Re: Seven Ways to Reduce Unnecessary Medical Costs --Right Now

On Sep 17, 4:42 pm, Islander <nos...@xxxxxxxxxxx> wrote:
Allan wrote:
On Sep 17, 11:29 am, Islander <nos...@xxxxxxxxxxx> wrote:
Allan wrote:
On Sep 17, 10:12 am, Islander <nos...@xxxxxxxxxxx> wrote:
Allan wrote:
On Sep 17, 7:37 am, Islander <nos...@xxxxxxxxxxx> wrote:
Allan wrote:
On Sep 16, 7:10 am, Islander <nos...@xxxxxxxxxxx> wrote:
Allan wrote:
On Sep 15, 8:03 am, Islander <nos...@xxxxxxxxxxx> wrote:
Allan wrote:
On Sep 12, 7:15 pm, Islander <nos...@xxxxxxxxxxx> wrote:
Gary wrote:
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
   1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
   2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
   3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
   4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good.. More
billions saved.
   5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
   6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
   7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost.. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"
Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.
Because it has nothing to do with rationality.  It is politics.  The
political right would have a field day!
Then the left should be prepared to be called the liars that they are?
Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected.  That is far more than (but may include)
discontinuing treatments that are not effective.
The problem with comparative effectiveness is the challenge of
actually collecting the data.  The second challenge is that CE is that
it must be, by design, population based.  It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted.  Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.
I think that you have a blind spot on this.  From a business point of
view, cost is the metric of choice, but from a broader point of view,
cost is only one of several metrics, necessary, but not sufficient.
I would argue it is exactly the opposite.  Comparative effectiveness
looks only at one parameter - the outcome.  For example, the number of
cases detected (specificity and sensitivity for example), or the
number of hospitalizations, or the cure rate, and so on, are effect
variables that comparative effectiveness targets.  Cost effectiveness,
on the other hand, requires that the input side, not just the outcome
side be considered.
All cost effectiveness analyses – every last one – no exceptions –
that are done correctly compare between two (and sometimes more)
choices.  The metric used is called the incremental cost effectiveness
ratio (ICER).  The definition of the effect variable is subject to
debate and discussion (not to be confused with a cost-benefit
analysis) and as such EVERY cost-effectiveness analysis is comparative
effectiveness.  Therefore, your statement that CEA is necessary but
not sufficient is incorrect – the opposite though, can be argued as
true – comparative effectiveness is necessary but insufficient IF the
objective is to select the treatments that provide the best value as
opposed to selecting the treatment that maximizes the clinical
outcome.
So instead of case finding, now we have cost per case found.
As you may have recognized, I probably know more about this stuff than
most.  There's a reason for this.
allan.
Yes, you work in the field.  It does raise an interesting question,
however.  How is the average person supposed to deal with a system this
complex?  
By becoming informed and by NOT believing the 30-second sound bites
from congress critters, Maddow, and Glenn Beck.
It is clear to me that we cannot trust the health insurance
industry.
There is no need to trust – just to hold them accountable.  One
advantage of the insurance industry over single payer is that one can
change insurers much more easily than governments.  Accountability is
based on choice.
The reform I believe is critical is not in designing health care but
how to make more health care insurance available and affordable..  The
downside is that CE is not an insurance reform initiative – it is the
practice of medicine. And when governments practice medicine, I get a
little queasy.
 While you have a lot of experience and can speak
knowledgeably on the topic, you, like everyone, have a bias.  
No – I am not biased, I am pragmatic.  I have an opinion based on
experience, knowledge, and evidence – not based on political mood or
social equity mandates as defined by a preference for socialism,
fascism, capitalism, or any other ism you want.
It is not
at all clear to me at this point that Congress is acting with any more
knowledge of the field than the average citizen.  
The Whitehouse has an agenda that is driven by something other than
consensus.  Personally, I believe the “trigger” recommendation for the
public plan indicates that universal public sector health care is the
endpoint – and that drives the less is more regarding what they tell
the public.  Hence my first point.
Who is the
knowledgeable, yet impartial advocate for the public?
Not my remit anymore – I am retired (though I did get a call last
week….from an old friend asking if I’m interested in visiting DC).
allan
I've been reading lately about the Netherlands system which increasingly
looks to me like where we might end up.  Are you familiar with it?
What do you think of the idea of having an all-private insurance system,
but with a standard policy that the companies must quote to enrollees?
I did a bit of work with the Dutch a few years back - mostly hospital
