Can we lower medical costs by giving the neediest patients better care?
January 28, 2011 9:02 PM   Subscribe

The Hot Spotters examines the possibilities of a strange new approach to health care: to look for the most expensive patients in the system and then direct resources and brainpower toward helping them. — by Atul Gawande

“High-utilizer work is about building relationships with people who are in crisis,” Brenner said. “The ones you build a relationship with, you can change behavior. Half we can build a relationship with. Half we can’t.”

Previous essays by Atul Gawande on MetaFilter.
posted by netbros (34 comments total) 24 users marked this as a favorite

 
Also known as Pareto's Law - used most efficiently in business marketing strategies for maximum ROI.
posted by infini at 10:16 PM on January 28, 2011


Malcolm Gladwell wrote about this a few years ago. He called it an example of a power-law problem.
posted by scalefree at 10:19 PM on January 28, 2011 [2 favorites]


Dr. Gawande was on Fresh Air earlier this month; he's quite an engaging speaker.
posted by fairytale of los angeles at 10:44 PM on January 28, 2011


Dr. Gawande has over the years written many excellent medical articles for The New Yorker. This article really was interesting. I used to know a woman who lived in Camden, N.J. She described the place as a war-zone. I think a lot of the points made in this article are of interest. In medicine and social services there has been a lifeboat mentality, instead of a true mentality of helpfullness.
This mentality of telling people no all the time is not always cost-effective. Good preventative care will cut costs and make peoples lives better.
posted by Katjusa Roquette at 11:37 PM on January 28, 2011


this is brilliance.
posted by Ironmouth at 11:41 PM on January 28, 2011


There was a good post on Flip Chart Fairy Tales recently, Why are public sector efficiency savings so hard? which talks about "failure demand":
Most of the theories, methods and case studies about productivity improvement come from manufacturing... Service processes differ from those in manufacturing in that the customer is actually an actor in the process, rather than someone consuming the product from it at the end... This is exacerbated in the public sector because public-facing organisations have to deal with whoever comes through the door...

To standardise and streamline processes, service organisations often try to design out the complexity and unpredictability -- because simple equals cheap right? . According to John Seddon, standardised processes lead to ‘failure demand’ -- the demand caused by failing to meet the customer’s need the first time around. Many organisations, he says, fail to account for failure demand when calculating their unit costs...

For example, let’s say that I run a claims operation. I have led an efficiency programme which has reduced my unit costs to £100 per transaction. My boss says, "Bloody impressive, Rick. Well done! Have this huge bonus." What I haven’t told him (because it hasn’t even occurred to me) is that 80 percent of transactions have to be reworked because they haven’t met the customer’s need and so the customers go back through the process again. For every ten customers I am therefore spending not £1000 but £1800. My unit cost per transaction might be £100 but the cost per customer is actually £180.
posted by TheophileEscargot at 12:00 AM on January 29, 2011 [5 favorites]


My mother works for the local county doing medi-cal applications. The county that I'm in also has it's own low income/high risk medical care program. As such county employees are allowed to buy in to this program for what amounts to a pittance compared to the other insurance options. This culture of no towards preventative care seems invasive in this system.
It took me six months of calling to get in to see a primary care doctor; when I went to the appointment they had made a mistake and scheduled me to see a prenatal specialist. The people who I talked to that evening were very nice and scheduled me for the next available appointment with my primary care doctor, which was four months away. My condition is not generally considered life threatening but in my case it is.
I went to the emergency room four times last year to get refills of my prescriptions. Being privately insured on this plan meant that I could go to the emergency room down the street from me. No co-pays. No cost to me at all. Getting in to see my normal doctor three or four hours total last year probably would have saved twenty thousand dollars.
posted by JackarypQQ at 1:46 AM on January 29, 2011 [4 favorites]


I'm pretty confident that if every struggling organisation hired me for a week I'd solve most of their problems using strange new approaches like common sense and the Pareto principle.
posted by doublehappy at 4:22 AM on January 29, 2011 [1 favorite]


The problem I see here involves how much they can really help the highest-cost patients... They tend to cost the most because they have untreatable conditions.

