Monday, August 10, 2009

Trimming The Fat From Health Care

Where do we really need to trim the fat in order to give every American health care? It seems to me that this photo is as descriptive of how we finance health care as it is of the condition of our literal butts:

Unfortunately, there are folks who seem to think that what we need to do is get everyone down to LA Fitness and get them off the Vicodin:

But we also need to transform what is covered. If we want to make affordable health care available to the 48 million Americans who do not have health insurance, then the fundamental causes of many chronic diseases need to be addressed — which are primarily the lifestyle choices we make each day — rather than only literally or figuratively bypassing them. - Dr. Dean Ornish

Speaker Pelosi and Rep. Steny Hoyer have penned a whopper of an op-ed: ‘Un-American’ attacks can’t derail health care debate. Wanna bet? To some extent it’s already happened. But it does prove that the politics surrounding health care “reform” have nothing to do with actual reform or making anyone healthier. Just read the opening line: Americans have been waiting for nearly a century for quality, affordable health care. Never mind that the actual solution has been in our hands for decades.

But finally, someone spotlights the real issues behind health care and why whatever “reform” comes down will ultimately fail, both articles at Huffington Post. And neither has a thing to do with this drivel coming from Democrats, though it’s very safe to say that Republicans are miles worse.

Why Health Care ‘Reform’ Will Fail

[links from original]

Personally, I think actually getting everyone in America proper access to health care would be one hell of an accomplishment, but apparently it's all for naught if we don't trim away those excess pounds and stop running to the doctors all the time. So says the new medical editor at the Huffington Post, Dr. Dean Ornish.

When I saw Taylor’s mention of getting health information from Huffington Post, I knew there’d be some comedy gold there. Ms. Huffington’s never met an alternative medicine quack or anti-vax charlatan to whom she wouldn’t provide a soapbox. I hadn't heard of this Dr. Ornish, but was pretty sure that medical professionals would have some strong opinions. Over at Respectful Insolence, Orac summed Dr. Ornish up this way:

Although I can totally understand why Dr. Ornish might not appreciate my criticism, he should actually know that, of the Four Horsemen of the Woo-pocalypse, I consider him (probably) the least objectionable. Certainly he would not be Death (that would be Andrew Weil). Smart-ass that I am, maybe I’ll consider Dr. Ornish to be Famine, given that his claim to fame is the use of very low fat diets, along with major lifestyle alterations, to effect changes in health. The reason that I find Dr. Ornish perhaps the least objectionable is that at least he tries to do science. It’s preliminary science, and usually the controls aren’t the greatest, but it is for the most part science. My main beef with him is how he represents that science to the public. For his claims for dietary treatment of prostate cancer at least he tends to take preliminary studies of highly select patients and make way too much of them. Indeed, he often says one thing in his papers, where peer-reviewers force him to remain tentative and keep him from going too far off into the deep end with his claims, but quite another thing to virtually everyone else, including the aforementioned Senator Harkin and, even worse, to the recent Institute of Medicine/Bravewell Collaborative conference on alternative–excuse me “integrative” medicine–from which he hopped over to the Senate to do a two-fer of woo promotion in our nation’s capital.

Dr. Dean Ornish: Turn away from the Dark Side! It's not too late!

In short, Dr. Ornish seems to be playing a high-wire act of writing reasonable things in medical journals so his peers won’t call him out, then making outlandish claims in the general press. That article is worth reading in its entirety.

PalMD of White Coat Underground put it a bit more bluntly:

Dean Ornish. They called in Ornish. Really it’s more of the same. He gives another impassioned plea for ending the madness, the madness of treating sick people.

Our research, and the work of others, have shown that our bodies have a remarkable capacity to begin healing, and much more quickly than we had once realized, if we address the lifestyle factors that often cause these chronic diseases. Medicine today focuses primarily on drugs and surgery, genes and germs, microbes and molecules, but we are so much more than that.

Genes, germs, microbes, molecules…all those hard, science-y things. Does he have a diet to keep me from throwing up in my mouth?

Tom Harkin's War on Science (or, "meet the new boss...")

I’m going to have to lose a lot more brain function before I take guys like Dr. Ornish seriously on the issue of managing health care costs. Doing a search, as I did, for Dr. Dean Ornish at the Scienceblogs site will yield a treasure trove of smart dissection of Ornish's recent career.

I don’t think there are too many M.D.’s engaged in clinical practice who’d disagree that we need to work on getting the U.S. to eat better, and maybe exercise a little more. The notion that this should be the centerpiece of our health care policy is nonsense, however.

Roughly one third of this country doesn’t get the health care it needs. That’s not because they’re fat. It’s because they either don’t have insurance, or have insurance that won’t cover their conditions, because it’s not profitable. Because preventive medicine isn’t as expensive, and therefore isn’t as profitable, it tends to be de-emphasized as well.

We have one of the lowest rates of cigarette smoking in the industrialized world thanks largely to education and targeted taxes. A similar effort regarding weight control would probably yield similar results. Nothing about changing the way we finance health care, or how the government negotiates prices of health care services, would change that. The cost, relative to that of insuring everyone in this country, would be trivial.

