TCS Daily

Well Treated: The Road to McMedicine

By Arnold Kling - October 10, 2007 12:00 AM

"Our relentless search for wellness through medicine has created a kind of therapeutic imperative, the urge to treat every complaint, every deviation from the norm, as a medical condition."
--Shannon Brownlee, Overtreated, p. 206

Below is a list of characters in Shannon Brownlee's story of America's health care system. Try to guess which are the good guys and which are the bad guys.

  • A doctor who found a way to treat breast cancer with massive doses of chemotherapy and bone marrow transplants
  • Insurance companies that refused to pay for the breast cancer treatment, until attorneys fought on behalf of patients
  • A typical independent practicing physician
  • Kaiser Permanente and other medical care behemoths
  • Doctors who rely on intution, experience, and personal knowledge of the patient to make treatment recommendations
  • A statistician who looks at data to evaluate treatments

If you made the usual guesses about the villains and the heroes, then Overtreated will surprise you. For example, concerning the aggressive treatment for breast cancer, Brownlee concludes (p. 141):

insurers unwittingly made the treatment a feminist cause by refusing to pay for it. Breast cancer advocacy groups...threw their weight behind the embattled women...When transplanters like Peters testified in court that the procedure was established practice, when in fact it was not, they stoked the perception among patients that high-dose chemo offered a shot at cure.

Hope Rugo stopped performing transplants on breast cancer patients in 1999...she said, "We believed in it passionately. Now I think about all the women who died during transplant, who would have lived much longer without it."

Doctors and hospitals did not wait for clinical trial results before embracing what turned out to be an ineffective, painful, and debilitating procedure. Brownlee repeatedly chides physicians who rely solely on habit and intuition while remaining ignorant of statistics. The biggest hero in her book is Jack Wennberg, the Dartmouth statistician who has documented the large differences in rates of medical procedures across regions--with the procedure-intensive regions showing no better outcomes than the those regions with fewer procedures.

Why Not McMedicine?

Another point that Brownlee stresses repeatedly is the inefficiency of independent physicians, as compared to large managed-care companies. Independent physicians do a poor job of co-ordinating care of the individual patient, and they lag behind in their use of electronic medical records.

Brownlee does not come right out and advocate McMedicine, but she comes close. She writes (p. 278), "How often does all of this coordinated care actually happen? Outside of a few systems, like the VHA [Veterans' Administration], Group Health, and Kaiser, rarely at best."

As a journalist, Brownlee assumes that the lack of co-ordinated care represents a market failure that government needs to fix. As an economist, I wonder why the market has not produced more McMedicine. Here are some possible answers:

1. With consumers responsible paying for less than 15 percent of personal health care spending out of pocket, health care providers are insulated from the pressure to provide quality service at low cost.

2. Perhaps, for the majority of patients, fragmented care works well. When you only have one condition at a time, the cost of co-ordinated effort may exceed the benefits. Co-ordination only becomes important when you have multiple conditions, or a disease like diabetes that requires thoughtful management.

3. Most of the potential for efficiency gains from large-scale medical providers are precluded because of licensing laws and practice restrictions.

I think that (3) is worth pondering. Our system for licensing doctors, nurses, physical therapists, and so forth, makes it very hard to rationalize and improve our health care delivery system. If you wanted to make McMedicine really work at delivering quality care at low cost, you would economize on the use of highly-educated professionals. Instead, you would use technicians and trained apprentices. You would attain the trust of consumers by earning an overall corporate reputation for reliable service, not by having each employee display a sheepskin on the wall.

The point is that getting the advantages of McMedicine may not be a matter of sheer collective will, as Brownlee would have it. Instead, it might require radical deregulation of medical licensure and practice regulations.

Physician Compensation

Brownlee points out, as many others have noted, that compensating physicians for procedures creates some unwanted incentives. In particular, it rewards doctors for doing more procedures. Doctors try to see as many patients as possible who are in their particular "sweet spot:" if you are an orthopedist who specializes in knee surgery, then you try to see lots of people with bad knees.

Brownlee proposes the alternative of paying doctors a salary, based on the number of patients that they see. However, I would argue that this would create the opposite incentive. Under a capitation based compensation system, a doctor would want to see as few sick patients as possible, because each one takes a lot of time. You will be paid more if you have a large roster of healthy patients than if you have a small roster of sick ones.

