kottke.org posts about healthcare
I posted earlier about Atul Gawande’s piece in the New Yorker on the importance of incremental care in medicine. One of the things that the Affordable Care Act1 did was to make it illegal for insurance companies to deny coverage to people with “preexisting conditions”, which makes it difficult for those people to receive the type of incremental care Gawande touts. And who has these preexisting conditions? An estimated 27% of US adults under 65, including Gawande’s own son:
In the next few months, the worry is whether Walker and others like him will be able to have health-care coverage of any kind. His heart condition makes him, essentially, uninsurable. Until he’s twenty-six, he can stay on our family policy. But after that? In the work he’s done in his field, he’s had the status of a freelancer. Without the Affordable Care Act’s protections requiring all insurers to provide coverage to people regardless of their health history and at the same price as others their age, he’d be unable to find health insurance. Republican replacement plans threaten to weaken or drop these requirements, and leave no meaningful solution for people like him. And data indicate that twenty-seven per cent of adults under sixty-five are like him, with past health conditions that make them uninsurable without the protections.
That’s 52 million people, potentially ineligible for health insurance. And that’s not counting children. Spurred on by Gawande, people have been sharing their preexisting conditions stories on Twitter with the hashtag #the27Percent.
The 27% figure comes from a recent analysis by the Kaiser Family Foundation:
A new Kaiser Family Foundation analysis finds that 52 million adults under 65 — or 27 percent of that population — have pre-existing health conditions that would likely make them uninsurable if they applied for health coverage under medical underwriting practices that existed in most states before insurance regulation changes made by the Affordable Care Act.
In eleven states, at least three in ten non-elderly adults would have a declinable condition, according to the analysis: West Virginia (36%), Mississippi (34%), Kentucky (33%), Alabama (33%), Arkansas (32%), Tennessee (32%), Oklahoma (31%), Louisiana (30%), Missouri (30%), Indiana (30%) and Kansas (30%).
36% uninsurable in West Virginia! You’ll note that all 11 of those states voted for Trump in the recent election and in West Virginia, Trump carried the day with 68.7% of the vote, the highest percentage of any state. The states whose people need the ACA’s protection the most voted most heavily against their own interest.
Update: An earlier version of this post unfairly pinned the entire blame for the lack of coverage of those with preexisting conditions on the insurance companies.2 I removed the last paragraph because it was more or less completely wrong. Except for the part where I said we should be pissed at the Republican dickheads in Congress who want to repeal the ACA without replacing it with something better.3 And the part where we should be outraged. And the part where we regulated cars and cigarettes and food to make them safer, forced companies to build products in ways they didn’t want, and saved millions of lives. We can’t make everyone healthier and raise taxes to do it? Pathetic for what is supposedly the world’s most powerful and wealthy nation. (thx @JPVMan + many others)
In a piece called The Heroism of Incremental Care for the New Yorker, surgeon Atul Gawande argues that our healthcare system is built for and celebrates heroic intensive care over the slower but more effective efforts of long-term primary care givers.
We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases that it had been thought only God could touch. New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heart, transplanted organs, and removed once inoperable tumors. Heart attacks could be stopped; cancers could be cured. A single generation experienced a transformation in the treatment of human illness as no generation had before. It was like discovering that water could put out fire. We built our health-care system, accordingly, to deploy firefighters. Doctors became saviors.
But the model wasn’t quite right. If an illness is a fire, many of them require months or years to extinguish, or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.
Steven Brill has written a book about the making of the Affordable Care Act called America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System.
America’s Bitter Pill is Steven Brill’s much-anticipated, sweeping narrative of how the Affordable Care Act, or Obamacare, was written, how it is being implemented, and, most important, how it is changing — and failing to change — the rampant abuses in the healthcare industry. Brill probed the depths of our nation’s healthcare crisis in his trailblazing Time magazine Special Report, which won the 2014 National Magazine Award for Public Interest. Now he broadens his lens and delves deeper, pulling no punches and taking no prisoners.
