



And the first step is recognizing and acknowledging it.
And the first step is recognizing and acknowledging it.
Spending & Coverage (2010)
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France
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U.S.
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Total health spending per capita
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$3,974
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$8,233
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Government health spending per capita
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$3,061
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$3,967
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% uninsured
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0%
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15.7%
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Health outcomes (2010)
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||
Life expectancy at birth (2011)
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81.3 yr.
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78.7 yr.
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Infant mortality per 1,000 births
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3.6
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6.1
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Costs per episode (2012)
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||
Doctor’s office visit
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$30
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$95
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Hospital day
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$853
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$4,287
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Angioplasty
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$7,564
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$28,182
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Appendectomy
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$4,463
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$13,851
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Childbirth delivery (normal)
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$3,541
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$9,775
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Hip replacement
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$10,927
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$40,364
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Heart bypass
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$22,844
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$73,420
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Tests (2012)
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||
Abdominal CT scan
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$183
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$630
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Angiogram
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$264
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$914
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MRI
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$363
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$1,121
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Name-brand drugs (30-day prescription, 2012)
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||
Cymbalta
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$47
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$176
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Lipitor
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$48
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$124
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Nexium
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$30
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$202
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Sources: Organisation for Economic Co-operation and Development and International Federation
of Health Plans. |
So, what’s up? Were the experts trying to fool us? No, but the flaw was the assumption that Medicare spending reflected overall spending. The data in this article demonstrates that it does not. It also reveals something about integrated health systems, especially those that dominate their smaller cities, given that some of the “top performers” for Medicare, like Grand Junction and Rochester, MN, were so high for private insurance. The integrated nature of these plans allows them to save money on patients by a variety of methods – they can be seen in ambulatory settings rather than in hospitals or ERs, and they share electronic medical record systems, and thus the information recorded therein, saving money by not having to repeat tests, x-rays, etc. This lower utilization is good for these health systems because Medicare is a relatively low payer, and because they can’t negotiate these rates – Medicare pays what it pays (it is a single-payer system, with minor regional variations). However, the same characteristic – being the dominant player in town – allows such integrated health systems to negotiate much higher rates with private insurers. Thus the mismatch; overall cost is a multiple of price for each service times the number of services delivered. These systems decrease the number of services for people insured by Medicare, for whom they cannot control the price (whether this does or does not decrease quality is a separate question) but they raise the price for services to people with private insurance. That places like Tucson and Kansas City have relatively lower prices for private insurance reflects the absence of a single large dominant system in those cities.
And this is the real point. The web of multiple strategies for achieving coverage are incredibly complicated, with roots in both the Clinton plan and Massachusetts’ “Romneycare’ and (ironically) in the ideas of right-wing think tanks over the last several decades. This patchwork of fixes has always been a Republican (and conservative Democratic) hallmark. While Silvers titles his final section “What does it mean for the future and what can be done?”, in fact he mostly tells us what the risks are rather than what could be done. There are many who suggest (or fear) that the biggest threat from a potential failure of Obamacare would be that it would make the fact that a single-payer system would be much simpler and effective more obvious; see Morici “First Obamacare, Then a Single Payer System” on www.breitbart.com, cited by Don McCanne in Quote of the Day.
If we trained doctors in the right way in the right place we might have a better shot at getting the health system, and even the health, our country needs.
I often write about the things that I believe make a big difference in the health of people. Some of these are access to the health system, particularly financial access in the US. The bizarre and inappropriate structure of the US health system in terms of overemphasis on high-tech, subspeciality care at the expense of adequate primary care is extremely important. I also believe that the “social determinants of health”, the characteristics of people’s lives that are not usually considered as part of the health system (socioeconomic status, environmental exposures, stress, education, housing, etc.) are major contributors to health.
I have also written about medicine in terms of recommendations for prevention and screening from different organizations (I tend to advocate for those from the US Preventive Services Task Force) and about treatments that are promoted but are often of minimal benefit and sometimes harm to people. Occasionally, I even venture into the area of medical research, trying to help folks understand how science progresses, and how there is rarely a “breakthrough” as big as the news media like to trumpet. As a medical educator, I am very concerned about how we train doctors, and have also frequently written on that topic.
Most of these themes are focused on “population health” rather than the management of individual patients with individual diseases, not because the latter is unimportant but because these issues are extensively addressed in many other outlets, and the ones that I have described are, I think, not as well understood both by the medical community and the general population. I believe that the almost exclusive emphasis in our country on treatment of individuals limits both our commitment to addressing population and system issues, and the resources available to do so.