"One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million."

The former patient didn't need medical care, he needed psychiatric care. The latter almost certainly died of cancer and aggressively (and expensively) did everything possible to put it off for just one... more... week. He didn't need a doctor, he needed a priest.

Even the "good" cases cited consist exclusively of people with self inflicted problems! Morbidly obese, drug addicts, totally noncompliant patients - These people should cost us zero.
posted by pla at 5:30 AM on January 29, 2011


He didn't need a doctor, he needed a priest.
Death Panels, ftw, amirite?
posted by Thorzdad at 5:55 AM on January 29, 2011 [1 favorite]


The problem I see here involves how much they can really help the highest-cost patients... They tend to cost the most because they have untreatable conditions.

This seems like a willful misreading of the article. The whole point is the list of highest-cost patients does not perfectly correlate to the sickest patients.
posted by yerfatma at 6:05 AM on January 29, 2011 [1 favorite]


Thorzdad : Death Panels, ftw, amirite?

People should have every right to spend an infinite amount of their own money prolonging the inevitable.


yerfatma : This seems like a willful misreading of the article. The whole point is the list of highest-cost patients does not perfectly correlate to the sickest patients.

If by "willful misreading" you mean "not buying a sack of turds dipped in gold paint", then yes. TFA presents case after unsympathetic case of people who don't bother to take care of themselves, but have no qualms about expecting us to do so. And to make it a bit more palatable, the author tosses in a few cheerful hypotheticals such as the pair of 10YO boys with asthma (or the entire gratuitous lead-in about a guy shot and denied medical care by police on the scene). Golly, only a monster would deny a 10YO his inhaler, right, so how can anyone possibly oppose paying a doctor to follow a crackhead around to force him to eat better and take his meds?

Yes, technically, most of the patients described could substantially recover (though thirty people "only" costing half a million a year still strikes me as beyond outrageous). I don't, however, consider it society's place to badger them into taking care of themselves - If you want to kill yourself slowly, have at it; just don't waste my tax dollars expecting the ER to save your worthless butt the one day a month when you have regrets about your lifestyle choices.
posted by pla at 6:21 AM on January 29, 2011


pla I have to disagree. I work in a community health center whose patients are like those in the article. Yes there are few people who alcoholics whose livers are oozing into there bloodstream and are just too late in the game to actually help.
Most of the patients are diabetics or have some cardiovascular issue on top of whatever social/psych issues that are treatable for a very low cost. Probably more expensive than letting them die in their homes and letting the garbage men pick up their bodies. They work crap jobs and if they are lucky they get medicaid and food stamps. They have no resources to get back on their feet. They have minimal education and unlikely to have friends who are educated. Without some sort of outreach or social network that encourages them to make the right decisions these people could be lost causes.Heck these diseases might even be the reason the reason they are in a bad situation in the first place, but we don't know unless we try to help.
We also get patients who do have insurance, jobs, and a education. However they still have just as many problems managing their heart disease and diabetics. They require changing habits that you have built up over a lifetime. The only thing is they get more chances, because they can get treatment and can be seen by doctors.
Atul Gawande talks about a lot of this, but our insurance system(not healthcare) is not designed around managing chronic conditions. We bill for stuff being done to patients, but not for the outcome of the patient. This has the effect on conditioning a lot of healthcare providers to not actually treat the underlying condition, but only the symptoms. The healthcare industry makes more money if they don't actually treat people correctly. This affects everyone. Not just these hotspot patient.

posted by roguewraith at 7:39 AM on January 29, 2011 [6 favorites]


Hate to pull this big of quote, but I'm still not clear pla is talking about the same article we are:

Fernandopulle carefully tracks the statistics of those twelve hundred patients. After twelve months in the program, he found, their emergency-room visits and hospital admissions were reduced by more than forty per cent. Surgical procedures were down by a quarter. The patients were also markedly healthier. Among five hundred and three patients with high blood pressure, only two were in poor control. Patients with high cholesterol had, on average, a fifty-point drop in their levels. A stunning sixty-three per cent of smokers with heart and lung disease quit smoking. In surveys, service and quality ratings were high.

