A few days ago my daughter, a physician serving largely the uninsured, came home emotionally drained from a typical day at the office. Most of her afternoon’s patients were seriously ill, facing expensive, complex care, and needlessly so. They had come into such poor health because of inadequate management of chronic conditions and mostly it was due to their inability to pay.
One of the day’s patients was a man in his forties who had been diagnosed with high blood pressure four years prior. Uninsured, he received inconsistent treatment for his condition, leading to a heart attack two years later. The attack precipitated heroic emergency room and then hospital treatments, free to him but expensive to the rest of us, including placement of a stent; however, with the immediate crisis over, lack of money for drugs led once again to gap-filled care. Key in his follow-up care should have been the drug Plavix, considered critical for avoiding clotting after stents, but he couldn’t afford it so he stopped taking it ten months too early. Now, just two years later, he’s developed severe high blood pressure that has damaged both his heart and kidney. Our medical system will provide him once again with heroic and very expensive hospital care, all of which likely could have been avoided if proper health care insurance had enabled his condition to be systematically managed for the past two years. The system as a whole, and likely government funding in particular, will end up paying hundreds of times more because his care was so poorly managed. Of course, we’re also losing a potentially productive man all the while, if not forever.
She’d had other patients that day with similar levels of inadequate early medical attention, each now facing expensive, heroic medical efforts to keep them alive. There was the gentleman with a prostate tumor that upon diagnosis was already stage 3, the young woman who’d gone two years without treatment for bulimia and now faced chronic medical problems for the rest of her life, and the diabetic who’d developed heart problems because proper monitoring of her condition was financially out of reach.
“We almost never saw cases like that in Cuba,” my son-in-law exclaimed. He was, until my daughter snatched him off the island in a romantic heist, a Cuban family physician. “Those kinds of patient histories are what you’d expect to see in the poorest of Africa, but not in a country with a health system.” Cuba, contrary to popular wisdom among the left, does not provide technologically advanced medical care consistently; however, it has highly systematic, comprehensive primary care for all. It does the simple things in medicine very well.
Our “system” for medicine in America provides wonderfully heroic, technologically advanced medicine for almost everyone, also for most indigent once they show up at an emergency room. However, simple, inexpensive care management is neither covered nor provided for many, as both the uninsured and underinsured fall through gaping holes in primary care access. This leads to poor primary care for a substantial chunk of Americans. The gaps in attending to the simple lead to belated reliance on the complex and expensive.
There are ample statistics that drive home this point. The Commonwealth Fund assembles many in its National Score Card on health system performance. Compared to benchmarks set by best performing countries, in 2008 the United States comes out poorly in providing systematic care management. The US had:
- Nearly twice the percentage of adult hypertensive patients with blood pressure above prescribed limits (140/90 mmHgd)
- Nearly twice the rate of heart failure hospitalizations that were deemed avoidable if the patient had gotten proper outpatient care prior
- Nearly twice the number of diabetics hospitalized in cases where the hospitalization could have been avoided with proper primary care
- Over three times the percentage of patients treated in an emergency room for conditions that could have been treated by regular doctor
- Over three times the rate of hospitalizations for acute attacks among pediatric asthma patients, attacks that are fully avoidable with proper primary care management
The point is that when Americans can’t afford proper care we don’t just let them die, we first spend lots of money on them to provide expensive, avoidable care. And then we watch them die: The USA had in 2008 a 59% higher rate of “mortality amenable to health care,” i.e., people dying of diseases that they wouldn’t die from if they lived in countries with health systems providing benchmark levels of chronic care management. The USA is at the very bottom in this critical statistic, among 19 industrialized countries.
These statistics suggest that the potential to save on medical bills by eliminating avoidable hospital care through better primary care are huge. Remember that three quarters of the health care dollar goes to care for the chronically ill, for which significant chunks of hospital treatments are avoidable with systematic, consistent care management.
Then come the additional economic gains, and thereby also tax gains, from keeping people of working age alive and productive. Medicare funds would also be relieved of caring, once they reach 85, of those grossly undertreated in younger years.
So let’s turn to economic assessments that were given Congress about health reform costs and benefits. Is it probable that a health reform bill, by providing health insurance for 94% of Americans, will make a difference in getting them proper, early care? Yes. Will it save money, also for the government, and by substantial amounts? Yes again. Yet the $1 trillion, 10 year cost estimated by the Congressional Budget Office (CBO) fails to account for these probable huge economic gains for society and financial gains for government coffers. Indeed, these likely savings are considered too soft to “score” in CBO land. By mandate the CBO isn’t allowed to estimate the financial gains of reforms succeeding in making Americans healthier, however solid the case for savings can be made.
Thus, the CBO numbers present economic half truths, but full lies. They’re grossly misleading by putting hard numbers on a narrow set of issues, direct government costs and revenues under the assumption that health care practices remain as they are, while refusing to evaluate the much larger and more important gains from changing care for the better. And then these full lies get tossed like hand grenades into the debate, a discourse so degraded that best practice guidelines become “death panels” and malinformation spearheads most attacks.
To those that believe the costs of current health reform packages are exorbitant: Have you truly considered the economic costs of not creating more rational financing of care? The default of failed reform is one for which also you will be footing the bill. And then comes the moral costs of letting Americans unnecessarily lose their lives’ quality if not their lives altogether. Be careful what you wish for as you work so feverishly to derail reform.
David Hansen has aided organizations with health care strategy, IT planning, and new venture development for a couple decades, both in Scandinavia and in the USA. He holds graduate degrees in Economics and Business Administration from the University of Bergen, Norway and the University of California. He, like thousands of other health economists, has dreamed of significant health care reform in his lifetime.
