OP-ED

OP-ED

Does Life Expectancy Matter?

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U.S. life expectancy declined in 2015 for the first time in more than two decades, according to a National Center for Health Statistics study released last week. The decline of 0.1 percent was ever so slight ― life expectancy at birth was 78.8 years in 2015, compared with 78.9 years in 2014.  However, this reversal of a long-time upward trend makes these results significant.

While many researchers are scratching their dumbfounded heads in utter astonishment, I hypothesize the decline in life expectancy is partly due to the decrease in the primary care physician supply.  Studies have shown the ratio of primary care physicians per 10,000 people inversely correlates with overall mortality rate.  It is a well-known and reproducible statistical relationship that holds true throughout the world.  In the U.S., increasing by one primary care physician per 10,000 population, decreases mortality by 5.3%, ultimately avoiding 127,617 deaths per year.

Headlines last week highlighted how much these unexpected results left the researchers baffled.   Jiaquan Xu, a lead author of the study told The Washington Post, “This is unusual, and we don’t know what happened…so many leading causes of death increased.”   Age-adjusted death rates went up by 1.2 percent, from 724.6 deaths per 100,000 people in 2014 to 733.1 in 2015.  Death rates increased for eight of the ten leading causes of death, including heart disease, chronic respiratory illness, unintentional injuries, stroke, Alzheimer’s disease, diabetes, renal disease and suicide.  Differences in mortality were most prevalent in poorer communities, where smoking, obesity, unhealthy diets, and lack of exercise are ubiquitous. 

Lead Time Bias and Court Rooms

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By SAURABH JHA MD

In 2014, a jury in Massachusetts awarded $ 16.7 million in damages to the daughter of a Bostonian lady who died from lung cancer at 47, for a missed cancer on a chest x-ray. The verdict reminds me of the words of John Bradford, the heretic, who was burnt at the stakes: “There, but for the grace of God go I.” Many radiologists will sympathize with both the patient who died prematurely, and the radiologist who missed a 15-mm nodule on her chest x-ray when she presented with cough to the emergency department few months earlier.

The damages are instructive of the tension between the Affordable Care Act’s push for both resource stewardship and patient-centeredness, and between missed diagnosis and waste. But the verdict speaks of the ineffectualness of evidence-based medicine (EBM) in court. If EBM is a science, then this science is least helpful when most needed, i.e. when trying to influence public opinion.

EBM tells us that had the patient’s cancer been detected thirteen months before it actually was, it would have made little difference to her survival, statistically speaking. Researchers from Mayo Clinic examining the impact of frequent chest x rays in screening for lung cancer in a large number of smokers found that the intensively screened group knew about their cancers earlier, had more cancers removed, but did not live longer as a result. This is known as lead time bias, where early detection means more time knowing that one has the cancer, not more time one is actually alive. This means had the nodule been seen on the patient’s initial chest x-ray she would probably, though not certainly, not have survived much beyond 47.

Could Price Be Right?

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If confirmed as Secretary of HHS, Tom Price will oversee a $1 trillion budget – roughly one-third of all health expenditures.  His proposed legislation “Empowering Patients First” seeks to control costs by giving patients more choices and providing the information required to make them. He calls for publicly available standardized information on the price and quality of physicians, hospitals and other health care institutions.

It sounds like Dr. Price is prescribing a single data system. 

Medicare has had a single data system on the over-65 population for decades.  Since 2005, these data have informed Hospital Compare, a consumer oriented website comparing the quality of over 4000 hospitals.  And while prices in Medicare are relatively fixed, these same data have shown substantial variation in costs because the quantity of service – the number of hospital admissions, procedures and physician visits – varies substantially from place to place.

But Medicare is only one piece of the data puzzle.  A National Bureau of Economic Research report[nber.org] added another piece last year with data from large insurance companies like Aetna and United.  For the under-65 commercially insured population, it’s not just the quantity of services that are all over the map – it’s also the prices. 

Medicaid, Meet Indiana

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We will soon have a Vice President and a head of CMS who hail from the great state of Indiana, and are proud of what they’ve done with Medicaid there through the Healthy Indiana Plan. Seema Verma, the proposed CMS Administrator, is credited with being the architect of Healthy Indiana, and Mike Pence, the Vice President-elect, presents Healthy Indiana as one of the signature achievements of his term as governor of that state.

It is too early to tell if the program will be enough to raise Indiana up the ranks on health and healthcare from the bottom quintile (1, 2). However, since Republicans have run the table with Congress, the White House and soon the Supreme Court, we can reasonably conclude that the future of Medicaid in America is going to look more like Indiana.

That doesn’t mean that income-based Medicaid eligibility will dramatically change. Pence was one of the few Republican governors who took advantage of the opportunity to expand Medicaid eligibility up to 138% of poverty, and President-elect Trump has promised, in his emphatic way, that people will not be denied healthcare coverage in his administration. Some Republicans in Congress have different ideas, however, and the outcome is not at all clear yet.