But was the program saving money? The team, after all, was more expensive than typical primary care. And certain costs shot up. Because patients took their medications more consistently, drug costs were higher. The doctors ordered more mammograms and diagnostic tests, and caught and treated more cancers and other conditions. There’s also the statistical phenomenon known as “regression to the mean”: the super-high-cost patients may have been on their way to getting better (and less costly) on their own.

So the union’s health fund enlisted an independent economist to evaluate the clinic’s one-year results. According to the data, these workers made up a third of the local union’s costliest ten per cent of members. To determine if the clinic was really making a difference, the economist compared their costs over twelve months with those of a similar group of Las Vegas casino workers. The results, he cautioned, are still preliminary. The sample was small. One patient requiring a heart transplant could wipe away any savings overnight. Nonetheless, compared with the Las Vegas workers, the Atlantic City workers in Fernandopulle’s program experienced a twenty-five-per-cent drop in costs.


If this is buying a "sack of turds dipped in gold paint", then put me down for a few bags.
posted by jalexei at 8:09 AM on January 29, 2011 [1 favorite]


Even the "good" cases cited consist exclusively of people with self inflicted problems! Morbidly obese, drug addicts, totally noncompliant patients - These people should cost us zero.

This is the reason Atul Gawande and others argue so strongly not only for this "hot-spot" care, but more importantly for improved preventive care. If you can see a primary-care physician for a yearly checkup, then someone can remind you that you need to stop smoking and eat better and not use drugs. Someone can refer you to free or low-cost smoking cessation programs, or teach you that the sugar-laden Orange Drink at McDonald's doesn't count as a serving of fruit, or get you in touch with a social worker who can help you get treatment for addiction. They can teach you to manage your blood sugars so you don't end up blind and/or with your feet amputated. Heck, if your KIDS can get good primary, preventive care, perhaps you can convince them not to start smoking at all, or to go outside and play instead of watching tv all day.

Perhaps you'd have more sympathy for "totally noncompliant patients" if you take an honest inventory of the things you do every week that aren't good for your health. I bet you know that fast food and dessert are bad for you. I bet you know that an evening walk is healthier than an evening of must-see tv. But I bet you still give in to the "bad" stuff sometimes too. Nobody plans to become morbidly obese or diabetic or to have their heart fail, but decades of less-than-stellar choices sometimes add up to those results.
posted by vytae at 8:11 AM on January 29, 2011 [4 favorites]


just don't waste my tax dollars expecting the ER to save your worthless butt the one day a month when you have regrets about your lifestyle choices.

I hope none of your doctors ever feel that way about you in an emergency.

They might be worthless to you, but they might mean the world to someone else, despite their faults. I'd wager you're 'worthless' to quite a few people yourself.

I hate to consider what it would mean if only 'worthwhile' people deserved to have their bones set and wounds closed.

Medical professionals aren't there to diagnose moral failings. I don't think they should add that to their list of responsibilities, either.
posted by edguardo at 12:05 PM on January 29, 2011 [3 favorites]


Nice piece by Dr. Gawande, but it only is a small piece of the solution and, as a person of his analytical capability wisely states.....even this model might ending up costing more in the long run as these people live on using expensive medications and health care resources.

Why?

FEE FOR SERVICE HEALTH-CARE.

Other countries cut costs by avoiding that. We cut the fees and then hope to control costs. Since we have 600,000 small businesses delivering the health care in this nation -- most of such business would do what any business would do in the face of declining profits or reimbursements for their product:

MAKE IT UP IN VOLUME.