Malcolm Gladwell has a review in the New Yorker this week.
Brill’s intention is to point out how and why Obamacare fell short of true reform. It did heroic work in broadening coverage and redistributing wealth from the haves to the have-nots. But, Brill says, it didn’t really restrain costs. It left incentives fundamentally misaligned. We needed major surgery. What we got was a Band-Aid.
I haven’t read his book yet, but I agree with Brill on one thing: the ACA1 did not go nearly far enough. Healthcare and health insurance are still a huge pain in the ass and still too expensive. My issues with healthcare particular to my situation are:
- As someone who is self-employed, insurance for me and my family is absurdly expensive. After the ACA was enacted, my insurance cost went up and the level of coverage went down. I’ve thought seriously about quitting my site and getting an actual job just to get good and affordable healthcare coverage.
- Doctors aren’t required to take any particular health insurance. So when I switched plans, as I had to when the ACA was enacted, finding insurance that fit our family’s particular set of doctors (regular docs, pediatrician, pediatric specialist that one of the kids has been seeing for a couple of years, OB/GYN, etc.) was almost impossible. We basically had one plan choice (not even through the ACA marketplace…see next item) or we had to start from scratch with new doctors.
- Many doctors don’t take the ACA plans. My doctor doesn’t take any of them and my kids’ doc only took a couple. And they’re explicit in accepting, say, United Healthcare’s regular plan but not their ACA plan, which underneath the hood is the exact same plan that costs the same and has the same benefits. It’s madness.
- The entire process is designed to be confusing so that insurance companies (and hospitals probably too) can make more money. I am an educated adult whose job is to read things so they make enough sense to tell others about them. That’s what I spend 8+ hours a day doing. And it took me weeks to get up to speed on all the options and pitfalls and gotchas of health insurance…and I still don’t know a whole lot about it. It is the most un-user-friendly thing I have ever encountered.
The ACA did do some great things, like making everyone eligible for health insurance and getting rid of the preexisting conditions bullshit, and that is fantastic…the “heroic work” mentioned by Gladwell. But the American healthcare system is still an absolute shambling embarrassment when you compare it to other countries around the world, even those in so-called “developing” or “third world” countries. And our political system is just not up to developing a proper plan, so I guess we’ll all just limp along as we have been. Guh.
According to an article in The Journal of the American Medical Association, the obesity rate of American 2- to 5-year-old children has dropped from 14% in 2004 to 8% in 2012.
Children now consume fewer calories from sugary beverages than they did in 1999. More women are breast-feeding, which can lead to a healthier range of weight gain for young children. Federal researchers have also chronicled a drop in overall calories for children in the past decade, down by 7 percent for boys and 4 percent for girls, but health experts said those declines were too small to make much difference.
Barry M. Popkin, a researcher at the University of North Carolina at Chapel Hill who has tracked American food purchases in a large data project, said families with children had been buying lower-calorie foods over the past decade, a pattern he said was unrelated to the economic downturn.
He credited those habits, and changes in the federally funded Special Supplemental Nutrition Program for Women, Infants and Children, for the decline in obesity among young children. The program, which subsidizes food for low-income women, reduced funding for fruit juices, cheese and eggs and increased it for whole fruits and vegetables.
Kevin Drum calls the drop “baffling”.
Sandra Fluke writes that the portion of Affordable Care Act that guarantees women access to preventative health services went into effect today.
Women across the country have reason to celebrate tonight. Why? Because on Wednesday, the law that provides American women with access to preventive health services, including birth control, at no cost-no co-pay, no increase in premium, no deductible-goes into effect.
Under the law, women are guaranteed “a free annual well-woman visit” (including screenings for domestic violence and HIV), DNA screenings for HPV every three years, free screenings for gestational diabetes for pregnant women, and no-cost contraception. Sometimes it almost feels like we’re not living in the Stone Age here in the US. Almost:
But they do need to find out when their next insurance plan year begins, and make sure their plan qualifies. That’s because — with the exception of women who access their insurance through certain religiously-affiliated non-profits and schools, who unfortunately must wait another year for contraception coverage — this policy takes effect August 1. But each woman’s insurance plan will implement these benefits with the next new plan year after today. So if a woman’s insurance plan year begins on September 15, she’s eligible for these services beginning September 15.
