Friday, November 21, 2008

Care for Chronic Conditions in the U.S. Stinks

Although the issue of healthcare was largely absent from the recent elections, I continue to be amazed at the naïveté of many Americans who truly believe that healthcare in the U.S. is vastly superior to most other countries (not that they've ever used the healthcare systems in any other countries to make a comparison). I think I may have mentioned this, but in 1987, I actually lived as an exchange student in Finland -- the home to Santa Claus (where they actually eat reindeer, which is not half bad when prepared properly, unless you happen to be a vegetarian), and the birthplace of the sauna (which is a Finnish word, BTW). Finland is also home to cell-phone giant Nokia, and the country which has the highest incidence of type 1 diabetes bar none.

These "average Americans" (perhaps best depicted by "Joe the Plumber") I mention tend to base their uninformed opinions on unsubstantiated rumors related to healthcare rationing and long waits for live-or-die surgeries. In reality, their perceptions are usually overblown or just plain wrong. Even conservative publications like BusinessWeek as well as more liberal publications like The New York Times are reporting a rise in "medical tourism" because the cost differential between the U.S. and most everywhere else on earth is simply too big, and its actually cheaper to send people to Asia, South America or Europe to have major surgery done there than it is to do those operations in the U.S. -- and that includes the cost of air transportation and everything else. Although residents in other countries sometimes complain about their National Health Services, the irony is that few (if any) would consider trading their systems for the supposedly "superior" U.S. system -- the one which left 47 million Americans completely uninsured last year.

Less we need any further example, according to a new STUDY by the Commonwealth Fund, a New York-based foundation that has pioneered in international comparisons, chronically-ill Americans (e.g. those who suffer from at least 1 of 7 key chronic conditions: including hypertension, heart disease [including heart attack], diabetes, arthritis, lung problems [including asthma and emphysema], depression and cancer) suffer far worse care than their counterparts in seven other industrialized nations (the other countries examined include Canada, Australia, New Zealand, the United Kingdom, the Netherlands, France and Germany).

The U.S. also stands out in this study for having the most expensive system ($7,000 per capita vs. <$3,500 per capita in the other countries as of 2006), for its enormous gaps in coverage (e.g. many Americans are uninsured, even if they are employed full-time), and for its high cost-sharing -- even for patients with insurance. As one might expect, the uninsured suffered most, but even 43% of those who had insurance all year skipped some care due to the costs. The trend of high cost sharing in the U.S. continues unabated. In fact, the median deductible for traditional PPO plans (the most common type of insurance offered by employers) doubled in 2008 to $1,000 according to a new study from Human Resources consulting firm Mercer (see the WSJ Health Blog for more detail here). Not surprisingly, this week, The New York Times featured an editorial on our abysmal rankings for chronic disease care in the U.S. The author concludes "The care Americans with chronic conditions received — or more often did NOT receive — ought to be a cause for shame."

Taking a closer look at the Commonwealth Fund chronic care study, we see that more than half of the American patients went without care because of high out-of-pocket costs. This means they did not visit a doctor when sick, skipped a recommended test or treatment or failed to fill a prescription. But Americans with chronic ailments are also most likely to report wasting time because their care was so poorly organized (think of all of the referrals and redundant paperwork/forms typically required to obtain care or process claims as an example). About a third reported that medical records and test results were not available when needed or that many tests were duplicated unnecessarily. One-third experienced a medical error, such as being given the wrong medication or test results as a result. Overall, some 40% found it very difficult to get after-hours care without going to a hospital Emergency Room. The Times editorialist concludes "By contrast, Dutch patients reported far more favorable experiences with their health care system, largely because the Netherlands provides universal coverage (through individual mandates and private health insurance), a strong primary care system and widespread use of electronic medical records. It should be possible to achieve the same level of performance here."

That remains to be seen.