As a physician, I see this garbage everywhere.....ER docs and hospitalists routinely "upcoding" benign heartburn visits as possible heart attacks because the Medicare reimbursement rate is (I kid you not) -- $78 versus $198 for the initial assessment if something possibly fatal is being ruled out in the diagnosis.

I consult out to specialists routinely and I'm always surprised when say, a vascular surgeon, whom I've asked for a certain, specific question -- "Does my patient's foot numbness and tingling stem from a surgically correctable vascular problem?" -- and they'll write back a consult listing other non-vascular related co-morbidities like depression, anxiety, or the fact they have hypothyroidism (stuff I'd take care of). The thing is, the more problems they list in their consult, the higher coding they bill at -- again, it's along the lines of the $78 versus the $198.

Older physicians told me before -- when consults paid too much perhaps $450 for a thought or two by Medicare in the 1980s -- you would never see such nonsense.

So, you see, docs -- they and their multitude of excuses -- loans, fancy cars, big mortgage, college education, etc. -- are, of course going to adjust if reimbursements decrease. It's why procedures per capita -- like cardiac caths and colonoscopies as well as imaging -- are so much higher than in other countries, where less is spent and people live longer.

And, the medical home model, which Dr. Brenner is amazingly and selflessly doing for a very underserved community is taking hold in the nice-insurance realm. But, I was at a lecture by an advocate of this approach and I asked the question -- and I'm incorporating data from the talk here, "Ok, so you're going to incentivize internists and primary care physicians to keep people out of hospitals by paying them more and awarding them for good outcomes like lower blood pressures and lower blood sugars, and you've seen a 20% savings on this approach and about 25% of providers receiving higher salaries because of it........Great! But what happens when 75% hit these targets, do the cost savings still exist?" The gentleman avoided answering my question exactly directly stating that, "Well, it's successful at this point...." But, his floundering had me feeling less secure that a successful medical home model -- that is a 3/4 successful in place of a 1/4 successful one would actually save any money.

WHY?

Fee for service.

I despise this model of medicine. As long as we think money in different places and different points in the system is good, we're missing the point.

WE ALL HAVE TO PASS AT SOME POINT.

The docs, the hospitals, the imaging centers, the pharmaceuticals, etc.....will make it up on another end....As long as you state "Do this and get that much money....." people will be out there to do it.

I've even see it in EKGs.....very senior cardiology attendings in my residency would read hospital EKG's for confirmatory purposes at $20 a pop. These were people who were well published and changed how cardiac care is delivered in our country. And, they were "confirming" that the ER physicians read of normal EKGs were indeed normal. One attending told me that if he did 1000/month -- well, that pays for a vacation for his family. And, he said it was not so bad....he could go through 40 EKGs/hr. (the computer read is usually right or it overreads so if you verify that you're ok). There was actually a wait list to get on this "EKG duty".

So, you see.....almost no point is too low. Almost no fee is too below what is thought of as appropriate. Someone out there will do it.

Sorry to ramble, but we still spend 40% of health care costs in the last 6-months of life.

What happens, when the guy the piece, after being saved from obesity and cocaine, gets to 90, has a fall, and his family wants to work it up -- he goes to a hospital ($800/medicare per night), even if he has no type of neurological deficits (he might have a small bleed the lawyers would state) he gets a CT-Scan ($250/for the radiologist to read it), the History and Physical (HNP) for each person (ER doc, internitst, neurologist, cardiologist) involved -- please note the high level billing the HNP would be because the people should just never fall in this country -- it could be a cardiac rhythm problem, the beginning of Parkinson's, etc. -- about another $1000. He then gets an ultrasound of his heart, ultrasound of his carotids -- no care whether or not at 90 he wants an operation or whether he'd survive it ("Hey, let's just give the family the information so that they can make an informed decision, the thinking goes.....) and he's shipped out of the hospital after the doctors and the hospital get a good $8000 or so from Medicare (the hospital will bill $20,000 but will see about ($8000 of that) the billing reps tell me).

