Health Policy

Tara Parker-Pope, Well columnist for the New York Times website, highlighted overtreatment as a serious problem in a blog post yesterday. The post describes several people's direct experiences with unnecessary testing and treatment, and does a good job conveying the physical, emotional, and financial harm that comes from a disorganized system prone to overtreatment.

Overtreatment is a human issue, and reducing the personal harm it causes is at least as important as controlling healthcare spending growth. But healthcare spending is a crucial political issue, so it was smart to put the post on the Times's current campaign issues channel, The Agenda. Tackling overtreatment will be a defining issue of the next few years--either because we make crucial progress toward eliminating overse and reducing total medical spending, or because the next President ignores the problem while we continue on the ruinous path of letting healthcare strangle the rest of our economy.

Given the importance of the issue, though, I wish the post had looked a little bit closer at the policy issues involved. Most importantly, the post doesn't address the causes of overtreatment, including the financial incentives faced by clinicians and hospitals, lack of research on what treatments are effective, and physicians' failure to communicate to patients about their treatment options. The thing is, there are huge differences in policy between the two tickets on those issues. Since the post appeared on The Agenda, it could have done a lot more to point out those differences--like the fact that the ACA moves Medicare away from paying for the volume of services and toward rewarding higher-quality, more cost-effective care, or that it funds patient-centered outcomes research to determine which treatments actually work. On the other hand, Romney's running mate, Paul Ryan, recently parroted the absurd idea that IPAB is a "death panel," even though it is specifically prohibited from rationing care. That kind of rhetoric is hard to square with the notion that a Romney/Ryan administration would be willing to take any political risk to push back against unnecessary care.

Finally, on a related note, Dr. Aaron Carroll of The Incidental Economist has pulled together an incredibly useful set of politically difficult truths about reducing healthcare spending, in a set of posts titled "Why is this so hard to understand?" All of them are important and worth reading:

Part 1: When Medicare spending goes up, seniors’ premium costs go up.

Part 2: You can be for reducing Medicare spending, or you can be for increasing Medicare spending, but you can’t be for both.

Part 3: If you spend more on Medicare, someone has to pay for it.

Part 4: Don’t argue that reducing government involvement is the way to reduce spending.

We don't often weigh in on electoral politcs here on New Health Dialogue, but the introduction of Paul Ryan into the race as Mitt Romney's running mate has distinctly shifted the focus of the debate onto Medicare, at least for the moment, and the editor of Delve Into '12, the New America campaign blog, asked for our thoughts.

You should definitely check out the full post (here) and the rest of their campaign commentary, but if you're short on time, here's an excerpt from the end of our post:

[...T]he Ryan budget slashes government healthcare spending, but it does relatively little to reduce total health spending. (In fact, if Ryan’s plan was implemented, it could reduce Medicare’s bargaining power and actually increase total spending.) While the ACA includes specific programs aimed at reducing waste (for instance by giving doctors incentives to reduce spending on ineffective treatments, funding research on which treatments actually benefit patients, and making it easier for cheaper generic drugs to get approved), the Ryan plan’s main savings mechanism is competition among private insurers. In theory, giving people a choice of insurer should reduce healthcare spending –people will choose plans that offer  better value, forcing inefficient plans out of the market. But competition among private insurers has failed to control spending in the private insurance market for decades, so some skepticism of its ability to rein in spending on the elderly is warranted. If that doesn’t actually work and total medical spending doesn’t go down, the Ryan budget saves money by shifting spending from the federal government to individuals.

Ultimately, the Ryan budget's laser-like focus on reducing the federal deficit has led to a glaring oversight in the proposal’s healthcare component. Policy should be focused on reducing total healthcare spending, including private insurance premiums and out-of-pocket payments, not just on reducing what the federal government spends. Healthcare spending has become a drag on the economy, accounting for up to two percentage points of unemployment—and that drag isn’t dependent on whether it’s funded by the government or the private sector. That’s the much more important challenge, and the Ryan budget ignores it completely.

Enjoy the weekend!