The FDA, the CDC, Medicare and Medicaid all fall under one federal department: the Department of Health and Human Services. This week, news broke that Tom Daschle, the former Senate Majority Leader, will soon be Obama's HHS secretary. Daschle will likely face easy confirmation by his former Senate colleagues, but the bigger job will be to implement a universal healthcare system for the U.S., a $2.3 trillion industry that accounts for about 16% of the U.S. economy (whose share is growing). By turning to the former Democratic leader to serve as his Department of Health and Human Services secretary, President-Elect Obama hopes that Daschle will be well-placed to work with Congress and pull together various interest groups to try to build consensus behind a sweeping overhaul. But its worth noting that every other Democratic President from Harry Truman to Bill Clinton has tried -- and failed -- to accomplish this herculean task. Daschle could also pose some thorny conflicts-of-interest problems for Obama's promise to change the way Washington does business. For example, the Obama Administration could require him to recuse himself from any matter related to either the Mayo Clinic or some of the clients he advised at Alston & Bird — a potentially broad swath of the health secretary's portfolio. But Daschle will be responsible for managing a $707.7 billion department with nearly 65,000 employees spread across 11 operating divisions. As HHS secretary, he will be under enormous pressure to revitalize the Food and Drug Administration (FDA), bring financial stability to the Medicare and Medicaid programs, and move away from what the consensus seems to be is the ideologically driven scientific agenda of the Bush administration.

Mr. Obama and Daschle will also be limited by a lack of money, as runaway deficit spending under Republican leadership ballooned over the last 8 years. I can't do that particular topic much justice, but a visit to has more than enough facts to validate this assumption.

During the long primary, Hillary Clinton kept nagging Mr. Obama about his healthcare plan's lack of an individual insurance mandate. The health insurance industry, not surprisingly, wants the federal government to require all Americans to have and maintain insurance, but Obama wants the rule, at least initially, to apply only to children. Think for a moment why a universal mandate is necessary. The many moving parts of healthcare reform simply don't work together unless the young and healthy are also paying into the system (and can therefore help defray the cost of caring for the older and sicker). Without all groups paying into the system, the economics of serious healthcare reform really don't work. But if the 1993 Clinton Healthcare experience taught us anything, it is far easier to work with incremental change rather than broad change -- initially.

Dashle even wrote a book entitled "Critical: What We Can Do About the Health Care Crisis", published in Feb.) to give us an idea of where he'd like to take things. The Wall Street Journal Health Blog wrote:

His basic idea: Create a board modeled on the Federal Reserve to "offer a public framework within which a private health-care system can operate more effectively and efficiently — insulated from political pressure yet accountable to elected officials and the American people."

Also, Henry Waxman just unseated John Dingell as chairman of the powerful House Committee on Energy and Commerce. That's a big deal for the health-care world, because the committee will be one of the key power centers for any big health-care reform bills. And it's a central player in Congress' relations with the drug and device industries. Perhaps 2009 will FINALLY bring some meaningful changes, even if they are only incremental.

Since 1993, U.S. Congress has done nothing to address this elephant in the room. But in the meantime, people with diabetes and other chronic diseases, which are demonized as being huge burdens on the cost of U.S. healthcare, might have a role to play. If they can make these people healthier, that would almost certainly help stem the rise in costs, but that also means taking better care of us to reduce the long-term costs that are associated with the current short-term business model for handling people with chronic conditions. Perhaps it would be wise to take another look at the Netherlands as a model on how to approach our reforms (last year, I suggested looking at the Netherlands model ... that country ranked highly in the Commonwealth Fund chronic care study, but its also important to look at the reasons why that country scored better than we did.


Jenny said...

I have been giving a lot of thought to the possibility of health care reform and the fact that every group involved in this reform has high paid lobbyists bending the ears of congresspeople except for us patients.

I don't see an easy solution for that, because most chronic disease patients can barely pay for their meds so they can't buy even a small share of a congressman, nor do they have the time or energy to invest in effective political action.

But because we patients aren't organized, we'll get whatever plan benefits the doctors, hospitals, insurers and drug companies. Not the one that benefits us.

Any plan that gives all Americans affordable access to some kind of health care is better than what we have now. But we may see some nervous making tradeoffs.

Right now as a MA resident, I have access to full health insurance despite my diagnosis. But the insurers I can choose from tell me which insulin they'll cover and it isn't the kind I do best on (Apidra). Pens are out, too, so it is back to vials and syringes. The only way you can get a pump is if your C-peptide is zero and even then, it's a struggle. CGMS? Don't ask.

Even so, a person with diabetes is much better off in MA. And if they are poor, their insurance is subsidized. So it's a lot better than in, say, Indiana, where if you have a chronic condition you can't buy insurance no matter how wealthy.

But we are going to end up having treatments foisted on us because they are "cost-effective" in the aggregate, not because they are best for our own, personal health.

Scott S said...