You may not believe me, but this postmortem by SCOTUSblog’s Tom Goldstein of how the media covered the Supreme Court’s decision regarding the Patient Protection and Affordable Care Act is super fascinating. It’s impeccably sourced, straighforward, and surprisingly compelling.
The Court’s own technical staff prepares to load the opinion on to the Court’s website. In years past, the Court would have emailed copies of the decision to the Solicitor General and the parties’ lawyers once it was announced. But now it relies only on its website, where opinions are released approximately two minutes later. The week before, the Court declined our request that it distribute this opinion to the press by email; it has complete faith in the exceptional effort it has made to ensure that the website will not fail.
But it does. At this moment, the website is the subject of perhaps greater demand than any other site on the Internet — ever. It is the one and only place where anyone in the country not at the building — including not just the public, but press editors and the White House — can get the ruling. And millions of people are now on the site anxiously looking for the decision. They multiply the burden of their individual visits many times over — hitting refresh again, and again, and again. In the face of the crushing demand, the Court cannot publish its own decision.
The opinion will not appear on the website for a half-hour. So everyone in the country not personally at 1 First St., NE in Washington, DC is completely dependent on the press to get the decision right.
Reading it, the thing that struck me most is that these huge media machines still operate mostly on an individual basis. One person read the ruling for CNN, told one person in the control room, and then millions and millions of people heard that (mis)information just a few seconds later on CNN, on Twitter, and even in the Oval Office.
I’m surprised and mostly pleased that the Supreme Court has upheld President Obama’s Patient Protection and Affordable Care Act.
The Court’s ruling means, that unless Congress acts, in 2014 all Americans will be required to purchase health insurance in the most sweeping overhaul of the nation’s health care system since the Great Society. The Court, according to early analysis, redefined the mandate as a tax, skirting some Constitutional questions but offering a dramatic affirmation to Obama’s key initiative.
Update: Josh Marshall speaks for me here.
This is an imperfect law. But what’s most important is that it provides a structure under which the country can make a start not only on universal coverage — as an ethical imperative — but on doing away with the waste and inefficiencies created by the chronic market failure of the US health insurance system. Again, that matters. And I suspect that there’s no going back.
Before he died last year at the age of 44, Mike DeStefano shared the story of his wife’s final days many years earlier. She’s in hospice care, DeStefano shows up with his new Harley and takes her for a ride, morphine drip and all.
She’s holding the pole [of the IV drip]! Marc, it was a pole with four wheels on the bottom, and we’re riding around this hospice, and you could hear the goddamn wheels jangling and banging; it was insane.
And then I pass the front door, and all these nurses are standing out front, and they’re all crying. They’re watching us, and they’re crying. And I didn’t know why they were crying. I was like, Why are they crying? I didn’t get what they were seeing. I didn’t know. Because I was just in it; I was living it. I knew my wife who had suffered, she was a prostitute, she was a freakin’ heroin addict, she was beaten by pimps — this was her past — and then she ends up with AIDS, and she’s dying, and all she wants is a goddamn ride on my motorcycle.
So the next thing you know we’re on I-95, because women, it’s never enough for them. We’re on I-95, and she unhooks the pole, and she’s holding the morphine bag over her head with her gown that’s flying up in the air so you could see her entire naked, bony body with the morphine bag whipping in the wind, and we’re passing by these guys in their Lamborghinis, and I’m looking at them like, What the hell kind of life are you living? Look at me, I’m on top of the world here.
I love this story. The podcast from which it was taken is available here.