As an economist, I believe that there is no perfect way to compensate doctors. I would like to see experiments tried with different systems than the one we use today, to see if they improve things. But I would definitely not say that shifting to a capitation based salary system would bring nirvana.

More Evidence

One of Brownlee's primary recommendations that I can wholeheartedly endorse is an effort to obtain more knowledge about the effectiveness of medical procedures. She writes (p. 291-292),
[Doctors] are required to take a statistics course, but they don't actually learn how to interpret medical evidence...Does every patient who undergoes major surgery need a vena cava filter...Doctors still disagree. Is lithotripsy, using ultrasound to blast kidney stones into tiny bits, better than surgery? It might not be as safe as doctors and patients think it is. Does everybody with slightly elevated cholesterol really need to take high doses of cholesterol-lowering drugs? These questions represent a microscopic fraction of the mysteries that remain in medicine.

On this point, I have no quibbles. Ian Ayres, in his new book Supercrunchers, gives an example of a straightforward exercise in probabilistic analysis that 75 percent of doctors get wrong (p. 214 of his book). I know I once had a Harvard-trained doctor who got a similar problem wrong and gave me bad advice as a result (he is no longer my doctor).

In my own book, I advocated a Medical Guidelines Commission to try to add to our medical knowledge. I think that such an approach will threaten the typical doctor, just as the Moneyball baseball stat geeks threaten traditional scouts. But we need to turn the supercrunchers loose on medical data and see what they can do for us.

Overall, Shannon Brownlee deserves praise for providing a more nuanced and accurate picture of the problems in our health care system than what gets portrayed in the popular media. My main reservation with her book is that she tends to make the solutions seem more straightforward and less problematic than I believe them to be.

Arnold Kling is an adjunct scholar with the Cato Institute and author of "Crisis of Abundance: Rethinking How We Pay for Health Care."


Who controls state medical boards?
Doctors complain about many things. How many are of their own making?

Supercrunching is profit motivated
The fact that healthy patients and effective doctors are money makers has already spurred a huge boom in the healthcare industry for data warehousing and business intelligence expertise.

It is the pursuit of profit that makes an organization lean and efficient. It is a known fact to all of the evil insurance companies that healthy members equals greater profits.

Through the mining of data, these evil insurance corporations are looking into the behaviour of the physicians and the outcomes of the procedures and medicines they perscribe. The doctor is then presented with the results in order to run his practise in a manner that keeps his patients healthier.

Many see this as insurance companies "telling" doctors how to practise medicine. What it really is doing is offering doctors the ability to see the effects of their current methods. Some physicians, not familiar with being told their way is not the best, have issues with this. The smart ones use the information to their, and their patient's, benefit.

Also, all insurance companies require proper coding of procedures by the physicians. What you often see is doctors "upcoding" a procedure in order to make more money off of a less expensive procedure.

I have actually been in the room when a doctor accused us of telling him how to practise medicine when we presented him with evidence of his extensive upcoding. Be cautious when you hear anecdotes of the evil insurance companies coming down on innocent physicians.

This will all change, of course, when the evil insurance companies hand over all their data to the benevolent government. Upcoding will no longer occur since that would be defrauding the government and we all know that defrauding the government never happens.

But neither will the system be motivated by profit. Why would Big Pharm(!) throw billions into researching new drugs when there is no profit? Why would huge amounts of money be spent on healthcare business intelligence when there is no profit to be had? Does innovation and medical advances come from government intrusion?

These questions already have answers in the bankrupt socialized medical programs of Europe, Cuba, and Canada.

There is much to like and much with which I can agree in your post. However, the operative word to describe the incidence of upcoding is "occasionally" or even "rarely" since doing so is, indeed, fraud (your unfortunate experience notwithstanding). What has been shown time and again in audits of physician records is that physicians routinely DOWNCODE in an effort to avoid the possibility of being accused of upcoding. In other words, a physician codes for a procedure or exam that is less than what was actually done. In fact an entire consulting industry has been spawned to help physicians avoid this, and a major selling point of most electronic medical record programs is automatic accurate coding.