Jenny, I agree, but the time to stand around and discuss how to address the problems is gone. My feeling is we need to do something (anything? and we can worry about making it better (or perfect) later. Right now, U.S. businesses are burdened with healthcare, which explains why GM, Ford and Chrysler collectively manufacture more cars in Ontario, Canada than they do in neighboring Michigan, where the corporate headquarters are. I realize they may not be the best example (the CEOs for these companies were in Washington panhandling this week), but these businesses do demonstrate the burden that healthcare puts on all U.S. industries. Massachusetts will be an important test-bed for any national reform, even though the state's higher per-capita income, higher education levels, level of white-collar employment, and other facts don't make the state an ideal model for the U.S. as a whole. I think we need to hope that our elected leadership in Washington has the guts to actually do something on this issue, because they've historically ignored it hoping it would just go away ... which it didn't! As you note, affordable access to some kind of health care is better than what we have now!

Anonymous said...

When I saw your headline for this post, I had to click on the link because doesn't the title really just say it all?! I was at the eye doctor today (good report) and to see the care I got compared to the elderly man after me on Medicaid... it was just sad.

Anonymous said...

Scott, your post include lots of statistics but fails to explore what they really mean. It's clear your mind is made up, and no one is going to convince you otherwise, but if someone else is reading...

Healthcare is a finite resource. There are not enough great doctors to see every patient on the suggested schedule. Under nationalized healthcare, doctors' salaries are capped. Bright college students deciding on their future career can then choose between a doctor with a finite salary, or an attorney or businessman with higher salary potential. Most will not choose doctor. A shortage in quality healthcare like that takes awhile to feel, but once it happens, it's VERY hard to reverse. You can't make more doctors overnight.

Under NHS, you only qualify for an insulin pump if you cannot get your A1C under 8.5 on injections. Most people can achieve that kind of control on injections, so you'd have to intentionally damage your body for over six months (and somehow keep your doctor from figuring out your sabotage) to get one. Also, the number of endocrinologists in England is very small, and there's no automatic provision for endocrine care - they consider type one diabetes a disease treatable by a normal family doctor.

The current U.S. system is in no way a free market. In a free market, insurance companies would have to compete for your business, so they'd offer *more* services for a *lower* price. No lobbyists involved, no politicians to pay off. (Also, they can't collude to fix prices, because that's illegal in a free market system.)

Minimed will give anyone an insulin pump on a no-credit-check three-year payment plan. No one is forcing them to do it. They do it because it means they get more sales, and in turn it makes lives easier for lots of people. That's a lot different than skipping injections for six months to try to qualify for a pump in England.

I have great insurance as a self-employed individual in Washington State. If the government wasn't involved, anyone in the entire country could buy my policy - $200/mo, $500 deductible, low co-pays ($20 for two months of Novolog).

As a diabetic, who do you feel should be making decisions about your healthcare: you/your doctor, or politicians? Because under socialized healthcare, your doctor's hands are tied AND expenses go up. That's a no-win for everyone.

Thanks for listening.

Scott S said...

The question is not whether the decisions should be made about doctors or politicians making decisions, but whether the decisions should be made available only to is the system now in place in the U.S. I'd rather have a system which is available to everyone over a system that is increasingly unavailable except to only the young and healthy.

Scott S said...

For everyone interested, see The Washington Post article for more details on this subject: highly worth reading!

Jenny said...


Ms. Martin posted the same message over on my blog when I discussed health care reform. Other posters questioned her and found out that her "wonderful plan" is not available anymore and current plans offered are much more expensive with extremely high deductibles.

Read discussion here

I wonder if she is an industry flack--one of the many who are paid to pretend to be real people and post online in ways that advance the agendas of their employers.

Scott S said...


As always, thanks for your comment (always relevant!).

Anonymous said...

I'm not an industry flack. The plan is through Regence Blue Cross of Washington and you can see their rate sheet right here:

My plan is $203 a month for a $500 deductible, but since August the lowest deductible they offer is $1,000 - for $147 a month, which still ends up being pretty close.

No one addressed my point. You want NO access to insulin pumps, as decided by your legislators and not your healthcare team? Really?

Scott S said...


Healthcare is indeed a finite resource, but I challenge your underlying assumption that private, for-profit insurers will necessarily make better patient care decisions than government-run insurers. So far, you have only cited a single example of a National Healthcare Service in the U.K., rather than taking a more global look at countries including places like Sweden, Finland, Denmark, Norway, Germany or France. You also imply that doctors should make the decisions, but the reality is that with the current "system" in the U.S. (surely, that is a misnomer, since far too many people are excluded for it to be considered a "system").