The US military is often thought of by many Americans as being identified with conservative politics, making it an unlikely blueprint for progressive reform. But a recent pair of articles demonstrates that the US as a whole might have something to learn about the US Armed Forces’ liberal leanings. In the NY Times, Nicholas Kristof argues that the US military’s universal healthcare and focus on education is worth looking at as a model:
The military is innately hierarchical, yet it nurtures a camaraderie in part because the military looks after its employees. This is a rare enclave of single-payer universal health care, and it continues with a veterans’ health care system that has much lower costs than the American system as a whole.
Perhaps the most impressive achievement of the American military isn’t its aircraft carriers, stunning as they are. Rather, it’s the military day care system for working parents.
While one of America’s greatest failings is underinvestment in early childhood education (which seems to be one of the best ways to break cycles of poverty from replicating), the military manages to provide superb child care. The cost depends on family income and starts at $44 per week.
And the WSJ recently covered remarks made by Sgt. Maj. Micheal Barrett, the top non-commissioned officer in the Marine Corps and general all-around hardass, about gays in the military:
Article 1, Section 8 of the Constitution is pretty simple, It says, ‘Raise an army.’ It says absolutely nothing about race, color, creed, sexual orientation. You all joined for a reason: to serve. To protect our nation, right? How dare we, then, exclude a group of people who want to do the same thing you do right now, something that is honorable and noble? … Get over it. We’re magnificent, we’re going to continue to be. … Let’s just move on, treat everybody with firmness, fairness, dignity, compassion and respect. Let’s be Marines.
Now that’s some semper fi I can get behind. (thx, meg)
Riffing in part off of Atul Gawande’s recent piece in the New Yorker about controlling healthcare costs, Jay Parkinson argues that most health solutions aren’t medical, they’re social.
In the past 4 months, I’ve changed my life for the better in three significant ways.
My relationships changed, and thus my everyday changed. I began eating with someone who ate differently than me. I adopted her eating habits, which spurred me to change how I ate. I also spent more time with Grant, who introduced me to the world of urban cycling. I adopted his lifestyle and his interests. And then I changed myself and started pushing my heart in the gym.
I’m playing Health Month this month, mostly just for the hell of it. The game is built to be social…there are teams, players offer each other support, etc. Just two days in, I can see why this might work for me: it turns private goals into public rules.
You may have seen a reference to this last week, but the New Yorker just posted the full text of Atul Gawande’s latest article on their site. The article is about efforts to lower healthcare costs by focusing on the patients who use (and often misuse) healthcare the most. Like many of Gawande’s other articles, this is a must-read.
“Let’s do the E.R.-visit game,” he went on. “This is a fun one.” He sorted the patients by number of visits, much as Jeff Brenner had done for Camden. In this employed population, the No. 1 patient was a twenty-five-year-old woman. In the past ten months, she’d had twenty-nine E.R. visits, fifty-one doctor’s office visits, and a hospital admission.
“I can actually drill into these claims,” he said, squinting at the screen. “All these claims here are migraine, migraine, migraine, migraine, headache, headache, headache.” For a twenty-five-year-old with her profile, he said, medical payments for the previous ten months would be expected to total twenty-eight hundred dollars. Her actual payments came to more than fifty-two thousand dollars — for “headaches.”
Was she a drug seeker? He pulled up her prescription profile, looking for narcotic prescriptions. Instead, he found prescriptions for insulin (she was apparently diabetic) and imipramine, an anti-migraine treatment. Gunn was struck by how faithfully she filled her prescriptions. She hadn’t missed a single renewal — “which is actually interesting,” he said. That’s not what you usually find at the extreme of the cost curve.
The story now became clear to him. She suffered from terrible migraines. She took her medicine, but it wasn’t working. When the headaches got bad, she’d go to the emergency room or to urgent care. The doctors would do CT and MRI scans, satisfy themselves that she didn’t have a brain tumor or an aneurysm, give her a narcotic injection to stop the headache temporarily, maybe renew her imipramine prescription, and send her home, only to have her return a couple of weeks later and see whoever the next doctor on duty was. She wasn’t getting what she needed for adequate migraine care — a primary physician taking her in hand, trying different medications in a systematic way, and figuring out how to better keep her headaches at bay.