However, sometimes there is an issue that is mostly about human behavior, something that could be changed, and would make a big difference in the healthcare experiences of most people. One of those I have touched on before (Medical schools are no place to train physicians, January 5, 2014), because I see it as a key part of medical education, is communication between health care providers and their patients. This was addressed in an outstanding “Opinionator” blog that appeared in the New York Times on February 9, 2014, “Lost in Clinical Translation” by Theresa Brown.
Ms. Brown is apparently a nurse, but what she discusses is at least as applicable to doctors and to other health professionals. Starting with a reference to the Gary Larson “Far Side” cartoon here, she gives excellent examples of failures of communication that were disturbing to patients, but did not, apparently, disturb the health professionals who, presumably, thought they were communicating as clearly as Ginger’s human owner does. One story is of her friend’s husband, who a heart procedure called a “cardiac catheterization” to look for blockage in the arteries that supply the heart itself, which can cause a heart attack. (That description is, I hope, clear; when I told my residents, however, I just said “he had a cardiac cath”, which was very clear to them but would likely have mystified most patients.) As it turns out the test was completely normal, but this was not clear to the obviously very worried wife who understood almost nothing about what she was being told (for example, that he was being kept overnight in the intensive care unit because this is routine after such a procedure, not because his condition required intensive care!).
This sort of thing happens a lot. Daily. Hourly. There are many reasons for poor communication to occur between health professionals and patients. Some are that people, when they are scared and sick and in a strange place, have difficulty listening to strange words and understanding unfamiliar concepts. They may have to be told again and again, just as, I tell my students and residents, we all had to study to pass exams even though we’d be “told” everything once, in the lecture. But there are a lot of other things that are our fault, and can be remedied by different behaviors.
One, we – doctors, nurses, and other health professionals — are very comfortable in the hospital, and we take it in stride; it is our “briar patch” and we’re at home, but for patients and families it is a scary place full of thorns. I ask doctors and nurses to think about they would feel if they had to go to court, as witness or defendant or plaintiff, and look at how easily the attorneys comport themselves. It is a good reminder of how patients feel in a hospital.
Two, we speak “medical” fluently. We have such familiarity with both words and concepts that we assume that they mean something to regular people (which is, by the way, the correct English term for “patients” and “patients’ families”). But usually they don’t; words that mean very different things sound a lot the same; even if people have heard them before they usually have only a vague idea of what they mean, and the difference between “is” and “is not” is, while obviously very significant, not always clear to folks. I point out, just for an easy one, how often we use “negative” when we are describing a normal test. We should ALWAYS use “normal” or “not normal”. “Negative” sounds bad. “Positive” (which is often bad) sounds good!
Three, we often use obfuscating words, unnecessarily medical words when regular ones will do fine, and use lots of modifiers and adverbs that make what we are saying even more unclear. The use of such modifiers (“probably”, “likely”, “potentially”, ‘possibly”) may make what we say more technically accurate, but can obscure the message. Similarly, we are often uncomfortable giving bad news, and when we use such modifiers we may think we are lightening the load a bit for the patient, but really we are being more unclear. When we hide behind medical words, we are protecting ourselves from having a long and perhaps difficult discussion; completely subconsciously, I’m sure, we expect that maybe they won’t understand, and thus won’t ask hard questions. Also we tend to speak in the third person, kind of distancing both ourselves (first person) and the patient (second person) from what we are saying. All these are illustrated by thinking about how a statement like “The biopsy result showed that the tumor was probably malignant” conveys a very different (and probably incomprehensible) message than “you have cancer”.
It is a lot to think about, but the good part is that these behaviors can change. We just have to want to, and work at it.
In summary, the flaw is not just the RUC, but the entire nonsensical non-system of medical care we have in the US. Medical care should be paid for by a single payer, and rates determined by an independent body without a financial stake in the outcome. Health care should be a lot more than simply medical care. And the health of our people will be most impacted by investment in the core functions of society: housing, food, education and jobs.
and support from your family. In short, they are “the rest of life”, outside and often ignored by the healthcare system. Camara Phyllis Jones, in her wonderful “cliff analogy” (which I have also reproduced before) creates a metaphor in which medical care services are provided for those who need them (or “fall into them”) along a cliff face, while the social determinants of health are represented by how far a person, or a group of people, lives from that cliff face. As such, it illustrates the degree of protection that we all have from falling off that cliff, more for some and less for others.[1]
Even when they are uncomfortable, even when they challenge your beliefs, or more importantly your sense of self-entitled comfort. To not do so is part of no one’s religion. This is the responsibility of free people.