After all that, the guy sadly passes peacefully a couple months later of natural causes -- perhaps an infection or something that his old body simply can't beat.

The above is scarier problem I see. And, we have a nation of 65,000,000 baby-boomer Medicare to be people that the government is going to finance the "Fallen and can't get up" workup for and not get much back in return other than rising Medicare costs and worsening debt.

So, while I love Obama health care bill because it humanely gives health care to those who need it and work still not have it, I have VERY SKEPTIC that it will cut costs. I'm more sure it will blow a huge hole in the deficit like no war we've ever seen.

Perhaps that's the point where, the citizenship having got an entitlement they love (Wow, I can quit this piece of garbage dead-end work I hate and sitll have health care!, Wow, I can retire at 60 instead of hanging on till 65 and still have health care!), something that can't be taken away......perhaps at that point we'll truly address the flawed system.......high utilizers plus end of life care alike.
posted by skepticallypleased at 12:35 PM on January 29, 2011 [7 favorites]


Even the "good" cases cited consist exclusively of people with self inflicted problems! Morbidly obese, drug addicts, totally noncompliant patients - These people should cost us zero.

Pla, it's really, really hard for me to respond to this kind of statement in a civil manner. So if I fail to do so, I hope you can forgive me. I tried. For realz.

"Noncompliant patients" and the "morbidly obese" and "drug addicts" did not choose to be that way. Given different genes, family backgrounds, and societies to grow up in, they would not be any of those things. But, this is what they got. Fast food and soda-created diabetes, broken homes, busted genes, broken education systems, a senseless drug war, a society that does not provide an external safety net and has consistently minimized the role of traditional safety nets such as extended family and integrated communities.

I have a picture in my mind of who you are: white, middle class, from a protestant family. I don't know if it's true or not. It's probably not right in some really large ways, but here we are. I'm creating an image of you in my mind based on your point of view because of how typical it is. I could talk to you for hours about your assumptions and why I think they're wrong. If we ever met in person, I'd like to do that. Online it would just be a shitty wall of text with little redeeming value.

But I will share the two big ideas that I think are simple and true and might somehow adjust your worldview:

Individuality is most freely expressed, cultivated, and enjoyed from within strong, healthy, mutually supportive, diverse communities. And most people, at the end of their lives, would rather see mercy than justice for all they have done.

I truly hope that you think about those two ideas and see where they take you.
posted by jsturgill at 12:47 PM on January 29, 2011 [1 favorite]


If by "willful misreading" you mean "not buying a sack of turds dipped in gold paint", then yes.

My company has developed a process to separate gold painted turds into their component gold and turd parts. The turds we market to affluent white progressives who use it on their organic urban farms, the gold we market on Fox News to Glenn Beck viewers. We've optimized our manufacturing process via analysis of power-law and Pareto inefficiencies.

In short, plz snd more gold turds. Oh, and also, some things and people are valuable to others, even if you see no value in them.
posted by formless at 1:26 PM on January 29, 2011 [1 favorite]


Morbidly obese, drug addicts, totally noncompliant patients - These people should cost us zero.

Yet these people are still going to show up in emergency rooms and receive treatment no matter how vociferously you wag an admonishing finger at them, so maybe we should concentrate on figuring out what best practices serve to lower that cost, because the burden of paying it gets spread around to everyone receiving care, through the free-market magic of fee-for-service healthcare.

Maybe your solution of just ignoring them and letting them die would be cost-effective. But given that many will still drag themselves to the ER beforehand, perhaps we should proactively find out who they are and shoot them, since ammo is really, really cheap.

Or, you know, we could actively look for solutions instead of moralizing about it.
posted by BitterOldPunk at 2:46 PM on January 29, 2011 [2 favorites]


I hate to consider what it would mean if only 'worthwhile' people deserved to have their bones set and wounds closed.