Hosted this week by Dr. Jaan Sidorov at the Disease Management Care Blog, it's "A Brainy Health Wonk Review on Health Reform, the Affordable Care Act and Lots More!" Go check it out.

Health Wonk Review will be back on September 13th, hosted by Louise Norris of the Colorado Health Insurance Insider Blog.

Boston Globe health reporter Chelsea Conaboy has a brief profile of Dr. Bernard Lown in the most recent edition of the Boston Globe Magazine. It covers some of the most important moments in a truly remarkable life, including our conference this April on Avoiding Avoidable Care. Check out the piece here.

If you haven't seen it yet, you can also read more by and about Dr. Lown at his blog.

Last year Dr. Ken Murray, a pediatrician at USC, published an article called "How Doctors Die." In it he describes how physicians, many of whom witness end of life care and death as a regular part of their practice, often choose to die differently than their patients. He gives the example of a friend of his, an orthopedist who found out he had a very lethal form of pancreatic cancer. Instead of enduring surgery, chemotherapy, radiation and long hospital stays, he instead chose to close his practice and spend his last months at home, surrounded by his friends and family. Dr. Murray goes on to talk about "death with dignity" and how many physicians choose to avoid the extreme end of life measures that they regularly provide to their patients.

Though the article was beautifully written and thought provoking, it wasn't very academic. He spoke from personal experience, and included no references. Some readers asked for data to back up his observations, so last week Dr. Murray posted a follow-up article with a more critical examination of the evidence. That article, "Doctors Really Do Die Differently," entertained a variety of studies with topics ranging from living wills to CPR effectiveness. Both are good and worth a read.

The topic of end of life care is eerily applicable in my life right now. On Saturday morning I got a call from my Mom telling me that my great-grandmother passed away. She was 101 years old (almost 102!) and her health had been in decline for decades now. A couple of nights ago she fell and broke her hip. The paramedics came, options were discussed, and it was decided that taking her to the hospital and trying to perform surgery wouldn't do much good--she was on the way out. They provided morphine to be administered through the night, to keep her as comfortable as possible. My wonderful mother sat with her through the night and held her hand as she passed away in the morning. (You can read my tribute to Grandma Ada here).

As I sat down to start writing this post I thought about the hard decisions that were made that night. I thought about Dr. Murray's comments about “death with dignity.” Grandma Ada did have a living will, but it wasn’t accessible at the time. She had made it clear, however, that did not want her hip replaced (again) if she broke it and that she did not want to die in the hospital. Had she been rushed to the emergency room and aggressively treated it would have just been prolonging the inevitable, not to mention putting her through a lot of unnecessary pain and discomfort. It was her time to go, and I’m glad that it was at home, surrounded by family, and in peace.

The topic of end of life care is one that has been receiving quite a bit of attention from some big names. Time Magazine’s Joe Klein recently did a cover story about his experience being, as he described it, his parents’ “death panel.” The story, called “How to Die,” is both a memoir of his parents and an indictment of our fragmented, “fee-for-service” healthcare system (the article requires Time membership; the video summary is free). Newsweek also had a cover story broaching the subject. Written around the time of the claims that the ACA included "death panels," Evan Thomas’s "The Case for Killing Granny" told the story of his grandmother’s experience of having to insist that she wanted to be placed in hospice rather than stay in the ICU. Both stories highlight different weaknesses in our current approach to end of life care and suggest ways that we can improve.

As a future physician, I am proud to become part of a profession that has such a high regard for life. Physicians are rightfully on the offensive to keep death at bay. However, if we always equate life as a “win” and death as a “loss,” without regard to quality of life, then in the grand scheme of things medicine is a zero-sum game—in the end, we always lose. If, however, our determination--our almost righteous zeal--to protect life is accompanied by a reverence for the inevitable experience of death, then helping to ease a patient’s departure from this life, according to her preferences, can be seen as one of medicine’s sweetest triumphs.