What drives up the overall cost of health care in the U.S. in the physicians' office is the practice of defensive medicine, the ordering of care that does not materially affect health outcomes but helps to protect against a lawsuit. Upcoding is a rounding error in the realm of health care finance and is rendered even more so by the more common downcoding. We agree that socialized medicine inevitably fails and becomes bankrupt because it has no acceptable way to address demand.

The costs of coding
Indeed downcoding does occur as well as upcoding. The difference lies in intent. When one downcodes they are not reimbursed as well as they should be. In effect, they are not doing themselves any favors.

Both upcoding and downcoding can be the result of improper claims handling or just plain ol human error. If one looks at the myriad ways in which one codes, heavily regulated by the federal government BTW, a treatment/diagnosis one can see how this can easily happen.

The issue I was pointing out was that, when confronted with extensive upcoding, some physicians and physicians will attempt to accuse others of malfeasance. You are correct in saying that entire businesses have been created to address this issue on both sides.

My company has software in place to flag consistent upcoding as well as coding errors.

While I agree that litigation is definitely driving up the cost of healthcare I do not believe it to be the major driver. The major driver, from an insider's POV, is government interference and regulation.

The cost of the software to detect coding errors and fraud is driven by the fact that government regulations require you to code in a government-regulated fashion. Stack that on top of the millions of other regulations our industry has to abide by day in and day out and you begin to see the enormous amount of money being spent just to be able to claim that you are compliant. Clearly more regulation and government interference is not the answer (not that this was what you were suggesting).

evidence based medicine
Good article and more reasons why there's a growth in demand for what they're calling now, 'evidence based medicine'. Unlike much of current medincine which is done for other reasons. The herd mentality also applies to doctors, as well as other supposed scienttists.

litagation fears
Litigation fears are a major factor in the increase in healthcare cost in the US (and to a smaller degree in Europe as well).

If people get told to get a full body CAT scan when they come in with a headache that's clearly related to their case of the common cold just so the doctor can exclude any possibility that there may be a brain tumour masked by that cold induced headache, he'll not put it on his bill like that.
He'll call it something else, or at least give a definite reason.
The insurance company isn't going to be able to see that procedure as "defensive medicine", as it's nowhere labelled as such in the paperwork submitted to them.

Same with doctors prescribing all kinds of vitamin supplements and other normally harmless drugs on the off chance that the patient might need them and sue if she gets any disease related to not having had those pills.

And then there's the increasing cost per procedure brought about by the ever increasing insurance premiums doctors have to pay to protect them in the case they do get sued (which is all but certain to happen every few years by now for your average physician).
That cost is forwarded to each patient in the price for each visit and procedure, and through them to the health insurance industry (who dutifully pass it right back to the person paying the policy through increases in their own rates).

This is why...
it is so hilarious that Edwards says he wants to fix healthcare. He and his ilk are one of the biggest reasons for the costs in the first place!

Foreign competition will eventually deliver health care goods and services "better, faster and cheaper".

There is simply too much money on the table.

What we are doing today and the direction are going with Health unsustainable. By definition, this must stop.

How? What? When? Where? Who?

How: Foreigner entities will develop their own Health Care delivery systems that are superior to ours.

What: Fully integrated, foreign owned, tertiary hospitals, clinics and pharmacies with salaried staff licensed to operate under the laws of the State.

When: At the last possible moment just before we actually hit the wall.

Where: Inside one of our 50 States first. And then everywhere in America almost immediately after that.

Who: (My guess.) Philippine owned corporations owned by their physicians, nurses, pharmacists and medical technicians working as partnerships. With their own clinical real estate, banks and health insurance companies.

Splain me, Lucy
"Foreigner entities will develop their own Health Care delivery systems that are superior to ours."

And how come is that?

litigation costs
Actually, doctors are under contract for a very specific fee for each service they perform. In general those fees have decreased or remained constant on a yearly basis for at least 10 years. Doctors are contractually prohibited from passing on increased costs by increasing their fees for services they provide. You have quite adequately described a free-market version of capitalism, one that no longer exists in American medicine.

cost drivers
Once again there is much on which we can agree. However, from another insider's POV inumerable studies have shown that the amount of medical care rendered as part of defensive medicine in the U.S. is 15-25% of all care. 15-25% or $2 Trillion worth of care. This is, by definition, care that does not contribute materially to the health of the recipient; it does not affect health outcomes and is therefore unnecessary. Defensive medicine is an enormous driver of cost in the U.S.

