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In (Gasp) Defense of the Coronary Stent

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A kerfuffle ensued recently when an oncologist and expert on evidence based medicine took the field of cardiology to task over the evidence for placement of the ubiquitous coronary stent.  What started with a lengthy article in Propublica that included coronary stenting for stable coronary disease as a prime example of a procedure done without evidence to back it up turned into this fiery twitter exchange between Drs. Kirtane (cardiology) and Prasad (oncology).

The crux of the debate revolves around placement of coronary stents in patients with stable coronary artery disease.  Stable coronary artery disease refers to narrowing of the arteries by a build of plaque that has occurred slowly over time.  Unstable coronary artery disease refers to eruptions that occur within the coronary vessel when a plaque ruptures, quickly leading a patent vessel to become completely occluded or nearly occluded.  Unstable coronary artery disease, otherwise referred to as an acute coronary syndrome is regarded as an emergency that requires urgent intervention by skilled operators (interventional cardiologists) who must race against time to abort a process that if left unchecked may lead to death or severe damage of the heart muscle.

Figure 1. Stable angina/Acute Coronary syndromes

Stable coronary artery disease on the other hand is not considered an emergency, but can result in patients being symptomatic because of diminished blood flow through the culprit artery. Angina pectoris is the descriptor one uses to describe chest pain that relates to a mismatch between the blood flow the heart muscle needs and what it receives. It is almost always the case that angina in stable coronary disease is triggered by activities such as physical or emotional stress that require more blood flow than the narrowed artery can supply.

Paying Doctors For Outcomes Makes Sense in Theory. So Why Doesn’t it Work in the Real World?

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For decades, the costs of health care in America have escalated without comparable improvements in quality. This is the central paradox of the American system, in which costs outstrip those everywhere else in the developed world, even though health outcomes are rarely better, and often worse.

In an effort to introduce more powerful incentives for improving care, recent federal and private policies have turned to a “pay-for-performance” model: Physicians get bonuses for meeting certain “quality of care standards.” These can range from demonstrating that they have done procedures that ought to be part of a thorough physical (taking blood pressure) to producing a positive health outcome (a performance target like lower cholesterol, for instance).

Economists argue that such financial incentives motivate physicians to improve their performance and increase their incomes. In theory, that should improve patient outcomes. But in practice, pay-for-performance simply doesn’t work. Even worse, the best evidence reveals that giving doctors extra cash to do what they are trained to do can backfire in ways that harm patients’ health.

Non-Alternative Facts About the Healthcare System

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The economic fundamentals of healthcare in the United States are unique, amazingly complex, multi-layered and opaque. It takes a lot of work and time to understand them, work and time that few of the experts opining about healthcare on television have done. Once you do understand them, it takes serious independence, a big ornery streak, and maybe a bit of a career death wish to speak publicly about how the industry that pays your speaking and consulting fees should, can, and must strive to make half as much money. Well, I turn 67 this year and I’m cranky as hell, so let’s go.

The Wrong Question

We are back again in the cage fight over healthcare in Congress. But in all these fights we are only arguing over one question: Who pays? The government, your employer, you? A different answer to that question will distribute the pain differently, but it won’t cut the pain in half.

There are other questions to ask whose answers could get us there, such as:

  • Who do we pay?
  • How do we pay them?
  • For what, exactly, are we paying?

Because the way we are paying now ineluctably drives us toward paying too much, for not enough, and for things we don’t even need.

A few facts, the old-fashioned non-alternative kind:

  • Cost: Healthcare in the U.S., the whole system, costs us something like $3.4 trillion per year. Yes, that’s “trillion” with a “T”. If U.S. healthcare were a country on its own it would be the fifth largest economy in the world.
  • Waste: About a third of that is wasted on tests and procedures and devices that we really don’t need, that don’t help, that even hurt us. That’s the conservative estimate in a number of expert analyses, and based on the opinions of doctors about their own specialties. Some analyses say more: Some say half. Even that conservative estimate (one third) is a big wow: over $1.2 trillion per year, something like twice the entire U.S. military budget, thrown away on waste.
  • Prices: The prices are nuts. It’s not just pharmaceuticals. Across the board, from devices to procedures, hospital room charges to implants to diagnostic tests, the prices actually paid in the U.S. are three, five, 10 times what they are in other medically advanced countries like France, Germany, and the U.K.