In the New Yorker, Michael Specter reports on tuberculosis, the world’s deadliest infectious disease — worldwide, more than 5000 people die from it every day. In India, misdiagnosis and improper treatment result in tens of thousands of unnecessary deaths a month and even new genetic screening machines might not help matters.
Since late 2009, the hospital has had one unique asset: a piece of equipment called a P.C.R., which can multiply tiny samples of DNA and analyze them. The device is not as fast as the GeneXpert, but it can examine the genetics of virtually any organism, including tuberculosis. The hospital’s machine, which was purchased with money from a government research grant, has never been used. “The hospital has had this for months,” Mannan said. “But nobody knows how it works.” We were standing at the door of the virology lab, where the new P.C.R. Cobas TaqMan 48, made by Roche and sold for roughly fifty thousand dollars, was resting on a shelf, still wrapped in its shipping material.
How could that be? I was staring at a machine that could alter, even save, the lives of scores of the people who were sitting nearby in the gathering heat. Mannan said nothing, though his anger was palpable.
[…] “It’s a nice lab,” Mannan said when we left. “Beautiful, actually. But if the doctors used it properly that would interfere with their private practice.”
I asked what he meant.
“It is simple,” he said. “If patients are treated at the hospital, they won’t need to pay for anything else.”
Atul Gawande’s articles on healthcare for the New Yorker are all top-shelf, but his most recent piece on modern medicine’s difficulty in dealing with patients who are likely to die is a doozy and a must-read.
Almost all these patients had known, for some time, that they had a terminal condition. Yet they-along with their families and doctors-were unprepared for the final stage. “We are having more conversation now about what patients want for the end of their life, by far, than they have had in all their lives to this point,” my friend said. “The problem is that’s way too late.” In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”
Warning: it’s good, but you’ll probably be crying by the end of this article.
Update: Shoshana Berger on How to Die in 5 Easy Steps.
My father didn’t die nearly so well. At 74, after a 50-year career as a professor of mechanical engineering, he lost his mind. At first he’d cover his mistakes with jokes-a forced punch line after slipping up on calculating the tip at dinner. Have you noticed how forgetful he’s getting? His second wife whispered to me in the kitchen after a family meal. I hadn’t. But it wasn’t long before his colleagues politely suggested that it was time for him to retire. He’d been spotted in the elevator, the doors opening and closing repeatedly, as he stood there incapable of deciding which button to push. He could no longer locate his car in the lot. The faculty feared he was a danger to himself. Not long after, my father left his office; it’s piles of professional journals and papers, and the poster hung on the back door, “I’M GOING TO BE AN ENGINEER LIKE MY MOM,” expecting to be back.
This clever graph by National Geographic shows the cost of healthcare compared to life expectancy in a number of countries. The way that the US healthcare expenditure is pictured entirely outside the confines of the graph’s scale and legend is a particularly effective design decision. (thx, jim)
In the early days of the United States (and even in the colonial days), there were struggles about how to handle healthcare. Was it the responsibility of the federal government, the state government, or the individual?
Health care in Colonial America looked nothing like what we’d consider medicine today, but the debates it triggered were similar. The danger of smallpox and the high cost of its prevention led to divisive questions about who should pay, whether everyone deserved equal access, and if responsibility lay at the feet of the individual, the state, or the nation. Epidemics forced the early republic to wrestle with the question of the federal government’s proper role in regulating the nation’s health.
A recent blog post by Roger Ebert shows that more than 200 years later, we’re still having this same basic argument.
I am told we cannot trust the government. I believe we must trust it, and work to make it trustworthy. We are told the free enterprise system will sort things out, but it has not. When insurance companies direct millions toward lobbying and advertising against a health care system, every dollar is being withheld from sick people. When it goes to salaries, executive jets, corporate edifices and legislative manipulation, it isn’t going to Amy Caudle.