Upcoding is wrong. It is an attempt to be paid for work not done. Your company and your experience is colored by the fact that it is in your favor to have doctors routinely and regularly downcode for fear of being accused of upcoding. Downcoding contributes to a discount, given out of fear, for work performed.

Government interference and regulation is also a culprit. The man-hours necessary to comply with the myriad regulations is a drag on the system. The "guilty until proven innocent" approach by government agencies fosters an atmosphere of fear and anxiety in the provider universe. And even more damning is the fact that each third party payer has its own individual reporting system, mandating expertise and time investment in needless redundancy. We can agree that more government involvement is not the answer.

I know, Lucy
They would do it because such private health care organizations already operate all over Asian, and yes, they do a good job and make money too, and are expanding to many other countries. If allowed, I'm sure they would invest in the US too. But probably they won't be allowed because the US is so restrictive on trade. This would be comparable to how they don't let foreign airlines just go about competing in the US. It would be too humiliating for domestic carriers because they'd never be able to match the likes of Singapore Airlines, etc. Anothe problem might be that since Americans can't even get health insurance from out of state, why would they let them get it out of country? I recommend that the US become a freer country, then many of their problems would be solved.

>"We can agree that more government involvement is not the answer."


In what capacity are you involved in the healthcare industry? While I am currently involved on the insurance end I have spent many years working from the hospital and provider group ends as well.

In all that time I have seen far more upcoding than I have downcoding. Downcoding is usually done in error rather than an attempt to avoid being accused of upcoding.

In fact, I have never actually witnessed a doctor being accused of fraud, which upcoding is, and prosecuted for it. The method for stopping it is to inform the doctor that is occurring and to offer to assist their process of coding in order to become more accurate. This ususally spurs the doctor to code properly as they now understand their shenanigans are being noticed.

It is so very nice to have an intelligent conversation about the reality behind the costs of healthcare. I can see that you understand the nature of problem and agree almost totally with what you say.

we deregulated our healthcare industry we could market our services overseas far more effectively than they could do so here.

We are already head and shoulders above the rest of the world when it comes to medical technology and know-how. All we need to do is reduce the costs and free the market. The world already runs to the US when they want the best medicine in the world.

Why not take the best medicine in the world to them?

You are very kind. I am a provider; I run a medium-sized specialty group; I consult for other groups and for industry on business matters (implementing new technology, medicines, and devices into the market), as well as deep background industry economic planning. I, too, enjoy the discussion.

What kind of technology are you involved in?

it's not that simple
I'm an MD of 30+ years' experience, with a Masters in Public Health, graduate-level courses in biostatistics and health care administration, etc. The limitation of the statistical approach to taking care of the Individual Patient is exemplified by the following thought experiment: Say 1% of patients presenting with headache have a brain tumor, and that there are no absolutely reliable symptoms or exam findings to distinguish him/her from the 99% without a brain tumor, and a $2000 MRI is required to find that one patient. Looking at the group of 100 patients, it would cost $200,000 in testing to find that one patient. Is it worth it? That depends on the "cost" of overlooking the person with the brain tumor by "saving" $200,000. To the undiagnosed patient who actually has the tumor, or to the doctor who is sued for "failure to diagnose", the cost is easier to overlook.
In occupational medicine (my field), several Treatment Guidelines already exist (ODG, ACOEM, Colorado Rule 17, etc.) and are already in wide use by doctors and insurers. They are reasonable guidelines, but when inflexibly applied to the individual patient, they limit interventions that might otherwise help.
As with any other large-scale solution, blanket approaches such as Treatment Guidelines may overall be of benefit, but still be detrimental to certain individuals. When those individuals reach their day in court, amid the trial-lawyer-enabled liability environment, juries are unimpressed by save-the-whole-system arguments, and just see the injured individual on the witness stand.

I agree
One disappointing thing about Brownlee's book is that she makes it sound as if statistical analysis is a total panacea, that we will only get rid of unnecessary care.

Instead, I hope we get rid of procedures that have very high costs and very low benefits. But as your example nicely illustrated, something that has very low benefits in the overall population will still have benefit for one individual. Understanding that and dealing with it is the crux of the health care issue, in my opinion.