Why Surgical Volumes Should Be Public

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Her voice cracked with strain. I could imagine the woman at the other end of the line shaking, overcome with remorse about the hospital where her husband had had esophageal surgery. Might he still be alive, she asked me, if they had chosen a different hospital?

The couple had initially planned to have the procedure done at a well-known medical center, but when she went online to do her homework, she discovered that the hospital’s patient safety scores were poor. Another hospital in her community had stronger patient safety ratings, so they decided to have the procedure there.

It made sense. Why wouldn’t they go to a safer hospital?

What she didn’t know was that multiple studies over several decades have shown outcomes are better when procedures are handled by surgeons and hospitals with higher volumes, and while the well-known hospital had performed the procedure her husband needed many times during the previous year, the hospital they chose had done one.

Repealing the Right to Redistribute ‘Other Peoples’ Money’

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Republicans are having a hard time agreeing on how and when to repeal Obamacare. The Patient Protection and Affordable Care Act (ACA) is difficult to unravel because it was designed to alleviate a problem too costly for the government alone to fix. The health care law was passed to make medical care more accessible for low-income Americans and those with pre-existing conditions. This was to be done largely by socializing the costs and spreading the burden among a much broader segment of the healthy population. This is not unlike a pyramid scheme, where a broad base of people at the bottom get ripped so a few at the top can benefit.

Republicans have it within their power to use a process known as budget reconciliation to repeal Obamacare provisions that involve the budget, with a simple majority vote. For example, Republicans can repeal the taxes, fees and appropriations that fund the ACA. The individual and employer mandates, with associated penalties, can also be repealed. What Republicans cannot do is repeal the costly insurance regulations that drive up premiums for most people. That would require the help of perhaps a dozen skeptical Democrats.

Purging Healthcare of Unnatural Acts

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Everyone knows (or should know) that forcing a commercial health insurer to write for an individual a health insurance policy at a premium that falls short of the insurer’s best ex ante estimate of the cost of health care that individual will require is to force that insurer into what economists might call an unnatural act.

Remarkably, countries that rely on competing private health insurers to operate their universal, national health insurance systems all do just that. They allow each insurer to set the premium for a government-mandated , comprehensive benefit package, but require that each insurer “community-rate” that premium by charging the company’s individual customers that same premium, regardless of their health status and even age (with the exception of children).

American economists wonder why these countries do that, given that in the economist’s eyes community-rated health insurance premiums are “inefficient,” as economists define that term in their intra-professional dictionary. 

The Affordable Care Act of 2010 (ACA, otherwise known as “ObamaCare”) also mandates private insurers to quote community-rated premiums on the electronic market places created by the ACA, allowing adjustments only for age and whether or not an applicant smokes. But within age bands and smoker-status, insurers must charge the same premium to individual applicants regardless of their health status.

As fellow economist Mark V. Pauly points out in an illuminating two-part interview with Saurabh Jha, M.D., published earlier on this blog, aside from the “inefficiency” of that policy, it has some untoward but eminently predictable consequences. It happens when healthier people disobey the mandate to purchase insurance, leaving the risk pools of those insured in the ACA market places with sicker and sicker individuals, thus driving up the community-rated premiums. As Pauly points out at length, a weakly enforced mandate on individuals to be insured can become the Achilles heel of community rating.   

Data For Improving Healthcare vs Data For Exasperating Healthcare Workers

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The phrase “healthcare data” either strikes fear and loathing, or provides understanding and resolve in the minds of administration, clinicians, and nurses everywhere. Which emotion it brings out depends on how the data will be used. Data employed as a weapon for purposes of accountability generates fear. Data used as a teaching instrument for learning inspires trust and confidence.

Not all data for accountability is bad. Data used for prescriptive analytics within a security framework, for example, is necessary to reduce or eliminate fraud and abuse. And data for improvement isn’t without its own faults, such as the tendency to perfect it to the point of inefficiency. But the general culture of collecting data to hold people accountable is counterproductive, while collecting data for learning leads to continuous improvement.