management.  We moved them from an inpatient to an outpatient surgical
approach for a few procedures as a pilot.  Worked fairly well except
patients (many of them elderly) didn't like the idea.  They wanted to
stay in the hospital for a week to recuperate and here they were being
sent home that afternoon.
In 2004-5 they moved to the current system.  It was fully implemented
just three years ago and it doesn't seem to be working very well if
cost control is your metric.  Their cost of medical care is rising
almost as fast as it is in the US and they expect that the 2008 and
more importantly the 2009 growth numbers are going to be a big budget
problem.  That, and the population isn't that keen on the new system.
If you read Baucus, you'll see some similarities - private insurance,
standard basic package, employer based premium sharing, some personal
contributions, but little in the way of cost controls.  It is
universal but that's about it.  As I suggested earlier - the only
meaningful change is not in how you push the dollars around but rather
in how many dollars there are to push.
allan
So, if the Netherlands system has all the constraints of forcing
insurance companies to provide a standard basic coverage and costs keep
increasing, that seems to me to be a failure of the private sector to
control costs given a level playing field.
It isn't a failure of the private sector to control costs - it is not
their remit. There is nothing in the 2005-6 law that requires cost
savings.  More health care, more access, more technology, happier
patients, that is the inferred remit.  Even in the presence of price
controls, which the Netherlands law includes but only as far as
premiums are concerned, there is little except pharmaceuticals where
any oversight on price is required.  In fact, direct negotiation
between payers and providers is infrequent.  Hospitals are still
funded through a budget setting mechanism which reinforces more as
opposed to less spend.
I'm not claiming that all cost savings can be squeezed out of the health
insurance industry, but the Netherlands example sure seems to me to
indicate that the competition provided by a public option wouldn't hurt.
Maybe you need to rethink that statement.  A public option doesn't
change anything other than where the money comes from.  The public
option under HR3200 (now a dead duck) simply moved some of the
"competition" from a bonafide business model to a public welfare
subsidy model.  When you look at some of the economic analyses done
and at other "public welfare" models (Medicaid for example), you find
that in the absence of utilization limits, you continue to have the
problems of expenditure expansion.  When you reflect back on the
Netherlands, they did this public stuff and found it not too work so
well either.
The good news is that I checked with an old friend (we did work in the
Netherlands together back in the dark ages) and her answer was - we
are changing, again.  She is working with folks in Rotterdam on some
new ways to get more patient incentives into the system and to do some
more formal HTA assessments.  If you may recall, Erasmus University is
a hot bed of HTA work and has been for years.  She is confident that
greater visibility of cost and better risk sharing can help reduce
utilization.  That, and they want to revise the hospital busgeting
process - one area that is creating havoc for cost control.  They have
a pretty good primary care gatekeeper system (capitated - sort of what
Kaiser has done in their group models), and some cost controls (but
not utilization controls) on specialty care.
The last thing is that they are starting (again) to do "soft"
rationing.  Unavoidable in her mind.  It will be interesting to see if
there is a backlash from the residents, especially in the elderly
population.
allan
It is not clear how the public option might be implemented, if it
survives, but to claim that it is a public welfare subsidy model is not
only premature, but not what has been proposed.  Your political bias is
showing!
The public welfare subsidy model is not a political statement, it was
a statement of fact based on simple economic principles and how it was
written into HR3200.  Sorry you took offense that the inference was
one that it is "bad" and I was against it.
The term Public Welfare is used to describe who manages (government)
and how money's are collected and distributed - Public is defined as
by an arm of the government, and Welfare is the redistribution based
on need as opposed to contribution.  That's how HR3200 wrote in the
"public option".  See section 222 and 241.  Much of the rest is also
based on a welfare model.  If everyone paid their own way then we
wouldn't be having this discussion - but that isn't the case and we
all know it.
The entire industrialized world is facing the same problem in health
care - no system is immune from the increased expenditures for health
care.  The reasons are multifactorial but boil down to three basic
things - - more people using more stuff that is more expensive.
Three ways to fix it - less people, less stuff, or less cost.  Three
strategies - pull the plug on grandma, ration access to stuff, or fix
prices.  Each comes with its own set of "externalities" as the
economists like to say.
Writing fancy bills that move money around is not the solution.  Time
for us to come to grips with reality.
Allan
Words carry implications and the words one chooses bias a discussion.
To describe the public option as a "public welfare subsidy model" seems
to me to be a choice of words that is intentionally inflammatory and
misleading.