Excellent article; is Google smarter than your doc?
Doctors do indeed have incentive to do more procedures -- and once they know how to do a treatment they are resistant to new, better (and especially) cheaper treatments.

I had personal experience with this. I had a degenerative vein condition in one leg. The first doctor I saw advocated traditional stripping (they use a hook to yank the vein out; this is obviously very traumatic), and when I tried to get some idea of what the operation would be like he practically fled, and had the nurse give me a remarkably vague and unhelpful pamphlet. He did not mention any possible alternatives.

Later, via Google, I found out there was a laser alternative, which was outpatient, minimally invasive and I could walk home (versus months of bedrest recovery with stripping). The doctor also scheduled saline injections for smaller veins, even though that procedure was purely cosmetic, which I cancelled on the grounds that closing the large veins had essentially cured the condition, and one should keep medical procedures to the necessary minimum -- but I had no economic incentive to do so, since insurance was covering it all.

Ah, yes...Why?...sorry...

We are locked into Health Care mechanisms operating between the FDA, the corporate hospitals, the AMA, the pharmaceutical companies and the health insurance industry. Furthermore, the Federal government continues to divert our excess Social Security-Medicare contributions into the general revenue fund.

Finally, the politicians who might be so bold as to disrupt this structure in time to reverse the current trends before a crisis becomes inevitable would take such heat that they could not stay in office long enough to follow through and make it happen.

What we are doing today is unsustainable, of course (health care costs are trending to take over our entire economy) but it is moving so slowly toward collapse that the government will not be able to reach in and reverse course before the system is past some critical moment.

This is worse than the inevitable decline of our automobile industry and the displacement of the Big Three by foreign entities who are simply "better, faster and cheaper" at our own game. With Health Care the stupidity of arrogance is held in place to be executed by the hypocrisy of the democratic process.

However, we will not actually be denied "better faster and cheaper" health care goods and services in the end (it is a matter of life and death after all)...any more than we were unable to purchase superior automobiles (from someone else) that Detroit could not deliver.

If our own Health Care players cannot do this then who will actually serve such demand? Foreign competitors must eventually be allowed into our markets. Like I said, there is simply too much money on the table.

Medicine is not sacred. All mature industries must move toward commodity pricing through global competition.

Pricing is ultimately restricted by costs.

Costs are made up of material, labor and overhead.

We are burdened by too much overhead.

OK...let's look at costs then...
Dr. Leishman,

The MRI procedure is priced at $2000 because of what? Let's briefly break down the material, labor and overhead costs involved.

We are trying to screen a substantial population of patients with acute, severe headaches to identify those whose condition is benign versus those with something quite life-threatening.

The medical technician operating the suite should be able to do 80% of these diagnoses, shouldn't she?

There are some number of (non-magnetic) MRI disposables...(and they are overpriced, of course).

But the major expense is the overhead burden rate associated with the MRI device itself. And the suite.

As the number of MRI machines being produced and deployed into the global health care market increases then the $3 million price tag (per suite) should come down. Currently the cost to operate such a facility is $500 thousand per year. At $2,000 per procedure this cost is covered with 250 such patients...approximately one a day during the work week.

Of course, there are other overhead costs, the fees paid to the various Radiologists on staff and then there is the profit for the hospital.

Anyhow. MRI is considered too expensive to use as much as we probably should because the various built-in costs are too high?

Failing to adequately diagnose a patient who might indeed have a serious, operable condition we could easily discover...because our costs in this industry are not subject to reasonable competition...this is the worst possible outcome.

"When those individuals reach their day in court, amid the trial-lawyer-enabled liability environment, juries are unimpressed by save-the-whole-system arguments, and just see the injured individual on the witness stand."

This is not what a physician is supposed to be concerned about. You should be reading Medical Journals. If you wanted to work on such matters you should have gone to Law's easier than Medical School.

Let's get these costs down here in America. If we don't then someone else (somewhere else) certainly will.

good points, forest
So, why do MRI's cost as much as they do? An excellent question indeed. Part of it is that imaging technology continues to improve in both speed and accuracy, and the new-improved models replace the old, giving an amortization period of two or three years for each unit. One could argue that today's version is "good enough", and may well be so in the thought experiment offered. I could equally well argue that my 1 megapixel digital camera of six years ago was "good enough", although my 6 megapixel camera of today (both cost the same $300 at the time of purchase) is so much better. Would I go back to a 1 megapixel camera for $80? Probably not. As to the second point, that physicians are not supposed to be concerned about medicolegal issues.........having been a defendent once, about twenty years ago, even when I was not at fault, it's something I wouldn't want to do again.