The reality is that in today's environment, doctors have a limited say anyway ... the decisions are often decided by insurance plans or made via third-party pharmacy benefits managers (PBMs) and various insurance appeals processes and claims. To imply that in the U.S., doctors are making these decisions is a joke.

Consider that in the U.S., many people are effectively forced to use a different drug to treat a condition because it is a "preferred" brand or it is on the formulary of their insurance plan, rather than the one their doctor might normally prescribe, and this is no different than having a national insurance plan making these decisions.

In terms of your claim on insulin pumps, as a former-pump wearer myself (and I have type 1), I did not find a pump to be a necessity by any stretch of the imagination, so if that wasn't covered tomorrow, I would not be losing sleep over NO access to insulin pumps. However, others might disagree, but the published scientific literature is remarkably clear on this, too: pumps tend to show the most clinical benefit among patients who a) have poor glycemic control to begin with (there is almost no incremental improvement in glycemic control at lower HbA1c levels), for those whose basal insulin needs vary considerably throughout the day, or for those who are sensitive to even small changes in dosages and therefore need to be able to dose in units smaller than 0.5 IU. The cost of pumping has gone down considerably since competition entered the market, in fact, today, Insulet can offer a product which has considerably smaller out-of-pocket outlay than Medtronic, Roche or J&J (not to mention Sooil, Nipro and some others who now compete in this space). Competitive bidding would, however, impose a particular brand on patients, unless rivals could match that, and that is a perfectly acceptable option. Some National Health Services (in places like Sweden and Germany, for example) DO cover insulin pumps (in Germany, coverage may vary from one state to another), so not all operate the same way the U.K. NHS does. But I would argue that this conversation is kind of like bickering about what kind of caviar you should have to go with your champaign while millions don't even have food -- how selfish!

Any plan that gives all Americans affordable access to some kind of health care is better than what we have now, and yes, tradeoffs will need to be made.

But why is it that you seem to subscribe to the belief that healthcare is not a right, but a privilege, the way it works in the U.S. today? With the current U.S. system, healthcare is a PRIVILEGE, not a right!

Anonymous said...

Blog comments will always be overly-general because I don't have room to fit my PhD thesis in economics in this character count. That said...

When the government pays for all healthcare, you have only one choice - that is, no choice. With no competition, there is nothing to lower cost and increase benefits, which is what happens when, say, insulin pump manufacturers compete against one another to offer the best possible pumps at the lowest prices (or different types of pumps to meet different needs - I love a particular type of infusion set that another may not, and vice versa).

Ultimately someone pays for all of this healthcare. And that someone ends up being everyone - in the form of higher prices, higher taxes, etc. It also means you added a middleman - the government - who takes a significant cut to cover their own overhead, and the lack of competition means nothing keeps prices in check, so prices for everything go up, and everyone pays more. Attempts at keeping prices in check, like capping doctors' salaries, results in lower quality healthcare overall as talented people choose other, non-capped fields.

Current healthcare costs would be lower - and more accessible to more people - if the government got out of the healthcare business entirely. When Medicaid and Medicare set prices that are often below a doctor's costs, the only way the doctor can make up that deficit is to charge the non-Medicaid/Medicare people even more. If they didn't, they'd go out of business, and it's the fault of government intervention.

The poor in the United States have the highest standard of living *ever* - in most cases they have cars, television, washing machines, and air conditioning.

Healthcare is not a right. I understand that we care about the welfare of other human beings and want them to be cared for, and you may *want* it to be a right, but that doesn't make it a right.

Another point, with three premises: (1) everything is the result of individual actions/decisions ("The United States" cannot decide anything - individuals representing the United States can make decisions and take action, though); (2) individuals are almost always motivated by incentives (money, fame, power); (3) the ultimate priorities of healthcare should be: prevent, cure, and THEN treat, in that order. We'd rather no one get diabetes in the first place; next to that we'd rather have a cure; if neither is possible, we want better treatments.

Given those three premises, government officials have just enough incentive to earmark some amount of funds towards researching most diseases, so they can gain re-election (power). They have almost no incentive to craft policies and direct funding to cure or prevent disease. (What they really have is no incentive to research it closely enough, because they achieve their goal by just putting some money towards it as a token.) I want a healthcare system where private companies have the incentive to cure diseases, which is the only one where we'll actually see cures and not just more band-aids.