"The deserving poor". It's not a good image.
posted by Leon at 2:53 PM on January 29, 2011


edguardo : I hope none of your doctors ever feel that way about you in an emergency.

I'll take that risk, confident that it wouldn't happen.

Why, you might ask?

The article itself, amidst the unicorn farts, outright admits my core premise: For all the stupid, expensive, predictive-modelling[sic] software that the big venders[sic] sell,” he says, “you just ask the doctors, ‘Who are your most difficult patients?,’ and they can identify them.


jsturgill : "Noncompliant patients" and the "morbidly obese" and "drug addicts" did not choose to be that way.

Of course they didn't. Someone forced all those Big Macs down their throats, forced them to shoot heroin for a decade, forced them to... In Gawande's own words, Jackson asked him whether he was taking his blood-pressure pills each day. Yes, he said. Could he show her the pill bottles? As it turned out, he hadn’t taken any pills since she’d last visited, the week before. His finger-stick blood sugar was twice the normal level. - Forced them to not take the free drugs the doctor provided and then lie about it??? C'mon, you guys say I deliberately misinterpreted the article? The article's own author did the triple lindy of self deception, getting a perfect 10 even from the Bulgarian judge.

You can call a lot of medical issues not someone's own fault. Those three in particular, not so much.


BitterOldPunk : Or, you know, we could actively look for solutions instead of moralizing about it.

Fair point... As long as we have this problem, I do support finding the best way to deal with it. Don't mistake my stance for "moralizing", though - I really, truly don't care if someone wants to live in a way that destroys their body. I only object to paying a single penny, via taxes, to repair them. Of course, you might consider that even worse, but so it goes.
posted by pla at 4:58 PM on January 29, 2011


Don't mistake my stance for "moralizing", though [...] I only object to paying a single penny, via taxes, to repair them

Um. That's a moral stance. *shrugs helplessly*
posted by Leon at 5:46 PM on January 29, 2011


I really, truly don't care if someone wants to live in a way that destroys their body. I only object to paying a single penny, via taxes, to repair them.

My tax dollars go toward all sorts if things I'd rather they didn't. Military adventurism, oil companies, the manufacture of kitschy American flag lapel pins, etc. That's the price paid for living in a pluralistic society.

It's also completely beside the point. The point of TFA is that this technique of refocusing care on the patients who run up the highest bills reduces costs. And if hospitals can save money by doing this, your medical bills go down, which means your medical insurance premiums go down, which means you have more money in your wallet. That's the point.
posted by BitterOldPunk at 6:05 PM on January 29, 2011 [3 favorites]


Forced them to not take the free drugs the doctor provided and then lie about it???

Umm, you did notice that the guy was developmentally disabled, right? (this is the one whose home has "the old newspapers and unopened mail blocking the door... the ant trail... the stack of dead computer monitors, the barking mutt chained to an inner doorway, and the rotten fruit on a newspaper-covered tabletop")
posted by EmilyClimbs at 1:29 AM on January 30, 2011 [1 favorite]


TFA presents case after unsympathetic case of people who don't bother to take care of themselves, but have no qualms about expecting us to do so.

They're not expecting anyone to take care of them. That's why they aren't going to the doctor until a crisis hits. Paying taxes isn't caretaking, any more than it's corn-growing or war-fighting or utility-line maintenance.

The people profiled in this article don't expect your sympathy, either. The point is that healthcare access for medically underserved populations benefits you and your precious tax dollars. Hospitals can provide superior health care to everyone when the overall population receives basic, non-emergency health care.
posted by desuetude at 12:39 PM on January 30, 2011


Not helping them costs more than helping them.
posted by doublehappy at 12:59 PM on January 30, 2011 [2 favorites]


pla: " You can call a lot of medical issues not someone's own fault. Those three in particular, not so much."