Foreign Policy has a list of the worst healthcare reforms in the world…the list includes China, Russia, the United States, and Turkmenistan.
So, in a frankly insane healthcare reform effort, [Turkmenistan’s “President for Life” Saparmurat Niyazov] restricted the public’s access to care by replacing up to 15,000 doctors and nurses with unqualified military conscripts. The next year, he ordered hospitals and clinics outside of the capital, Ashgabat, to close — even though the vast proportion of Turkmenistan’s population lives in rural areas. The BBC quoted him as saying, “Why do we need such hospitals? If people are ill, they can come to Ashgabat.” He also implemented fees and created an “unofficial” ban on the diagnosis of certain communicable diseases, like hepatitis.
Atul Gawande and some colleagues searched the US for healthcare successes — hospitals and clinics where costs are relatively low and quality of care is high — and came up with a few lessons.
If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).
I wanted this article to be much longer than it was with breakouts of each of the ten lessons with lengthy explanations.
Can you put a dollar value on a human life? Peter Singer writes that the US needs to do just that if we’re serious about making our healthcare system work.
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man - and everyone else like him - with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.
I’ve got two follow-ups to share with you regarding Atul Gawande’s New Yorker piece about healthcare costs in the US (kottke.org post). In the Wall Street Journal, Abraham Verghese argues that in order for a healthcare reform plan to be successful, it has to include cost cutting.
I recently came on a phrase in an article in the journal “Annals of Internal Medicine” about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us — doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others — are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? — it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal.
In Gawande’s example, what Verghese is saying is that you can’t just make McAllen’s healthcare system adopt an El Paso type of system without a whole lot of pain.
Gawande addressed some of the criticisms of his article on the New Yorker site. One of the major criticisms was that McAllen’s higher costs were associated with higher levels of poverty and unhealthiness:
As I noted in the piece, McAllen is indeed in the poorest county in the country, with a relatively unhealthy population and the problems of being a border city. They have a very low physician supply. The struggles the people and medical community face there are huge. But they are just as huge in El Paso — its residents are barely less poor or unhealthy or under-supplied with physicians than McAllen, and certainly not enough so to account for the enormous cost differences. The population in McAllen also has more hospital beds than four out of five American cities.
Taking a cue from auto insurance, Safeway has devised a healthcare insurance plan that emphasizes personal responsibility.
Safeway’s plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight, which is well understood by the providers of health care, is that 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable.
The result is that Safeway’s healthcare costs have held steady over the past four years while the costs at other American companies have increased almost 40%.
On Friday, Atul Gawande gave the commencement address at the University of Chicago Pritzker School of Medicine. The address touched on some of the same themes as his recent piece on the differing costs of healthcare across the US. He began with an anecdote about how observation of well-nourished children in poor Vietnamese villages led to village-wide improvments in curbing malnutrition.
The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways — feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to.
And I don’t know why, but I’ve always thought of surgery as primarily a cerebral pursuit; a great surgeon is so because he’s clever and smart. A short passage from Gawande’s address reveals that perhaps that’s not the case:
In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful — the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
So surgeons learn surgery in the same way that kids learn Kobe Bryant’s post moves from SportsCenter highlights?
Obama read Atul Gawande’s article about the differences in healthcare costs in different parts of the US and was so taken by it that he had a meeting about it with his aides and mentioned the piece in a meeting with a group of Democratic senators.
As part of the larger effort to overhaul health care, lawmakers are trying to address the problem that intrigues Mr. Obama so much — the huge geographic variations in Medicare spending per beneficiary. Two decades of research suggests that the higher spending does not produce better results for patients but may be evidence of inefficiency.
Obama is indeed reading this guy’s stuff. (thx, cliff)
Atul Gawande discovered that McAllen, Texas spends more per person on healthcare than El Paso (which is demographically similar to McAllen) and set out to find out why. Along the way, he encounters a curious relationship between the amount spent on healthcare and the quality of that care: higher spending does not correlate with better care.