Anonymous said...

I would also disagree with Marina about future "doctors" choosing to go into law or business if they can't expect humongous ROI's after graduation. Somehow, I always felt that the very good doctors had a calling--either for "the science" or "the humanity" . . . possibly both. Those future doctors who only see dollar signs at the end of their (often subsidized) education probably SHOULD go into LAWYERING or business!

The argument is akin to the pharmaceuticals who claim if they can't extort high prices from patients, there will be no incentive to "do the research" and hence, the pipeline for all innovation and progress in medicine will dry up. True inventors and researchers (like the true doctors I referenced above) will keep right on tinkering--even in THEIR basements on THEIR time--because it is WHAT drives them. True, we might not see 3rd generation Prozac or Nexxium . . . but somehow, I don't think Salk or Sabin or Banting or Best . . . or even our crusader Denise Faustmann are DRIVEN by the big bucks at the end of the rainbow.

Marina obviously buys into 'American exceptionalism.' American exceptionalism is gone; with failing schools, offshored jobs, unions on life-support, and MBA's 'greed is good' mantra . . . she premises her claims on a lack of good doctors. For almost a century the AMA has successfully and intentionally limited the number of qualified candidates admitted to their brotherhood. It would be stupid to NOT consider the possibility that many excellent doctors have been excluded from medical schools because their 'spot' was taken by the 'chosen ones' of the rich alumni or the medical family that has graduated several generations of doctors from the chosen institution.

Marina's whole premise is based merely on the profit motive, free enterprise, and captive patients. Insanity is defined as doing the same thing, in the same way, over and over and EXPECTING different results. We MUST STOP the insanity.


Anonymous said...

Oh, boo hoo hoo, you can't get a pump. I'm uninsured and just hocked my TV so I could guy some Humulin R. Forget any Lantus, it's completely out of my reach, so I limp along on R only and wake up with what must be 900 blood sugars since I slept through my alarm that wakes me up so I can shoot up every four hours. Of course, I say "must be" because a test strip is something I haven't seen in years.

So boo hoo hoo about your precious little pump.

Jenny said...

Googling Marina Martin turns up the fact that she's a big Ayn Rand fan. 'Nuff said.

Also that she claims to have had Type 1 diabetes for many years in some postings, but says she was diagnosed with it in 2004 on her profile.

Anyway, her post gives us all a very good idea of what we are up against. Ideologues with great health insurance have NO clue what the rest of us have to deal with.

Anonymous said...

It would appear that Marina and most of today’s “free marketers”—who consider competition the best way to level the playing field—have not recognized the fact there are always unscrupulous doctors (or any other professional) who are willing to take the money and run.

Some of the most dedicated doctors in the world are located at our VA hospitals. Their salaries are pretty much capped. VA patients many times complain about their medical care—which is free; but if you consider the emotional state most (many) are in, these complaints must be taken with a grain of salt. I hope our new administration will provide better funding for care of military.

Good insurance for bad drugs and/or bad treatment amounts to bad patient outcomes and the only ones who win are those receiving the money. In my 53 years with T1 diabetes, I have tried more options than most of you can even consider as acceptable treatment. None of the treatments—including insulin pumps, continuous glucose monitors, the so-called life-line bG meters, and insistence on “good numbers”—are a substitute for better medicine. Diabetics, as patients, are at the bottom of the food chain in terms of good care, while providing the most profitable for doctors, hospitals, pharmaceutical companies, providers of high-tech equipment, and insurance companies who use our expenses to justify their continual rate-increases across the entire population. Free markets are never good with scam artists and crooks at the top—in other words, the markets are not truly FREE.


Anonymous said...

Scott hasn't approved my last comment, and probably won't approve this one either, but no comment

And Jenny, I've been diabetic since 1994, not 2004 - I haven't been to TuDiabetes in forever and must have picked the wrong option. Regardless, how does having diabetes for 14 years or 4 years make a difference to my case? And how does my enjoyment of fiction novels play into that, exactly?

Fine. You all live in your liberal bubble. I just wish you could keep your hands off MY healthcare in the process instead of forcing me to suffer along with your well-intentioned but ultimately misguided policies.

What will you all do if Dr. Faustman's totally-privately-funded study is the one that finds a cure? Damn those evil market profiteers for earning money so they could give it to her.