Monday, October 12, 2009

On Healthcare....

This is a big week in the national health care reform debate. For all of our sakes I hope that our legislators will begin to turn this ship around---

I'd like to direct folks to this week's installment of This American Life which is the first of a two-part series on how health care works (or not) in the USA from the perspectives of insurance, patients and facilities. Those of us who have worked around health won't find anything new in that description but there were astonishing data on utilization, costs and economic measures. Its politically very neutral (and makes absolutely no mention of President Barak Obama's Nobel Peace Prize), no worries about your blood pressure while listening.

I've spent nearly twenty years now professionally observing and thinking about access to health care in one way or another. Over those years the role of private insurance has represented a good proportion of the debates. Today, listening to this podcast, I was struck by a thought: for all of us, health care, and its costs) is virtually indistinguishable from insurance (and its costs): if you don't have insurance, you don't really have any health care---


1. current economic projections for *9 years* hence give the cost of healthcare INSURANCE at $38,000 per family of four per year...more than half the projected household income for that date. Half.

2. Fmr. President George W. Bush presided over the worst economic downturn of any 2-term president. When the proportion of economic change associated with health care costs are removed from the equation, however, his record rises to nearly the middle (at the lower end).

I'm saying only one thing: we have a huge and complex problem on our hands with respect to health care; every single stakeholder agrees that change MUST be made or the health care system *will* collapse---the costs are simply too high. The solution must consider access, utilization, standards of care, prescription costs and yes, insurance for every citizen. I am not saying a thing about the proposals on the table for consideration but failure to address the entirety of the health care delivery system will only prolong the problem. I hope we'll all give very serious consideration to the enormous scope of the problem and the values we hold as a nation. Let's walk the walk.

Thank you. We return you now to your regularly scheduled broadcast already in progress....


Special K said...

$38,000? That's hard to image (by which I mean, I can't wrap my head around it.) I haven't heard that TAL yet, but I'm going to check it out soon.

Special K said...

I listened to it today - very interesting. I have to say, the bit that surprised me was how supposedly a lot of tests are not helpful or even ahelpful, and most people agree that *other* people get too many tests. But that *oneself* does not get too many tests. I'm totally like that. I wondered what your opinion of that was, KHM, because, poor you, you've been through tons of tests the last year....

KHM said...

Right you are, K, and I've considered reflecting on it in a post. I think indeed I've had redundant tests because varying physicians in varying facilities haven't had access to the previous ones...that's bad administration---easily solved, too, by implementing uniquely identified electronic medical records but everyone gets all BigBrother-phobic about that. Honestly I think EMR would have probably saved my primary payer more than half of the costs I've incurred this year.

As for the value of tests, I can tell you that for a screening test to have merit it must balance four epidemiologic measures: sensitivity, specificity, predictive value positive and predictive value negative. PSAs, digitally-assisted mammograms are both very sensitive and not specific enough: they identify very many potential health issues but aren't at all good at weeding out the honest to god problems from the outcomes we're not interested in. What happens next in the cycle is that the diagnostic process is advanced to more invasive or more costly procedures... in this case its very likely that the lesions in my mammogram were associated with the over-sensitive screening tool and that started that whole chain that eventually required the very invasive and not at all pleasant procedure that put all fears to rest.

The costs, of course, are astronomical but those parties that establish "standards of practice" simply refuse to accept the risk of adopting a policy that might well miss a few cases in large populations. And that's another problem: no one is willing to accept any risks for themselves and when you extrapolate to the whole nation...whatcha' gonna do, then????? Should we all accept the notion that in the very near future most families will have to choose between a mortgage and health insurance in order to prevent a modest number of prostate and breast cancers, other diseases---or at least their very early detection? I have to tell you all: we're not going to get rid of cancer completely --- ever. Its simply something that cells do sometimes. Without completely engineering our genome, I think we have cancer with us. I've always refused to work in cancer epidemiology because of that fact---I think we spend too much money on its prevention and that the "cures" are too often toxic themselves and always far too costly.

That's not to say I don't think people shouldn't do what they can to reduce their risks...that gets back to the personal responsibility part of all of this and how it impacts community dynamics.

And now, I'll bet you're thinking: what else could she have possibly thought would be in a post that isn't here? Perhaps you'll see...

Don said...

So far we are in total agreement. The system need reformed.

I don't believe we need to completely scrap the current system. My concerns with the rhetoric in Washington is that while we can't afford to wait indefinately, we also cannot afford to be in a rush to push through a simple "solution" to what is a very complex problem.

As is generally the case in Washington, neither side of the debate is willing to truly compromise. They talk bipartisan solution but then fall back to their old position and refuse to budge.

You mention tort reform and Democrats refuse to go along. You talk government participation and the Republicans refuse.

A problem like this is not easily solved. In Washington today, I don't see it ever getting solved.

Don't stop now, I look forward to your future comments.

Khm said...

I think we agree, Don. I have concerns for the complexity of the problem and the climate among our legislators. I recently had a surprising boost of optimism from a completely random interaction. Boy, we could all use more of that.