Now, let's talk about a real cost of our current system. That's the overhead of having insurance companies pay for our medical services instead of our paying them directly. This, in terminology characteristic of the insurance industry, is referred to as medical loss. Yes, the money the insurance companies pay for the medical services their customers receive are considered "losses". The Washington Post provides an interesting example of the magnitude of medical costs:

· A number that traditionally ranges from 75 percent for the most profitable and efficient plans to more than 100 percent for money-losing plans.

· For Aetna, a figure that increased last quarter from 74.6 to 79.4, causing a 20 percent plunge in its share price when it was announced.

Primer: Medical Loss Ratio

In keeping with the general character of the health care debate, the Washington Post has the exact opposite view of efficiency that one would have if one were trying to evaluate how efficient an insurance company was at delivering health care. A medical loss ratio of 75 percent means that one in every four dollars that the insurer's customers spend on health insurance premiums is not passed on to the people who actually provide health care. Medicare's "medical loss ratio", by contrast, is about 97 percent. As this paper (PDF) makes clear, calculating this ratio is something of a black art. Still, when you add the fact that malpractice insurance, a major expense in most medical practices these days, it's reasonable to assume that having commercial enterprises provide health care financing is costing 20 percent more than having Medicare provide it all. As former insurance executive Wendell Potter said on Bill Moyers' show a few months ago:

BILL MOYERS: You told Congress that the industry has hijacked our health care system and turned it into a giant ATM for Wall Street. You said, "I saw how they confuse their customers and dump the sick, all so they can satisfy their Wall Street investors." How do they satisfy their Wall Street investors?

WENDELL POTTER: Well, there's a measure of profitability that investors look to, and it's called a medical loss ratio. And it's unique to the health insurance industry. And by medical loss ratio, I mean that it's a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry's been dominated by, or become dominated by for-profit insurance companies. Back in the early '90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.

So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they'll punish them. Investors will start leaving in droves.

I've seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street's expectations with this medical loss ratio.

For example, if one company's medical loss ratio was 77.9 percent, for example, in one quarter, and the next quarter, it was 78.2 percent. It seems like a small movement. But investors will think that's ridiculous. And it's horrible.

BILL MOYERS: That they're spending more money for medical claims.


BILL MOYERS: And less money on profits?

WENDELL POTTER: Exactly. And they think that this company has not done a good job of managing medical expenses. It has not denied enough claims. It has not kicked enough people off the rolls. And that's what-- that is what happens, what these companies do, to make sure that they satisfy Wall Street's expectations with the medical loss ratio.

Bill Moyers Transcript: July 10, 2009

So let's look at the question of how much all those additional overweight people are costing us. A recent report, widely circulated in the press that I, in my more cynical moments, thought of as a campaign of "blame the fatties, not the insurance companies, for-profit medical conglomerates, and Big Pharma", mentioned that overweight people were responsible for excess medical costs that amounted to about 9 percent of what we spend on health care. In the part that most people didn't read, though it also said this:

Spending increased 82% for people who were obese in that period, from $167 billion to $303 billion. For people who were classified as overweight but not obese, healthcare spending increased 36% from $202 billion to $275 billion. For people of normal BMI, treatment costs increased 25%, from $208 billion to $260 billion.

Healthcare Costs for Overweight and Obese Patients Grow

The first thing that jumps out at me here is that the average cost of patient care for "normal" people rose at twice the rate of inflation for that time, which was about 13 percent. Even had nothing else about the population changed, we'd still be paying about 12 percent more for health care, after adjusting for inflation, in the space of six years.

Even in a really healthy population, some people will be overweight. This could be due to psychological or medical issues, but it will certainly be true. There are many reasons for this, but the interesting thing is the differential between that and our condition. Canada, a country with a similar society, but a very different way of paying for health care has seen a rise in obese and overweight people. This figure suggests that our rate of obesity is about half again more than Canada's, the United Kingdom's, and Germany's. These are societies similar to ours in political organization, degree of industrialization and modernization, and medical technology. The difference is what's interesting, and that's probably less than three percent of our health care costs.

So, class, what's larger, three percent or twenty percent?

While the jocks are pondering that one, I'll ask another of the skinny kids with glasses - how much bigger is 20 than 3?

Our corpulence isn't a trivial matter, but its contribution to our health care costs are dwarfed by the built-in inefficiencies of for-profit health care as it's currently being implemented. Focussing on it isn't quite on par with Sarah Palin's objections to ObamaCare. Still, it's a distraction at this point. It has more to do with lining the pockets of some folks than it has to do with getting quality health care to the masses. So I wish Huffington Post would stop focusing on the nonsense and focus instead on what matters.

How we pay for health care affects how it is delivered. It also clearly affects whether it is delivered. With at least 20,000 of us dying each year because we don’t have access to health care when we get sick or injured, I think that’s something worth getting excited about. Trimming the fat there, and delivering care to more people, is the thing we need to do now.

If the Congress and the President manage that much, I'll be both satisfied and amazed.

NOTE: This article began as a response I attempted to post on Taylor Marsh's blog regarding her article. Sadly, block quotes don't work there, and it was a mess. Thus was this article born.

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