Can We Cure the Health Care Crisis?
December 3, 2008 8:43 PM   Subscribe

Search for an Rx - We asked Johns Hopkins administrators, physicians, and researchers about the health of a system Americans rely on to keep them healthy. Afterall, an ounce of prevention...
Can we improve quality while driving costs down?
As contradictory as the notion might seem, there is a precedent for doing better work at a lower cost. "The thing that is so hard for people to understand, but that was proven in the auto industry, is that when you focus on cutting costs, you automatically reduce quality. But when you focus on increasing quality, as we've done with safety measures here at Hopkins, you almost always reduce cost. It's counterintuitive," Brody says.
and in addition to finance (and the auto industry) it's probably also applicable to education as well...
posted by kliuless (15 comments total) 3 users marked this as a favorite

 
Biggest four problems of the system:

1. Third-party payer system creates no personal incentive to shop for cost.
2. Government regulation & bureaucracy overwhelm the system.
3. Attaching health insurance to employments is wrong.
4. Med school system requires physicians to incur massive debt.

The healthcare system needs to be radically reformed. First, quit "tying" health insurance to employment and making it cover all manner of health needs.

We don't attach auto insurance or home insurance to employment, and they seem to work pretty darn well. We pay out-of-pocket for routine maintenance, and rely on insurance to cover the big-tickets, unexpected costs. And we have choices in auto and home insurance: the gecko, the pink cartoon lady, etc. And they compete on price and quality.

We deserve the same in healthcare.
posted by davidmsc at 9:38 PM on December 3, 2008 [1 favorite]


Afterall, an ounce of prevention...

...lacks meaningful profit margins.
posted by rokusan at 10:05 PM on December 3, 2008 [2 favorites]


Pretty darn well? Have you ever had to make a claim on your home insurance?

A while back I was contacted by an agent who offered to prepare me an estimate, so I said, "Sure." A couple days later he called me back to let me know that his parent company probably be unwilling to cover us since I'd made a claim on my home owners insurance recently. Oh, you mean that time my neighbor shot and killed a fireman, wounded two cops, set his house on fire and then shot himself in the head. I'm kinda thinking that's unlikely to happen again.

Compared to that, my employment based health insurance kicks ass.
posted by Kid Charlemagne at 10:07 PM on December 3, 2008 [6 favorites]


A couple days later he called me back to let me know that his parent company probably be unwilling to cover us since I'd made a claim on my home owners insurance recently.

I get the impression that the insurance industry has followed the credit industry, where it's all just one big automated database of lowest-common-risk assignment. It stopped being workable when the insurers (lenders) stopped actually knowing the insured (borrowers) in their own neighborhoods.
posted by rokusan at 10:19 PM on December 3, 2008


Oh, you mean that time my neighbor shot and killed a fireman, wounded two cops, set his house on fire and then shot himself in the head?

Dude, I totally hate it when that happens.
posted by rokusan at 10:19 PM on December 3, 2008 [2 favorites]


Dude, davidmsc, I'm glad you're here to tell us how to solve the problem. We were totally lost without you.

We don't attach auto insurance or home insurance to employment, and they seem to work pretty darn well.

Hah hah hah. That's funny, do it it again!

My parents house was burglarized twice. The insurance company paid for the damage and the stolen property--after a hefty deductible, of course. Then it was burglarized a third time.

Their insurance agent advised them not to make the third claim, since it would mean that they couldn't renew their policy.

We pay out-of-pocket for routine maintenance

You did it again!
posted by Kutsuwamushi at 10:49 PM on December 3, 2008


I don't know how to fix it, but I've always contended that buying health insurance and life insurance from seperate providers is basically giving your health insurance company a fiscal incentive to kill you.
posted by BrotherCaine at 12:22 AM on December 4, 2008 [2 favorites]


There's no money in quality health care. Healthy patients don't use the system. A patient record that traveled with you keeps

Your doctor takes X-rays, says your shoulder's busted and sends you to a specialist. The specialist orders new x-rays because your x-rays are on slides in your other doctor's office. A medical record that travels with you would deprive the specialist of that x-ray money. What are you, a communist?

There's a solution in place with 5 million customers with higher-than-market rates of survival and wellness. Fortune Magazine hired a guy to find the most cost-effective health care in America. When he found it was the VA, the magazine paid his kill fee and didn't publish it. Imagine a capitalist magazine endorsing socialized medicine as a best practice!

And there's no money in evidence-based medicine. In an expensive hospital, you're more likely to die. You get the heart-medicine-of-the-month instead of aspirin or a beta blocker. You don't get a flu vaccine because the nurses have more revenue-generating things to do.