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94% of americans? we need a better health care system now.
As a nurse from way back when with plenty of experience and credentials I can tell you this article is perfect.
As an employee with cadillac care insurance I did well and continued to work for years after I had a resp arrest followed up by three heart attacks.
Eventually I had to “retire” on disability (some 10 years later). I had coverage for another six months and then I was on my own for 2 years without any coverage for preexisting conditions. No medicine, no oxygen. I barely brushed my teeth once a week. People brought me food or I would not have eaten. My old patients took good care of me and some even brought different kinds of pills, in case I could use them.
Now the two year weeding out is over and those of us who survived have medicare. Some system.
Now I have medicine, the cheapest kind as I don’t want to hit that “doughnut hole” and most of all, oxygen. I cannot tell you what a difference that makes. I have AIR. And I can keep track of my blood sugar again! And maybe get my cholesterol back under control.
I can manage to shop, to stay clean, to keep the house clean, to go to church. I am sooooooo grateful.
But I wonder why I had to suffer for two years? Everyday I prayed my gallbladder would hold up, that I did not clot off a stent or two, that my blood sugar was OK and so on and so forth. I was so afraid of losing my home to pay for a hospital bill.
But, I will never be able to recover enough health to go back to work and I sure wish I could. Too late for me. Too much damage is done. I hope we come up with a better system of care for people who need help during that two year period of no coverage before soc sec medicare disability kicks in. I really do.
Often we forget the little guy, the SMB, in our discussions of the comings and goings of the Internet marketing industry. Sure there are times like this when a report surfaces talking about their issues and concerns but, for the most part, we like to talk about big brands and how they do the Internet marketing thing well or not so well.
http://www.onlineuniversalwork.com
1. Often we forget the little guy, the SMB, in our discussions of the comings and goings of the Internet marketing industry. Sure there are times like this when a report surfaces talking about their issues and concerns but, for the most part, we like to talk about big brands and how they do the Internet marketing thing well or not so well.
http://www.onlineuniversalwork.com
“Key in his follow-up care should have been the drug Plavix, considered critical for avoiding clotting after stents, but he couldn’t afford it so he stopped taking it ten months too early.”
The solution here should have been to prescribe dirt cheap low dose aspirin.
MD as HELL and Nate seem to using moral arguments: that since the individual doesn’t take responsibility, they don’t deserve primary care. I’m not talking philosophically on what is deserved or not, but about hard economics: If uninsured patients don’t prioritize primary care enough to get it, then we others end up footing the bill at hospitals. And the bill is orders of magnitude higher than if we just paid for rational chronic care management in the outpatient setting well in advance of acute, serious incidents.
You can be as indignant as you’d like about people not deserving care and you can preach all you want about them not sharing your priorities, but the fact remains that we don’t deny them advanced hospital care when they become seriously, but avoidably ill. And that ends up costing us far more.
Please, give us a break. If his healthcare was important to him, he would have found a way. There are too many stories where people with means to treat themselves had the same outcome as this man. We cannot care more than the individual cares.
Health care reform will probably cost a LOT more than people think. What people should focus on, however, is asking themselves how much they’re willing to pay for better health care?
Sounds like poverty has a great deal to do with regional variations in health expenditures, and the relative mix of dollars between primary care and specialty care.
Nate,
Health insurance is considered different from other kinds of insurance by most; the reason being: if a sick person has a life threatening condition, most feel that society has to help, regardless of ability to pay … even people who can be blamed for their misfortune, be it addiction, smoking or other unhealthy lifestyle. Therefore, it makes perfect sense to see whether life threatening conditions can be prevented with earlier care. Even in cases where, as you claim, wrong priorities may have contributed to the condition.
“It is difficult to get a man to understand something when his salary depends upon his not understanding it.”
“all of those are more likly to blame then a lack of insurance.”
Well Nate, maybe you can offer your services and go to the clinic where David’s daughter works and show her uninsured patients how inexpensive those HDHP are and how you could solve their problems with a good health savings plan – get your apps out Nate, there’s business down there. You could also show them that the combination of giving up their cell phones and smokes will more than pay their premiums and cronic care expenses.
“all of which likely could have been avoided if proper health care insurance had enabled his condition to be systematically managed for the past two years”
David you seem confused about what insurance is. When a person is diagnosed with a condition they no longer need insurance from that symptom the need financing. In this regard you provided absolutly no information. Why didn’t he get his Rx to prevent this? Cell phone bill was to high, chose Sunday Ticket instead of Rx, couldn’t afford plavix and his back a day habit? Or after his daily duece duece he just didn’t care, all of those are more likly to blame then a lack of insurance.
Contrary to your claim if you even took into account some imaginary savings from earlier treatment the true cost of the bill is still in the trillions. Far more cost was ignored and pushed 3 years behind the tax then any potential savings.
Seems like a sound argument for revising the way that the country deals with people who are unable to afford the preventive care that they need or persist in using it.
Not a sound argument for a nationalizing the entire medical economy.
Great post. My biggest concern is that by the time the US figures out that they need to make some serious investment in primary care to reap the rewards you write about, family physicians and general internists will be extinct. The small bump ups for primary care payment in the 2 reform bills are a help, but we still have a long way to go to rebuild primary care. And it will be an uphill road; witness the fierce lobbying of some sub-specialty groups against new CMS rules to slightly re-balance Medicare payment towards primary care.
From another primary care physician (Internal Medicine), this piece is right on.
I honestly believe we could provide affordable care for all, at 1/2 the current cost, if the system was built around primary care. I too am frustrated with the cost analysis of “reform” and with politicizing it.