom is more important than living with health care.

Right now, there are many strangers who are telling the American people to give them power over fourteen percent of the economy. They are promising the sun, moon, and stars with regards to healthcare, if only we socialize it. In short, give these strangers immense, unconstitutional power, and they promise to give you a healthier, happier life.

How absurd does this sound? But it is essentially what many politicians are now proposing.

Call me paranoid, but I don't trust the federal government with the ability to use the NSA to spy on Americans, or with the ability to detain American citizens without habeas corpus. I also don't trust them to run my health care. As for the insurance companies, no one should trust them either, but the difference between the government and the insurance companies is that these companies can't raise taxes on you and can't force you to buy their product.

If you want less expensive healthcare, than lead a healthier life. If you know someone who has high health care costs, and it is not their fault, then work through your community, your local community, to help them.

Don't expect strangers in Washington, D.C., which is pretty much a swamp of special interests, to solve your healthcare problems, nor those of your neighbor.

Posted by: brian on August 16, 2007 at 10:35 AM | PERMALINK

Kevin,

Your remark about the importance of quality of life, as opposed to mortality, suggest that you are interested in health care. This isn't the suject on the table.

You have to understand, George "Let 'em have emergency rooms" Bush is not interested in health care. He only pays lip service to illness-care.

On the evidence of his actions, however, the only thing he is willing to act on is subsidies to the drug and sick-care industries, without any regard to the actual outcomes of such subsidies.

Posted by: David Lloyd-Jones on August 16, 2007 at 9:27 PM | PERMALINK




 

 

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