Two Nations Separated by 5.3 mm

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A popular meme is that the U.S. spends more on healthcare than other developed nations but has nothing to show for that spending. This is different from saying that the U.S. spends more, but achieves something, but the something it achieves is so little that it isn’t worth the public purse. The latter is difficult to assert because the asserter must then say how little is too little in regards to how much is spent, and why. It is easier believing the excess spending has no effect whatsoever, zilch in fact, because this absolves one from having to apply a value judgment on how much a life is worth. This meme, a convenient heuristic, like other convenient heuristics, is wrong.

A recent study looked at trends and outcomes in the management of abdominal aortic aneurysm (AAA) in the U.S. and the U.K. An aneurysm, dilation of the aorta, is more likely to burst the bigger it gets. Aneurysms should be repaired before they rupture because the mortality of ruptured aneurysms can be 50 %. The study, which analyzed several databases that recorded surgery, size of aneurysms, and cause of death, found that Americans repair twice as many aneurysms as the Brits, and the repaired AAAs are smaller, on average, in the U.S. Between 2005-2012 elective AAA repair (i.e. repair of non-ruptured aneurysms) increased from 27 to 32 per 100, 000 in the U.K, and from 58 to 64 per 100, 000 in the U.S.

American Healthcare Rackets: Monopolies, Oligopolies, Cartels and Kindred Plunderbunds

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The Healthcare Dollar, the Healthcare Industry and the Healthcare System are shibboleths. All are parlance. All render terms such as Healthcare Profession, Service Profession, and Healthcare Professionals quaint. All drive linguistic determinism: if it’s labeled so, it must be so. Furthermore, all have become jingoistic. This is our dollar, our industry, our system and don’t dare tread on us.

These are shibboleths that engender considerable cognitive dissonance. If healthcare is no longer a service profession but an industry that transfers wealth in a systematic fashion, shouldn’t it comply with the legal constraints that tightly govern other industries including others that serve essential needs of the population?

Medicare Advantage – the Cup that Spilleth Over

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I was asked to see an unfortunate elderly man – Harry – one afternoon.  He had multiple coronary stents placed for coronary disease over the course of the last ten years, and after presenting with difficulty speaking, was found to have a brain tumor.  The neurosurgeon was hoping I could provide some reassurance about how healthy his heart was to undergo an operation.  An assessment revealed him to be high risk for a coronary event, and I had a lengthy discussion with the surgical team, and the patient, who elected to proceed with the surgery.  Three hours after the surgery, the nurse practitioner taking care of the patient messaged me to tell me his heart rate was slow – ‘in the 30’s’.  I was driving to another hospital, and when stopped, messaged back asking for an electrocardiogram to be sent to me. A quick glance at the image on my screen had me turning around.  There are three major arteries that feed the heart. One of Harry’s arteries had closed off.

The Perversion of Fiscal Federalism: Daniel L. Hatcher’s, “The Poverty Industry: The Exploitation of America’s Most Vulnerable Citizens”

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It’s not that we do not know that Medicaid and Medicare fraud is rampant.  A 2012 estimate by the former CMS administrator, Donald Berwick, estimated the amount at $100 billion annually.  Nor are we unaware, that drug companies routinely pay massive fines for illegal business practices: eight firms have paid in sum over $11.2 billion in civil and criminal fines since 2010.  Beyond these issues what is possibly most disturbing about the numerous inter-related health and human services issues “The Poverty Industry” raises is Professor Hatcher’s detailed discussion of how state human service agencies, in partnership with private contractors, have monetized poverty or turned vulnerable populations into a source of state revenue.  As Hatcher says in his introduction, states are, “strip-mining billions in federal aid and other funds from impoverished families, abused and neglected children and the disabled and elderly poor. ” 

Et Tu, Dr. Noseworthy?

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Premium Hikes in the Exchanges: Not Good News, But Not the End of Obamacare Either

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OK.  Yes, this is bad.  The Obama administration is being disingenuous if it tries to spin it any other way.   And, as has been clear for several months, this hands Hillary a “nasty” issue (pun intended). 

The “this,” of course, is the administration’s announcement on Oct. 24—after weeks of speculation and anticipation—that premiums in the exchanges will rise by an average 22% for 2017 coverage (if both state- and federally-run exchanges are included in the count.)

Despite the fact that tax subsidies will significantly soften the blow for the vast majority of people buying health insurance in the exchanges, millions of families will still be adversely affected.  

Specifically, about 2 million people who will buy coverage through the exchanges in 2017 will not get subsidies because their incomes are too high.  You could argue: hey, they can afford it.  But it’s still a pretty big hit when your monthly premium goes from $500 a month to $625.