Philipines and India.
There are already quite a large number of procedures being performed on patients (primarily from countries with socialized medicine,) in both the Philippines and India. In fact, a former roommate of mine works in a clinic in Bombay that specializes in the provision of orthopedic surgery to foreign patients. The phrase "medical tourism" was coined to describe this phenomena. Forest is not only using sound reasoning, he's already been proven correct.

If we Americans decide to take the Soviet route with regard to our health care, I'd expect the flights to Calcutta and Manila to be packed with sick and injured Americans trying to get timely care.

There is Cost Pressure
With consumers responsible paying for less than 15 percent of personal health care spending out of pocket, health care providers are insulated from the pressure to provide quality service at low cost.

Absolutely not. Major insurance companies are ruthless in negotiating fee schedules with hospitals and physicians. Medicare and Medicaid set fees by fiat, with Congress frequently stepping in to "defer" increases. They are also, on behalf of the companies that buy their policies, taking a hard look at outcomes on the most expensive procedures and diverting patients to the best facilities by increased copays at the less successful facilities. (Heart surgery is one area where this is being done.)

State medical boards have more than one interest trying to control them
Health insurers and doctors compete to control medical boards. Insurers often win.

defensive medicine is far more extensive than you think
There are plenty of instances of defensive medicine that do not traditionally get counted in the category. For instance doctors in the US do not train for stethoscope skills. Why should they? they run a test on a fancier machine which provides a marginally better result than a highly skilled physician but costs orders of magnitude what listening through a stethoscope properly does. The tests are sold as being better, and they are. But the tests are really conducted because if you don't order them and find yourself in front of a jury, you're cooked.

Physicians who *are* highly skilled with a stethoscope because they trained in a country without all the fancy machines (my wife is one of them) order the tests as well. The fear of lawsuit makes them forego a significant cost savings. It's not worth their license to save a patient $750 for the unnecessary test. No piece of software is going to properly adjust for the presence of a finely trained physician's ear and the cost savings possibilities of that skill. Exercising that skill is dangerous to your license in todays legal environment.

bring MRI costs down.
One way might be for the likes of Wal-Mart to run MRI facilities. Do you really think it would cost $2k if so? Or if foreign companies had such clinics; no way. But the reason WalMart probably wont' run them is for the same reason they wouldn't let them start a bank either. Why was that again?

Excellent explanations by Forest and Dietmar; thank you.
I understand much better now what your point was.

I suppose I am holding put the hope, however slim, that increasing the rate of health literacy in the United States could work to get people voting for the right policies.

I also kind of misunderstood your point (at first)about foreigners creating better health care in terms of quality, although I have long been an advocate for the United States needing to accept and absorb the good principles and aspects of Eastern preventive/holistic medicine into Western treatments.

On Friday, a new report released by the University of Connecticut stated that the cost of low health literacy -- or the degree to which individuals have the capacity to obtain, process, and understand basic health information -- to the United States economy totals anywhere from $106 billion to $236 billion annually. The report has experts discussing if improving health literacy is the real solution to providing affordable health care coverage for the nation's 47 million uninsured people.

According to the U.S. Department of Education's 2003 National Assessment of Adult Literacy (NAAL), which contained a health literacy component for the first time, 36 percent of the adult U.S. population , or approximately 87 million people, has just either a Basic or Below Basic health literacy level.

The new health literacy report was supported by a research grant from Pfizer.

Some medical experts are now asserting that the failure to provide or support a public policy educating Americans into a more than Basic health literacy level is bringing about needlessly high costs in terms of individual health, healthcare spending, and the economic well-being of the nation as a whole.

"Our findings suggest that low health literacy exacts enormous costs on both the health system and society, and that current expenditures could be far better directed through a commitment to improving health literacy," said John A. Vernon, PhD, Department of Finance, University of Connecticut, and lead author of the new report.