It is an ECONOMIC definition.  I don't make this *** up - it is how
it is defined in the economic literature.  The definitions are precise
and accurate - not inflammatory or misleading.  You are the one
inferring something that isn't there.

It is a PUBLIC system - and that is defined as one which uses the
PUBLIC sector to plan, implement, and control.
It is a Welfare subsidy model - it uses redistribution of funds to
subsidize those who cannot pay from funds collected from those who
can.  It doesn't matter if it is in premium redistribution, general
revenue redistribution, or whatever.  It is the definition of the
term.  You want the label to connote something regarding politics,
that is your problem, not mine.  Only bigots and illiterates think
welfare is a four letter word.

I also take exception to your three basic things.  That is a fixed size
pie argument

I never made a fixed pie argument - the fixed pie argument is one that
is being made by the President when he says we are spending TOO much
on health care and we need to reverse that.

and ignores efficiencies that can be achieved by covering
everyone

Define efficiencies in a way they cannot be categorized as

less people, less
less stuff, or
less cost.

You can't.  Economies of scale are at the margin, and not at the
total.  This is the economics not the politics.  Look it up if you
like.  The only time economies of scale reduce the total cost is if
the marginal cost is less than zero.

and eliminating the waste, fraud and abuse that are inherent in
our current system.

What makes you think waste and fraud are going to disappear by
changing the system of financing and if you believe it can, why do we
need to change the system of financing to accomplish it?  And it
doesn't fix the problem either - when the problem is defined as
expenditure growth.  You may be able to reset the clock but it does
NOTHING to change the dynamic - less people, less stuff, less cost
(though I should have said less price, but that is grammatically
incorrect).

And as for abuse - if you define an MRI and a SMAC 20 as an abuse for
a hangnail treatment, you just fell into the "less stuff" box.

Quit trying to infer that somehow I am not on your side on this.  I
think health care sucks the world over - we can and should do better.
I've played in these systems my entire professional life and have seen
far too much first hand NOT to question the proposals - and it's not
just Washingtonian spin - it comes out of Labor in the UK and even
from Andrea in Germany.  The French are sucking wind on this too.  The
Dutch are running around in circles like they did back in 2002-3.

Paying twice as much per capita for our health care for arguably poorer
outcome than that found in other industrialized countries having various
forms of universal health care speaks volumes to me.

Then you missed the point.  Too bad, I really thought you were beyond
the politics of the issue.

You do understand that every large economy in the industrialized world
is facing exactly the same problems with health care and that they
have systems of health care financing that range from none to complete
public universal care.  And you must know that every form of health
care financing is trying to fix it one way or another but each and
every one, without exception, is doing it using the three buckets that
I described - if you want the economic nomenclature for them, happy to
oblige - euthanasia, rationing, tariffs.  Want the Obamacare words?
Sure - end of life counseling, improved efficiency and quality, and
outcome based reimbursement.

Ask the Dutch how well #1 worked.  Ask the Brits how #2 works for
them, and then ask the Germans how IQWiG is working for them - becuase
that puts all three on the table at once.

Oh well - lesson learned.

allan

It appears to me that you are only addressing the cost growth in health
care delivery.  

It is termed health care expenditure inflation - not to be confused by
medical price inflation. It is what is central to the discussion - in
the absence of the increasing cost of health insurance, do you believe
that there would be a "health care crisis"? The uninsured is not the
problem, it is the cost of care and the cost of insurance that are the
problem.

Until the mid 60's, few people had health insurance at all because in
all honesty, they were he3althy until they died.

Yes, there is a common problem across all health care
systems that is due to the reality that the more we seem to learn about
new technology, the more alternatives that we discover, the more we seek
to give the patient all the options, then we will keep seeing costs
increase no matter what system we use.

Bingo - I think you got it. The expenditure run up in health care is
not a function of financing- it is all about utilization.

If this is common across all systems, and I don't doubt that it is, I
can understand your argument that the only ways to reduce cost is to
reduce the number of people covered,

Not exactly the number of people covered - I am assuming 100% coverage
- I am arguing that one way to cut costs in health care is to have
fewer people.

the number of options offered,

It's not about the number of options offered, it is about the number
of units of utilization provided. I really don't care if it is
lobotomies or appendectomies or breast augmentations. It's about how
many.

or
the price charged.  

If we cut the price of charged for each unit of medical care we use,
what would happen to our total expenditures?

From an economics point of view, yes, any savings
would be at the margin.

Savings due to the economies of scale by definition are at the margin
- and the savings are in the unit cost not in the number of units.
Therefore, economies of scale do not decrease total cost UNLESS the
unit cost at the margin is negative - and that is not how things
happen.

And, if these were the only variables that we could play with, then
there would be something very seriously wrong with our system in
comparison with other systems since we pay twice as much for poorer
service (not a political statement despite what the conservative think
tanks claim).

In the US we pay more per unit than in some systems of care - doctor's
visits for example. That is a function of pricing and pricing is a
local thing, not a global thing. If you look at PPP things are not as
much out of kilter as one might suspect. I personally think that in
the US we overpay for a lot of stuff - but man do we have some neat
stuff.

As to the poorer service, you might want to consider data to support
that. There is one thing the US is good at in health care, other than
massive technology, and that is responsiveness. Responsiveness is a
metric used in assessing "health care quality" by the WHO - it is the
ONLY metric that is unbiased as an estimator.

This is not rocket science.  Why are we getting such poor performance
compared with other countries?

We aren't. Not when you measure health care as opposed to the affects
that lifestyle, epidemiology, and behavior have on health outcomes.

 Is denial of service to so many of our
population making us a sicker nation and therefore costing us so much
more?

Technically there is a law against that - but then again, you are
equating health care quality with health care insurance access and
those are two different things.

 Is there really value added by the free market insurance
industry?  

Is there value added by ice cream trucks cruising the neighborhood?

Why is electronics for everything other than health care on a
very different cost/performance curve?  Something is rotten in our
system and we ought to be able to find it.

Not sure what that means.

The bottom line whether you believe it or not - the only way to reduce
health care expenditure growth is to have fewer people, and or use
less, and or charge less per unit. There is NO other way. You can
cut the waste and fraud in a one time approach - but that will do
nothing to fix the problem in the long term.

Which leaves as with three alternatives once again - euthanasia,
rationing, or tariffs. Just by paying for health care through taxes
doesn't change a damned thing with respect to the big problem -
expenditure growth..

allan
.

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