Archive for the ‘Health Care’ Category

The Health Care Bubble: The Status Quo is Unsustainable

This post also appeared on the Huffington Post on August 5, 2009 at this URL. You can comment on it there.

Everyone loves to be angry with Wall Street and the mortgage lenders for causing a big financial mess. That’s understandable, and I have certainly had my share to say about high bonuses on Wall Street. But I am struck by the sheer idiocy of some comments from defenders of the private health insurers in the U.S. who don’t seem to recognize that health care built on private insurance companies is headed for the same kind of train wreck. Planted by Republicans and lobbyists to disrupt town meetings, and writing comments on articles and blogs in support of health care reform, defenders of the status quo seem unable to see the big insurance bubble for what it is: an unsustainable out-of-control behemoth headed for a huge collision.

Never mind that I am chronically angry with my health insurance company, United Healthcare, which cost over $17,000 in the last fiscal year, a large chunk of which is paid by my employer. If that’s not a huge tax, I don’t know what is. No wonder we have not received adequate cost-of-living salary adjustments during the nine years that I have worked here. Meanwhile, they recently denied the claim for my son’s 2-year-old check-up. The American Academy of Pediatrics recommends well-child check-ups at 15, 18, and 24 months, and then every year after that. But the plan says that he has maxed out his benefits for well-child check-ups this year so I get the bill. Do the defenders of private insurance companies never receive this kind of absurd denial of payment after paying through the nose for the coverage that they love so much?

But all hatred aside, it is clear that the current system of private health insurance is economically unsustainable. Health care costs have been rising 12% per year, while incomes were rising 2% per year before the current recession. As increases in income are likely to be small or non-existent this year because many people have lost their jobs or had to accept pay-cuts or furloughs, health care costs just keep rising. The math simply doesn’t work. It’s like the housing bubble that few seemed to see coming as prices peaked in 2006. House prices can’t increase 30% a year forever. It doesn’t take long before people can’t afford to buy a house, and those who already own them can’t pay their mortgages. We all know how that story ended: in a huge recession. The story of a health insurance system built on private companies whose primary goal is the pursuit of profits for their shareholders will also have a bad, bad ending.

It is clear that retaining the existing health care system in the U.S. will drive the economy into the ground. It is also clear that the most economical solution to covering everyone and reducing costs is to implement a universal single-payer insurance system. Unfortunately there is no political support for that – partly because the health insurance and pharmaceutical industries own the two houses of Congress and partly because Americans fetishize the free market with its valorization of private over public (both of which, again, brought you the housing bubble and the financial meltdown). What isn’t clear is whether the lobby-funded lawmakers will reform health care in a way that benefits the public and the economy, or will keep letting big business run this country into the ground. Maybe then I will finally convince my husband that we should move back to Canada, where health care is both cheaper and has better results.


Address Medical Liability with Science, Not Caps: The “Standard of Care” is not the same as evidence-based medicine

This post originally appeared on the Huffington Post on June 17, 2009 at this URL.

On June 15, the New York Times described how Obama is open to reining in medical suits by trying to reduce malpractice suits.  There are some fundamental issues that need to be on the table when thinking about this issue, the most important being that the “standard of care” is not necessarily evidence-based.  There are also far more medical errors than there are malpractice suits, and the few frivolous suits that exist rarely make it to settlement, let alone court.  I am currently exploring the effects of malpractice on maternity care, and will address these issues below.

The AMA and doctors are in favor of protecting doctors from malpractice lawsuits, and they have good reason: medical liability insurance premiums are absurdly expensive, especially in some states (e.g. Florida).  Practitioners must then pass along the costs to consumers, leading to inflation of healthcare costs.  However, premiums are not based entirely on the risk of being sued: liability insurers invest the premiums and then must increase their rates when their return on investments decline (as would be happening now in the recession).  They also raise their rates when they don’t face competition, and some states have only one or two liability insurers.  So liability insurance isn’t in sync with actual malpractice activity.  Using the National Practitioners Data Bank, I have found that obstetric malpractice suits have fluctuated over the years 1991-2004 rather than increasing over time.  This is not what one would expect based on the increased fear of litigation that doctors express.

In fact, many doctors practice in fear of litigation, and some have argued that this leads to “defensive medicine”: medical practices designed to avert the future possibility of malpractice suits, rather than to benefit the patient.  This drives up the cost of healthcare, because payers end up paying for unnecessary procedures.  But again, their fear is out of proportion to the actual risk: the risks of lawsuits have not increased, and the average awards in medical malpractice suits have increased only slightly (adjusted for inflation).