"Providing the U.S. population with access to affordable coverage creates a more level playing field among those who are and are not health literate. It is particularly challenging to improve literacy among populations who lack affordable access to timely and appropriate health care," says Sara Rosenbaum, JD, The Harold and Jane Hirsh Professor of Health Law and Policy and Chair of the Department of Health Policy at the George Washington University School of Public Health and Health Services.

"An individual's health literacy skills have a profound impact on his ability to manage a chronic illness, such as diabetes or high blood pressure. If an individual understands and can act upon medical instructions, unnecessary emergency department visits and hospitalizations can be reduced, which in turn lowers overall healthcare costs," says Barbara DeBuono, MD, MPH, Executive Director, Public Health and Government,
Pfizer Inc.

Original Source:
University of Connecticut (PR Newswire), "New Report Estimates Cost of Low Health Literacy Between $106 - $236 Billion Annually"

But a physician has to be aware of what will impress juries,
because our litigious society is impacting the medical industry, even with it being Socalism-Lite as it is.

Too-narrow specialization is not effective for advancing society. Progress in science suffers a lot from too-narrow specialization even now.

Previous generation devices, that (by the way) were the equipment incorporated into all the published research have exceptionally low values on the secondary market. Especially for leased units.

In spite of its lower sensitivities all such hardware was thoroughly worked over by the FDA and, indeed, went into service when we already had the next generation models in clinical trials. There was nothing wrong with those somewhat older technologies. Or we would never have rolled them out when we already "knew better".

This would be important insofar as the older suites could be used to inexpensively screen patients who might otherwise be considered marginal, optional or as having "acceptable risks" if not diagnosed fully.

The problem with this is that the hospitals would canabalize some of their higher cost procedures...needed to justify the cost of the new machines. The good news is that many of those devices end up in foreign hospitals.

I realize that the very good minds who devote themselves to the practice of Medicine should have wide ranging interests throughout all aspects of our society. Legal considerations do impinge on your freedom of action regarding the medical profession. Just as business considerations must. Politics too.

I always believed that a spot in Medical School carried with it a sacred duty to immerse oneself in the practice of medicine itself...and to forsake all others. But that attitude was only childlike idealism.

The physicians of the world should, indeed, take into their own hands the power to do the right thing without the limitations placed on them by politicians and without egregiously serving the interests of those in other parts of the industry (pharmaceutical houses, hospital corporations, health insurance companies, the FDA and the CDC) who might have conflicting agendas.

We are way past a more passive "do no harm" posture now.

Only in America...
Well, many not only here...But if our litigenous tendencies make us less competitive in the global arena (once reasonable competition gains traction) then we will either stop behaving like every negative occurrence in our lives is an opportunity to "hit the lotto"...or we will suffer for it.

Wal-Mart Bank...
Anytime Wal-Mart wants to have one of its wholly-owned subsidiaries charter a bank in one or the other of the myriad foreign jurisdictions they operate within...they can. I would.

There's the problem with the mandatory insurance
If everybody in the country is required to buy healthcare insurance, there won't be any economic incentive to keep medical procedures at a minimum since 'we have to pay for it anyway' I hope at least one candidate isn't for making healthcare insurance mandatory. I don't need any mandatory expences beyond the ones I'm paying already.

The best defense...
is a good offense.

Although I have no doubt your wife has an excellent ear, that skill is usually the product of years of experience. An example would be my mother whose doctor found her lung cancer before it spread by listening to her lungs.

He had a suspicion and then ordered more tests. While I am sure that doctors order procedures to cover their ass I see that as symptom of litigation rather than an end unto itself.

Your Luddite attitude of human senses being better than technological advances is quite interesting. I have no issue with a doctor confirming a suspicion with further tests and, in a deregulated healthcare market, such tests would be the choice of the patient and not the doctor. Do you trust your physician's ear or do you wish a confirmation? Your call.

Chewing off the corners of the puzzle pieces
I think that there is a somewhat subtle problem with setting the "superquants" on analyzing medicine.

Ok, I'll start off with full disclosure: I practice a completely different discipline where diagnosis is a central skill -- I'm a computer programmer. And, quite frankly, I don't think much of how physicians approach the task of diagnosis.