As Evan Thomas put it,

“Our medical system does everything it can to encourage hope. And American health care has been near miraculous…But death can be delayed only so long, and sometimes the wait is grim and degrading. The hospice ideal recognized that for many people, quiet and dignity—and loving care and good painkillers—are really what's called for.”

This week I started my second year of medical school. I already consider my summer here at the New America Foundation an invaluable part of my medical education, and I am sad to leave. My great-Grandmother’s passing has coincidentally provided me with the perfect opportunity to craft a farewell post about one of the topics that I have become passionate about this summer—shared decision making. Throughout all of a patient’s life, she should have an active role in her care. Though this applies at all stages of life, it is especially applicable at the end of life. What makes these end-of-life decisions different from those made earlier in one’s life is that they must be made in advance.

As a final request at the close of my internship, I ask that you have a discussion with your loved ones about end of life care. Talk about what you want to happen and (perhaps more importantly) what you don’t want to happen. Consider drafting a living will or advanced directive, and making sure that someone always knows where it is.  It was fortunate that Grandma Ada’s wishes were honored without having to pull out the legal paperwork, but that is often not the case. Evidence has shown that those take the time to create a living will are far more likely to receive the care that they want when they can no longer speak for themselves. That goes for people who want every intervention possible, as well.

Ultimately, honoring wishes about end of life care isn’t about costs; it’s about your will being made known about one of the most important moments in your life. Then, and only then, can healthcare professionals do what they are called to do: enable you to live your life, as you want to live it, with minimal pain and suffering.

On Friday August 6th, the New America Foundation will be hosting an advanced screening of "Escape Fire: The Fight to Rescue American Healthcare." The event will take place in New York City from 6:30pm-8:30pm. Watch the trailer here.

Directed by Matthew Heineman, “Escape Fire” is a stirring documentary about the perilous situation of our current healthcare system, and what can be done to fix it. The film, which has been honored at both the Sundance Film Festival and the Full Frame Festival, is being screened nearly two months before it comes out in theaters. More details, as well as a link to RSVP, are available here, at the event's page:  "Escape Fire - Screening Event"

The New England Journal of Medicine just published a great article about physician stewardship as it relates to medical spending. The piece, called "Cents and Sensitivity—Teaching Physicians to Think about Costs," discusses whether or not we should be training physicians to consider the bills patients will face when making decisions about what treatment to choose. (Aaron Carroll’s treatment of this piece is here.) The authors propose that teaching physicians to be more cost-conscious will increase their capacity to care for the whole patient, not just their symptoms:

"Whether it’s lack of time, fear of “missing something,” or simple ignorance, the incentives to do more often overwhelm our impulse to use resources wisely. Now some educational reformers are offering us an added ethical incentive. Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment. Protecting our patients from financial ruin is fundamental to doing no harm."

We agree that overtreatment is a problem, and we applaud the NEJM for addressing it. It says a lot about how far we have come from even five years ago when everyone was thumping their chests and talking about how we have “the best healthcare in the world.” But we believe that there’s an even greater reason to address the topic of overtreatment: because it is dangerous. Starting with the Institute of Medicine’s 1999 report, “To Err is Human,” the research has continued to demonstrate that more does not always mean better. 

So yes, physicians should consider what patients can afford, but even before that, physicians need to realize that doing nothing is often safer than putting patients at risk with treatments that don’t work. Fiscal responsibility—making sure we aren’t sending Grandpa Frank from the ICU to the poor house—will be the natural consequence.

About six years ago, Netflix offered an award of $1 million to anyone who could mine its database of customer-provided movie ratings and improve the system’s overall accuracy by more than ten per cent. Many people tried. In 2009, Netflix awarded the prize, in the form of stock, to one participant.

The Supreme Court is poised next week to rule on the constitutionality of the Affordable Care Act, popularly known as "Obamacare." Assuming it strikes down the individual mandate -- a requirement that everyone purchase qualified insurance coverage -- rather than upending the Act as a whole, the impact on health reform is likely to be modest, contrary to what many believe.
 

Health Wonk Review is back with a summer edition packed with links to a myriad of topics. Check it out!