On the other hand, negligent medical errors are far more common than people in favor of capping damages want to acknowledge.  In the Harvard Malpractice Study, Dr. David Studdert led a team of eight researchers from Harvard School of Public Health, Brigham and Women’s Hospital, and the Harvard Risk Management Foundation.  The study used a conservative methodology to determine whether or not negligence occurred in 31,000 medical records, dating from the mid-1980s.  Practicing doctors and nurses evaluated the cases, and the study made a finding of negligence only if two doctors, working independently, separately reached that conclusion.  The study found that doctors were injuring 1 out of every 25 patients, and only 4% of these injured patients sued.  So the actual rate of negligent medical error is much higher than the litigation system suggests.  Also, fewer than 10% of cases were “frivolous,” meaning that no negligent medical error occurred, and the courts efficiently threw them out.  Only 6 cases where researchers couldn’t detect injury received even token compensation.

This issue of medical error is already part of the argument against reform: many who are against caps on damages point to the high rate of error and its impact on patients and their families.  But the missing piece that no one on either side of this debate seems to talk about is that the “standard of care” is part of the problem.  The New York Times article suggests that President Obama is “open to offering some liability protection to doctors who follow standard guidelines for medical practice.”  But standard guidelines are often not based on the best scientific evidence, and this is especially true in the case of obstetrics.  Evidence-based medicine suggests that optimal management of birth involves minimal interventions, and yet the standard of care involves high rates of induction of labor, often using drugs like Cytotec that are contra-indicated for this purpose (see here and here on the dangers of this drug), artificial stimulation of labor, amniotomy, confinement to bed, restriction of food and drink, non-physiologic positions for pushing, and very high rates of cesarean section (currently about 1/3 of births nationwide).  This is the “standard of care” but is not evidence-based – there is a large body of scientific research that finds that all of these practices are harmful and lead to unnecessary and preventable instances of fetal distress, cesarean section, and maternal mortality and morbidity.  Moreover, there is some evidence that doctors do more interventions and more cesareans as a defensive practice, because it fits the standard of care and despite the fact that it goes against the scientific evidence.  So offering protection to doctors who follow standard guidelines for medical practice will not reduce medical errors and preventable injuries, at least not in obstetrics.  In order to do that, President Obama’s healthcare reform should think about offering liability protection to doctors who practice evidence-based medicine.  To let the “standard of care” continue to rule is akin to letting the fox guard the henhouse.


American Healthcare: Frustration, being surgically implanted

This post originally appeared on the Huffington Post on June 29, 2007 at this URL.

Every time I drive by a billboard for United Healthcare that says, “Frustration, being surgically removed,” I wonder if they’re being sarcastic.  My employer pays through the nose to cover my family with United Healthcare, and it’s considered one of the more comprehensive plans.  But they still work really hard to deny coverage.  Last week my newborn came down with thrush.  When I tried to get a refill of the prescription to treat him, the pharmacy told me that it was too soon to get a refill – it could only be refilled after 15 days, even though the supply that they gave me the first time was only enough for 7.5 days.  It was simple math: at the dosage they prescribed, the bottle would only last half as long as the insurance company seemed to think it should.  It took about 10 phone calls to the insurance company, the doctor, the pharmacy, the insurance again, the pharmacy again, the insurance again, each time explaining the arithmetic, before I was able to obtain the refill.  The prescription cost United Healthcare $9.99.  The wages of the people I had to wrangle with over the phone probably cost them more than that, given all of the times I had to call.

I don’t remember ever having such problems when I lived in Canada.  I showed my card, got treatment, and that was it.  Preventive care was available, and even encouraged.  A single-payer system can reap the benefits of preventive care, since it reduces overall costs.  One might think that private health insurance companies could also reap savings from paying for prevention but that’s not true.  They don’t cover a large enough population to benefit from the overall improvements in health gleaned from providing more preventive measures like regular physicals.  And they are able to deny coverage to those with existing conditions, which reduces the cost to them of chronic health problems and debilitating diseases.  When everyone has to be covered, as in a universal single-payer system, existing conditions can’t be excluded and that means the system has to cover them.  There’s no downside to allowing people access to low-cost drugs like my son’s prescription.  But what saves private insurance companies money?  Denying coverage.  So much for the “culture of life.”

I haven’t seen Sicko yet, but I’m looking forward to it.