So, when my cardiologist put me on 200mg of a beta blocker due to an arrhythmia (a doctor later referred to this as enough medicine to take down a horse) and I was sleeping 14+ hours a day (because I couldn't do anything on that much medication) and put on 25 pounds in 3 months, thus pushing me over the edge from obese to morbidly obese, that was my fault?

Also, I'm thinking some noncompliant patients don't know they're noncompliant - it's due to ignorance, like taking antibiotics only until they feel better and then putting them away, and next time they get sick, just taking the rest of the leftovers.

BitterOldPunk: "Maybe your solution of just ignoring them and letting them die would be cost-effective."

Nah, I think in this case we'd just run into a backed up funeral industry with no one to pay for the burials.
posted by IndigoRain at 2:14 AM on January 31, 2011


IndigoRain : thus pushing me over the edge from obese to morbidly obese, that was my fault?

But... Wait, you mean... Seriously???

*facepalm*

Sadly, I find only one part of that surprising enough to really bother me:

How in the hell did you manage to eat enough in a mere 10 hours of groggy consciousness per day to gain a pound every 3-4 days?
posted by pla at 5:55 PM on February 8, 2011


Society really struggles with the concept of addiction. We need to realise that addiction exists, that it's chemical, that it may be triggered by a single exposure to a substance, and, once it has taken hold, it is difficult for an addict to control. A drug addict need only have made one bad decision, had one bad night, one great high to become an addict.

A guy's running late for work so he crosses on the DON'T WALK. Bad decision, lifelong consequences, no stigma, happy to help! A family don't buy smoke detectors. Bad decision, lifelong consequences, no stigma, happy to help! A young girl dives into a shallow pond. Bad decision, lifelong consequences, no stigma, happy to help

You don't get to decide who lives or dies. You're treating these people anyway, you're just doing it inefficiently.


How in the hell did you manage to eat enough in a mere 10 hours of groggy consciousness per day to gain a pound every 3-4 days?

You're being deliberately rude and obtuse now.
posted by doublehappy at 4:15 AM on February 9, 2011 [3 favorites]


doublehappy : We need to realise that addiction exists
Yes.

that it's chemical
Yes, in the same way you could say the same for "tired", "love", and "religious".

that it may be triggered by a single exposure to a substance
Back up there, cowboy... Name one drug that "instantly" addicts the casual user. You may have heard that administering an opiate antagonist to a person after a single dose of morphine will trigger withdrawal symptoms; That does not equate to "addicted", and the next day you won't find that guy robbing the corner Circle-K to pay for his new lifelong habit.

and, once it has taken hold, it is difficult for an addict to control.
Agreed... But here we part ways on matters of "blame" - You apparently absolve the junkie of responsibility at that point, while I most certainly do not.

A drug addict need only have made one bad decision, had one bad night, one great high to become an addict.
Not true, and irrelevant even if so. You still make the choice every single time you feed your habit, whether that habit involves shooting up, double cheeseburgers, or feeding the slots.

You don't get to decide who lives or dies.
Sadly, I do not. I do, however, get a vote, for whatever little that matters.


You're being deliberately rude and obtuse now.

I would say "incredulous", not obtuse. As for rude... Hey, sorry to say it so bluntly, but if that last 25lbs pushes your BMI over 40, the new drug (and one prescribed for a condition associated with obesity at that) doesn't count as the problem.
posted by pla at 11:11 AM on February 9, 2011


Yes, in the same way you could say the same for "tired", "love", and "religious".
All of which are difficult to rationally and consciously control.

Name one drug that "instantly" addicts the casual user.
I never said "instantly".

You may have heard that administering an opiate antagonist to a person after a single dose of morphine will trigger withdrawal symptoms; That does not equate to "addicted", and the next day you won't find that guy robbing the corner Circle-K to pay for his new lifelong habit
Most addicts don't rob the corner Circle-K to pay for their lifelong habit. Most of them pay for their lifelong habit in myriad other ways, including their health.