Vets will always complain about VA health care, but thanks to that evil evidence-based socialized medicine, they'll live longer to complain.
posted by basilwhite at 3:28 AM on December 4, 2008 [1 favorite]


i'm sure the unholy system needs to be resolved (i'm on board with sicko) but what intrigued me was the counterintuitive cost/quality false dichotomy, e.g. between acute vs. chronic or preventative care...
One way to attack the cost issue while treating patients better is to re-emphasize primary care. Barbara Starfield, a professor at the Bloomberg School, found that when primary care physicians lead medical teams, health improves and costs fall. The more physicians there are, the more mortality is reduced...

Brody and others also make the point that medical care is inconsistent across the country. When people get the wrong treatment, they don't get better and often cost the system more in the long term. According to the Institute of Medicine, the delivery of medical and preventive care is consistent with scientific evidence only about half the time. A bill introduced to Congress this summer to implement effectiveness standards here — already a fait accompli in England — has garnered little attention, however.

Brody says methods used in other countries could be applied in the United States. For example, gastroenterologists in Japan oversee a staff of technologists who perform colonoscopies at about one-third the cost. Anderson adds that other countries can become models of prevention as well, perhaps pointing the way toward curtailing the costs of chronic illnesses. Within the last 15 years, Brazil has gone a long way toward reducing its obesity problem by making people aware of how fat they're getting, providing more outdoor space for exercise, and making gyms more available in urban areas, he says...

Much of the research emphasis at Johns Hopkins has been on ways to reduce the cost of treating a population that is growing more elderly by the minute. Scientists here are banking on the idea that lowering the costs for the neediest segment of the population could go a long way toward making health care better and less expensive.

The United States ranks number one in the world in the rate of people who suffer from chronic diseases, such as asthma, hypertension, and kidney disease. Of the 125 million people who fall in that category, more than half suffer from more than one chronic ailment, and most are elderly. All told, more than 70 percent of Medicare's annual budget of around $450 billion goes to provide care for elderly people who are chronically ill. One Johns Hopkins program in development, called Senior Strategy, would create a "continuum of care" for patients who come into Bayview Medical Center for treatment — matching patients with teams of doctors who could consult jointly about their condition, prepare the patient to return home, and offer house calls and earlier palliative care for those who are terminally ill, thereby reducing the length of expensive stays in hospital beds.

Another developing program at Hopkins is led by Charles "Chad" Boult, a professor at the Bloomberg School's Center for Integrated Health Care. Boult's team is investigating whether so-called Guided Care — in which a registered nurse works closely with three to four primary care physicians to provide comprehensive care for patients with several chronic conditions — can improve quality and lower costs at the same time. A study involving 900 chronically ill patients found that those who received Guided Care rated their care more highly and used hospitals, skilled nursing facilities, and home health care less often than those who received "usual care," resulting in a net annual savings of $1,600 per patient. "We already know that Guided Care improves the quality of chronic care, and it appears to save money for Medicare and private insurers too," says Boult. "We've built this around primary care doctors. We're hoping it rejuvenates primary care."

Many who study health care say such programs represent much-needed change for the health care system. "But we need to do more than just switch money around to deal with the chronic care crisis," says Anderson. "We need a 50-year plan." In 1950, he explains, the United States moved from a system that had been focused on preventing infectious diseases, such as polio, to one that concentrates on acute illnesses, such as heart attacks and strokes. Somewhere around 2000, the transition from acute to chronic illnesses began.

But the wheelchair of change moves slowly — a metaphor for the entire medical system. The vast majority of grants still go toward research that is acute care–based. "We still train our physicians one body part at a time instead of thinking about the patient holistically," Anderson says. "It's going to be a real challenge taking the chronic disease focus very far very fast."

The same might be said for treatment of the ailing patient that is American health care. Whether a new president facing a crisis in international finance will have the economic and political wherewithal to change the system quickly and widely is the $2.1 trillion question.
also check out the 'low hanging fruit' of simply institutionalising best practises in clinical care:
So he turned to the checklist, an idea that dates back to the 1930s, when bomber pilots saw their crash rates plummet to zero once they began using a to-do list before takeoff. Pronovost's checklist reminded doctors to do five things: wash their hands; clean a patient's skin with chlorhexidine; put sterile drapes over the patient; wear a mask, hat, gown, and gloves; and place a sterile dressing over the site of a catheter once the line is in. He also persuaded doctors to allow nurses to make sure they completed each step every time...

In the first 18 months, the measure saved an estimated 1,500 lives and $75 million. He published those results in the December 2006 New England Journal of Medicine and soon after was profiled in The New Yorker. In that article, author Atul Gawande, a practicing physician himself, suggested that Pronovost's checklists heralded a new — if underappreciated — approach to health care. "Few other researchers are venturing to extend [Pronovost's] achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade," he wrote...