When you look across the spectrum from Grand Junction to McAllen — and the almost threefold difference in the costs of care — you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Obama, you’re reading this guy’s stuff, yes? Get him on the team.
Update: Dr. Peter Orszag is the Director of the Office of Management and Budget for the White House and is working on some of the problems that Gawande talks about in this article. Here’s a 40-minute video of Orszag speaking on “Health Care - Capturing the Opportunity in the Nation’s Core Fiscal Challenge”. (thx, todd)
I changed the bit in the first paragraph about El Paso and McAllen being “nearby”. Funny, I thought 800 miles in Texas *was* nearby. (thx, stephen)
I also changed “lower spending correlates with better care” to “higher spending does not correlate with better care”…those two statements are not the same. I misread the results of one of the studies that Gawande mentions. (thx, patrick)
From the New Yorker last week, Atul Gawande on how the US should nationalize healthcare. His answer: nationalize slowly, use what’s already in place, and don’t rebuild the whole system from scratch.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
As usual, Gawande makes a lot of sense. Whatever the solution, we should be doing all we can to avoid something like this from ever happening again:
“When I heard that I was losing my insurance, I was scared,” Darling told the Times. Her husband had been laid off from his job, too. “I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.” So she prevailed on her midwife to induce labor while she still had insurance coverage. During labor, Darling began bleeding profusely, and needed a Cesarean section. Mother and baby pulled through. But the insurer denied Darling’s claim for coverage. The couple ended up owing more than seventeen thousand dollars.
In an effort to curtail healthcare spending, the Japanese government is requiring companies to cut the number of overweight workers (and their dependents!) by 25% as of 2015. Companies which fail to do so will have to pay into a fund for elderly care.
Reduced exercise, the adoption of western foods and an aging population have made Japanese men about 10 percent heavier than they were 30 years ago, ministry statistics show. Women are 6.4 percent fatter.
The ministry estimates that half of men over age 40 and 20 percent of women will be diagnosed with metabolic syndrome. For men, a key yardstick is whether they have a waistline wider than 85 centimeters (33.5 inches). Body mass, cholesterol, blood pressure, blood sugar and smoking will also be taken into account.
A group of federal researchers reports that there were 100,000 fewer deaths in 2004 among the overweight than would have been expected of people of normal weight.
Overweight people have a lower death rate because they are much less likely to die from a grab bag of diseases that includes Alzheimer’s and Parkinson’s, infections and lung disease. And that lower risk is not counteracted by increased risks of dying from any other disease, including cancer, diabetes or heart disease.
Related to the dentistry post from the other day, comes word from England that even with socialized medicine, six percent of people questioned in a survey “admitted they had resorted to self-treatment using pliers and glue”.
As dentists push their fees higher and make more money on high-end services like cosmetic dentistry, a growing number of people cannot afford treatment for even minor work like fillings. And even though the dentists won’t treat those patients who can’t pay, the ADA has “fought efforts to use dental hygienists and other non-dentists to provide basic care to people who do not have access to dentists”.
“Most dentists consider themselves to be in the business of dentistry rather than the practice of dentistry,” said Dr. David A. Nash, a professor of pediatric dentistry at the University of Kentucky. “I’m a cynic about my profession, but the data are there. It’s embarrassing.
When celebrities have heart attacks, they go to *two* hospitals.
Brown had severe chest pains Tuesday night and was taken to two hospitals.
I wish Mr. Brown a speedy recovery and hope he isn’t required to visit too many more hospitals before receiving the care he needs.
In order to minimize recovery time and scarring, doctors are attempting to make use of existing holes in the body for surgery instead of making new ones. “Much of the discomfort and recovery time after conventional surgery — even keyhole surgery — is due to the incisions made in the abdominal wall. However, because transgastric surgeons reach the abdominal cavity through the mouth, there is no need for an incision, so patients should be back up on their feet much faster.”