You still make the choice every single time you feed your habit, whether that habit involves shooting up, double cheeseburgers, or feeding the slots.
Addicts' lives can be divided into two stages: not addicted and addicted. At some point, there is a chemical change (or aggregation of chemical changes) that turns a healthy1 consumption into an unhealthy consumption. Until that moment, the consumer is not unreasonably continuing their consumption. After that moment, the addict is not necessarily even aware that they are addicted.
Yes, it's a conscious choice, but it's a conscious choice made by a brain that controls a body that is wired to survive in environmental conditions that society has made almost obsolete.2 How often do you walk to work? I should be fit and underweight. I walk 7km each way to and from work every day and I play sport regularly yet my weight fluctuates between overweight and obese - often more than the 2lb a week you were so incredulous about. My weight has been the direct cause for at least one Doctor's visit and the indirect cause of many more.

Sugars, drugs, rewards3, &c. can bypass conscious thought. It's difficult to recognize unnecessary hunger - it feels just like hunger.

You apparently absolve the junkie of responsibility at that point, while I most certainly do not.
I do not absolve the addict of responsibility. Everyone makes their decisions and lives by them. Instead, I recognize that their problem has externalities that society must bear, e.g. the cost of dealing with their lower productivity, their health issues, potentially their criminal actions. Blaming them for their problems might make everyone feel better, and there are plenty of times I've looked at homeless or morbidly obese people and felt like they should just be able to stop drinking or gambling or taking drugs or eating or lazing around, but it doesn't save you money or help them get better.

Sadly, I do not. I do, however, get a vote, for whatever little that matters.
That's right, and your vote is to refrain from financially contributing to the treatment and/or rehabilitation of people whose decisions materially contributed to their poor health. This article isn't really about that; you're already contributing. This article is about how best to use your contribution. This approach to the public health is designed to appease you and people like you.

In devoting more short term resources to the most expensive 20% of patients, you free up more long term resources for the other 80%. Some people go back to ER over and over again and only get a cursory examination, leading to an inaccurate (percentage play) diagnosis, which cures the symptoms temporarily. Obviously, a longer initial examination would result in a better diagnosis which might prevent a return. Some people have addiction and psychological issues which can only be resolved by medium term hands on treatment. Some people don't understand what medicine is and that it matters that you take it with food and don't skip a week. They need someone to sit down and ensure they understand it.

I'm a smart guy. I spent a night in A&E a couple years ago. I was prescribed a bunch of stuff and sent on my way at 4am. I wasn't in any state to be receiving medical information and it turned out I misremembered something important and the drugs had little effect over the next two weeks and actually seemed to make me worse. I ended up back in A&E and this time the Doctor talked me through it. An extra five minutes first time round would have prevented a second visit (which necessitated scans, tests, a spinal tap, and 20 nurse hours, all paid for by the Government).

Your vote should be for helping them, because - and I'll say this again, because my entire position can be pretty much summed up in eight words - Not helping them costs more than helping them.

1. In a very loose sense of the word "healthy".
2. I think we should leave gambling "addiction" and overeating out of the addiction discussion, actually - it's a different thing altogether.
3. Overfeed your cat for six months and see what happens.

(There's a satisfying fibonacci thing going on re: the size of each of my responses up there.)

posted by doublehappy at 4:20 PM on February 9, 2011 [1 favorite]


Or let's put it another way: when you go to the Doctor, most of the people in the waiting room probably wouldn't be there if we'd spent more time and money on them earlier, and you'd be less likely to die of scurvy.
posted by doublehappy at 4:24 PM on February 9, 2011


pla: "(and one prescribed for a condition associated with obesity at that)"

The arrhythmia was caused by my taking Sudafed for the first time. I don't know why the palpitations didn't go away afterwards. The Holter monitor never caught them (they were very sporadic) and my cardiologist chalked it up to the palpitations being harmless.
posted by IndigoRain at 1:45 AM on February 10, 2011


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