Having seen how doctors are educated, I wonder if it doesn't start there. It looks to me like medical education is a matter or memorizing a catechism. There are a whole series of stylized case studies, where all of the symptoms are presented in a certain order, and the medical student memorizes the correct answer to the stylized case study.

And then real life happens. The patient with the blood clot doesn't have any copies of the gene that metabolizes warfarin. The woman in labor changes positions and her contractions get closer together, but shorter and less intense. Do you give the patient with no copies of the warfarin gene higher and higher doses of (totally useless to him) warfarin until the blood clot kills him? Do you tell the laboring woman to move herself into the position with the weak ineffective contractions until the clock runs out and you do the c-section?

What I have seen firsthand is that all of the health care professions are extremely wedded to their protocols, and once they stick you into a category they are resistant to noticing any information which would force them to move you into another category. So my friend who was going into the hospital for her scheduled c-section had an IV inserted, and her blood sugar got to over 600 before she realized that the IV had ringers in it. Because the standard protocol was c-section = IV, and IV = ringers, and so the nurse didn't read any further on the chart as to the reason for the c-section was that my friend, who is a type I diabetic, was 35 weeks into a very complicated pregnancy and it was time to get her 11-lb son out of there. Or the friend who was at 4cm when giving birth to 32-week twins, and then 5 minutes later told the nurses that she needed to push (she had given birth before, unmedicated, so was familiar with what "needing to push" felt like) and they ignored her, since the protocol is to check only every two hours when a woman is at 4cm. She did, fortunately, have the presence of mind to scoot up the table before delivering the baby 30 seconds later. I always tell a newly pregnant woman that if she knows when she ovulated, and it is significantly different from 2 week after LMP, then the most important decision that she can make is to lie to the nurse who asks her when her LMP was. It's a literally life-and-death decision if she finds herself in labor 28 weeks after LMP but is only 20 weeks post ovulation. (Most of the examples I know firsthand revolve around pregnancy and childbirth, since that is where most women have most contact with the health care system.)

What's the first thing that any quant doing analysis of medical effectiveness does? Model the problem. Which means, inevitably, assuming the diagnosis. Or, another way of looking at it, they are going to take the same stylized case studies that are used to educate medical students, and use them as the framework for their studies. What us quant types call systematic error...

Take the c-section example. This is a really big deal, because the c-section rate is now up to about 30% of all deliveries, and childbirth is not rare. The problem with guidelines-as-a-substitute-for-thinking is that with 4million+ births in the US per year, there are lots and lots of individual cases that don't fit into any of the half-dozen stylized memorized case studies, and the all-purpose OB solution to any unexpected labor happening is to grab a scalpel. Certainly the legal environment makes this far, far worse. Even more important than the legal environment is that the social value is that if anything goes wrong with the baby, no matter how clearly the doctor has no responsibility at all, and the doctor's actions had no bad outcomes, even accidentally, the doctor gets sued, while on the other hand, no malpractice against the woman, no matter how egregiously negligent (e.g. non-emergency c-section without anesthesia) results in any criticism at all, let alone legal action.

A big part of how we got to a 30% c-section rate is that doctors got very quick in going to sections because they were ignoring all of the individual case information which said that this or that individual section wasn't necessary. Then they decided that vbacs were perfectly safe, so they got really sloppy, doing things like inducing vbac labors for convenience, and even worse, using cytotec, and then when the rupture rate skyrocketed, they decided that vbacs were terribly dangerous. A big part of how they lurched into that situation was being unable to deal with anything not black-and-white -- either c-sections are trivial or terrible, vbac is perfectly safe or terribly dangerous, if cytotec is safe enough to use at all, then it's perfectly safe and no special precautions need to be taken. A big part of how we got into these two-valued systems is that we had medical research being done with too few variables in the model. (Usually because they are being done on the cheap and there are too few subjects to support all the variables that need to be measured.)

How sad but true.
"Having seen how doctors are educated, I wonder if it doesn't start there. It looks to me like medical education is a matter or memorizing a catechism. There are a whole series of stylized case studies, where all of the symptoms are presented in a certain order, and the medical student memorizes the correct answer to the stylized case study."

That's about the size of it.

To me, that's why the real solution to the American health care condundrum, as things stand now, is (at root) vastly increased health literacy. I think that could serve to drive all of the other needed changes.

That doesn't address the point at all.

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