Yet Pronovost worries whether his work has had enough reach. In testimony before the House of Representatives' Government Oversight Committee in April, Pronovost tied the lack of clinical science research in the United States to the relatively poor health outcomes for patients. For every dollar the federal government spends on research into diseases, it spends one penny on research that finds ways to deliver the best treatments. "It's completely out of balance," he says. "We could do nationally what we did in Michigan with $3 million, but money is hard to find." With health care costs for all types of hospital infections running at around $11 billion, a national checklist would be a bargain, he says.

Edward Miller, dean of the School of Medicine, echoes his concern. "I'd love to have a donor give me $12 million to $14 million for an Institute for Patient Safety here, a place where researchers from around the world could do projects on clinical work." But, he says, it's a tough sell because many donors prefer to give money to research aimed at curing disease.
kinda like manned space exploration :P or as ehrenberg sez:
These points are neither earth-shattering nor revolutionary. For each one of these issues there was a lot of debate at the time, yet politics, lobbying and short-termism dominated the discussion. And now we have what we have today. Taking a little more time and getting things right upfront; pretty basic stuff. Yet we as a society consistently fail at this. We always seem to be in a rush. We love complexity. We are impressed by extremes. So much so, it turns out, that it is to our peril. Maybe if we'd slow down just a little, try and get the big things right and weren't so impressed by fancy degrees and high IQs we'd be a lot better off. Innovation is great. It is the application of innovation that can either make you or break you. And at the moment, we're kind of broken.
sometimes it's the simple things!
posted by kliuless at 5:02 AM on December 4, 2008 [5 favorites]


We don't attach auto insurance or home insurance to employment, and they seem to work pretty darn well. We pay out-of-pocket for routine maintenance, and rely on insurance to cover the big-tickets, unexpected costs. And we have choices in auto and home insurance: the gecko, the pink cartoon lady, etc. And they compete on price and quality.

We deserve the same in healthcare.


Where in this model is there room for chronic illnesses, not preventable, which require daily, expensive medicine or therapy for the rest of the person's life. If a car had such a condition, you'd just junk it and get a new car. Unfortunately, that is not an option for one's body.
posted by hydropsyche at 5:13 AM on December 4, 2008 [1 favorite]


Now that I'm less angry. (Yes, this is a personal issue.)

The competition of the market isn't going to make health care more affordable, because insurance companies don't want everyone's business.

In simple terms, one company decides, "it's no longer worth it for us to insure people with warts, because people with warts make expensive claims." Other companies follow suit, because if they take on those clients who are looking for a new insurer, their own ratio of warted to non-warted clients changes, and their profit decreases.

And no company wants to be the only one insuring people with warts, because every single person with a wart will try to buy insurance from them.

So people with warts cannot get health insurance anymore, or can only get insurance for health catastrophes unrelated to warts, which means that they pay for wart-related care out of pocket or go without.
posted by Kutsuwamushi at 9:31 AM on December 4, 2008 [1 favorite]


Here's a scary chart from a related NY Times article.

The existing system of incentives is just broken:
Celgene’s first big seller was thalidomide, a decades-old medicine now used as a cancer treatment, which is so cheap to manufacture that a company in Brazil sells it for pennies a pill.

Celgene initially spent very little on research and priced each pill in 1998 at $6. As the drug’s popularity against cancer grew, the company raised the price 30-fold to about $180 per pill, or $66,000 per year. The price increases reflected the medicine’s value, company executives said.

In 2005, the company introduced Revlimid, a derivative of thalidomide that is supposed to be less toxic, but may be no more effective. Celgene priced it at about $260 per pill, or $94,000 per year.
posted by designbot at 11:28 AM on December 4, 2008 [1 favorite]


So people with warts cannot get health insurance anymore, or can only get insurance for health catastrophes unrelated to warts, which means that they pay for wart-related care out of pocket or go without.

People with freckles can't get insurance either, because the non-doctor making the coverage determination doesn't know the difference between a freckle and a wart.
posted by Quonab at 1:04 PM on December 4, 2008


Biggest four problems of the system:

1. Third-party payer system creates no personal incentive to shop for cost.
2. Government regulation & bureaucracy overwhelm the system.
3. Attaching health insurance to employments is wrong.
4. Med school system requires physicians to incur massive debt.


If you had used the Republican talking points checklist best-practice you wouldn't have forgotten to mention unions.
posted by srboisvert at 2:35 PM on December 4, 2008 [1 favorite]


Didja ever consider that the Republican "talking points" might actually be, you know, correct?
posted by davidmsc at 2:09 PM on December 7, 2008


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