This isn’t a matter of eliminating what some may consider to be bad metrics. It’s a matter of shifting the focus away from using metrics for accountability and toward using them for learning so your hospital can start to collect data for improving healthcare.

And the Democrats Wonder Why They Lost the Election?

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Now I have insurance. But I can’t use it. What am I supposed to do? I know this one is long but it’s worth a read if you want to understand issues pertinent to the Affordable Care Act. My personal story illustrates many of the problems with the ACA.

I started taking notes on the Health and Human Services Secretary hearing, and I will share more as I scrutinize the hearing in more detail but let’s start with the breakdowns below and my experience with Obamacare.  Here goes:

These are the breakdowns of who gets what coverage in the United States:

Medicare 18% – 52m

Employer 61% – 178m

Medicaid 22% – 62m

Individual 6% – 18m (exchanges cover 4% of the 6%–these are the people who have been forced onto the Obamacare plans)

Note: this writer is in the BOTTOM of the barrel here (Individual). Most of the individuals in the “Individual” category are either the upper contingent of the working poor, those who work for small businesses like restaurants or family owned grocery stores and the like that don’t provide health insurance benefits (more and more common these days), and/or sole proprietors like myself. Many health care providers are self employed hence we have been forced into the Obamacare exchanges if we are not high earners. High earners won’t buy on the marketplace and will purchase individual plans outside of the marketplace.

It’s Up to Clinicians, Not the Government or Payers, to Control Health Care Costs

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Behind many of the economic and political tensions of our time lurks the growing burden of health care costs. Does that claim sound inflated? Consider: when the public complains of stagnating wages, we can put our finger on health care costs as the monster that gobbles up employee compensation. When economists fret over the future burden of Social Security and Medicare (a cry echoed across the world as populations age), we have to recognize the scourge of increased health care costs. Most of the current debates over the Affordable Care Act–a recurring issue during the presidential campaign–touch explicity or implicity on health care costs.

The upward curve in costs became less of a run-away trend during the recession. Although the ACA might take a bit of the credit, most observers attribute the softening of the cost rises to belt-tightening by patients, and perhaps also to lower inflation. Inexorably, though, costs do rise. Small businesses and people on individual plans suffer most–a burden for which the ACA is not responsible, but that it brought to public attention–and the rest of us are bedeviled by rising premiums and deductibles as well. A study found spending increases across the board in 2015 by individual households, businesses, and governments alike. A number of people give up on health insurance because it’s still too expensive and does not end up covering their needs.

Insurers are suffering too, which is why even major companies such as Blue Cross and UnitedHealth are abandoning some markets.

Mylan Fiasco May Be “The Shot Heard Round the World”

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The Mylan EpiPen debacle may have inadvertently weakened the grip Big Pharma on U.S. lawmakers.  Last week, a bill proposed by Senator Bernie Sanders was narrowly rejected by a vote of 52-46.  Unexpectedly, 12 Republicans and 1 Independent voted with Senator Sanders in favor of allowing pharmacists and distributors to import cheaper prescription drugs from Canada and other foreign countries (something typically favored by Democrats.)  The winds of change are starting to blow in the bipartisan direction when it comes to the pharmaceutical industry.    

U.S. Healthcare needs a revolution ; ‘the shot heard round the world’ often refers to the opening shots of the American Revolution in 1775.  The Big Pharma lobby is holding the American people hostage with their exorbitant ransom demands.  Last summer, Mylan Pharmaceuticals, led by CEO Heather Bresch, overplayed their hand.  Mylan came under fire for a 400% price increase in the EpiPen two-pack.  This device is considered life-saving for children and adults with anaphylactic reactions to various food, insect, or environmental insults.  Ms. Bresch insisted the significant price increase ($600-$700 for a medication which costs pennies) was justified due to the more ergonomic appearance of the delivery device and improved safety profile.  Her miscalculation seems to have indirectly incited the war on Big Pharma by angering the public, the media, and the government simultaneously.