By Maggie Mahar
Dr. Nortin Hadler, author of Worried Sick and Stabbed in the Back, is well-known for debunking medical myths. But in his latest book, Rethinking Aging (UNC Press), Hadler, a professor at the University of North Carolina, Chapel Hill, commits what some might call medical heresy, suggesting that, perhaps, as we approach middle-age, “It’s OK to be Overweight.”
Wait a minute. What is Hadler saying? Everyone knows that obese Americans are driving our health care bills to the moon. Some argue that they should pay higher insurance premiums. Meanwhile, those extra pounds are sending millions to an early grave. And we all know that if our obese neighbors would just put down their forks and get on a treadmill, the pounds would melt away.
But as is so often the case, what “everyone knows” just isn’t true.
Myth #1: The U.S. spends so much on health care in large part because too many of us are just plain fat.
Here, the conventional wisdom ignores a compelling 2007 McKinsey & Co. study which demonstrates that obesity does not begin to explain why, in 2005, we shelled out $480 billion more for health care than peer nations.
Make no mistake, obesity is expensive, and linked to a host of diseases–especially later onset diabetes.
But when McKinsey’s expert number-crunchers compared the prevalence and cost of 130 diseases (including obesity, heart disease and diabetes) in the U.S. and six other countries (Japan, Germany, France, Italy, Spain and the UK), they discovered that the U.S. spent under $25 billion treating all 130 conditions—a fraction of the “extra” $480 billion that we spent on health care. Read more…
Patients who report being highly satisfied with their doctors are not always getting the best care and, surprisingly, are about 26% more likely to die than people who feel more ambivalent about their physicians.
In a study published in the Feb. 13 issue of the Archives of Internal Medicine researchers from UC Davis found that in a nationally representative sample of more than 50,000 patients, higher satisfaction was associated with a 12% lower use of the emergency department. That’s clearly a good thing. But, it was also associated with a higher elective hospitalization rate, and a 9% increase in health care expenditures, including on prescription drugs. And then there’s that higher risk of dying. The most satisfied patients—even though they were often the healthiest at the beginning of the study—were more like to die than the least satisfied patients. What’s going on here?
Patient satisfaction data has become increasingly important as these measures are used to help consumers choose providers and, in some cases, to determine physician compensation. As the UC Davis researchers report, “Patient satisfaction data may empower consumers to compare health plans and physicians, and both the Centers for Medicare & Medicaid Services and the National Committee on Quality Assurance require participating health plans to publicly report patient satisfaction data. Health plans use patient satisfaction surveys to evaluate physicians and to determine incentive compensation, and consumer-oriented Web sites often report patient satisfaction ratings as the sole physician comparator.”
That’s giving a lot of weight to a subjective measure that relies on what other, smaller studies suggest is a “tenuous link” between patient satisfaction and the quality of care and health outcomes. This is especially true when it comes to older, vulnerable patients, where studies have found that “patient satisfaction had no association with the technical quality of geriatric care.” Read more…
Mitt Romney’s latest attempt to portray himself as “severely conservative” has him fomenting the attack on new legislation that requires all employers, including religiously-affiliated institutions like universities and hospitals, to provide employees with health insurance coverage for contraceptives. He is certainly not alone among the Republican presidential candidates in condemning this recently-revised rule that now exempts religious employers from having to pay for this benefit, but his words (as they often do…) provide the perfect opportunity for a reality check.
Romney, speaking in a “packed gymnasium” in Colorado told the crowd that “churches and the institutions they run, such as schools and let’s say adoption agencies, hospitals, that they have to provide for their employees, free of charge, contraceptives, morning-after pills — in other words abortive pills and the like at no cost,” Mr. Romney said. “Think what that does to people in faiths without sharing those views. This is a violation of conscience.”
The use of the words “abortive pills” alone is chilling–conflating contraceptive use with abortion has been the purview of the ultra-religious right–but Romney’s assertion that this legislation will violate the conscience of most people of faith is just plain wrong. It will violate the conscience of the small minority of Americans, like Rick Santorum, who, writes Igor Volsky on the Think Progress blog, “has pledged to preach about “the dangers of contraception in this country,’ if elected president.” Santorum is basically opposed to women having sex that is not related to procreation; “It’s not okay,” he has said. “It’s a license to do things in a sexual realm that is counter to how things are supposed to be.” The data strongly suggests that this ship has long since launched.
If you want to know just how pervasive use of contraception is among women of all religions, check out the April 2011 report from the Guttmacher Institute; “Countering Conventional Wisdom: New Evidence on Religion and Contraceptive Use.” It includes the following findings:
“The overwhelming majority of sexually active women of all denominations who do not want to become pregnant are using a contraceptive method. Moreover, 69% are using highly effective methods: sterilization (33%), the pill or another hormonal method (31%), or the IUD (5%).” Read more…
It’s crunch time once again for Congress; on March 1, the much-dreaded (and much threatened) 27% cut in reimbursement for doctors who treat Medicare patients is poised to go into effect. Fee cuts are mandated every year that Medicare’s actual spending on physician services exceeds a target determined by a standard growth rate (SGR) formula linked to the growth of the nation’s economy. So far, Congress has kicked the SGR can down the road 13 times since 2003—including five short-term fixes in 2011 alone. The targets have long been considered unobtainable and the mandated physician payment cuts are opposed in Congress by Democrats as well as Republicans. They have never gone into effect and my prediction is that they never will.
Nearly everyone (aside from doctors who cry wolf each time the cuts come back on the table) seems to agree that the cumulative fee cut will not occur and that the SGR is a nonsensical formula that needs to be either repealed or refigured. But the problem is that the 27% pay cut has already been figured in federal spending and deficit projections. Even though these are artificial savings from what the Chicago Tribune recently called “a phantom cut,” the Congressional Budget Office calculates that if the Medicare SGR formula was repealed today, it would cost about $316 billion over the next 10 years. Figuring out how to pay for this increase in Medicare costs continues to stymie legislators and provoke battles between those who see the offset coming from long-term savings associated with the health reform law and those who insist on immediate dollar-for-dollar cuts.
In the current “Doc-fix” dust-up, Congress has bundled any short-term plan to avert Medicare reimbursement cuts with the extension of both the popular Social Security payroll tax cut and unemployment benefits. The problem (as if we needed reminding) is that the rising budget deficit has further solidified the current “pay as you go” approach to negotiations—especially among conservatives. That means lawmakers must find more than $150 billion to offset the cost of extending all three policies for the next 10 months before the last agreement—hammered out only in December—expires. Read more…
The decision by the Susan G. Komen For the Cure, a breast cancer non-profit whose income topped $350 million in 2008, to rescind $700,000 in funding for Planned Parenthood has inflamed passions on both sides of the abortion issue. As blogger Kivi Leroux Miller puts it, this action has resulted in “the accidental rebranding of what is surely one of America’s biggest and most well-known, and even well-loved, nonprofit brands. Komen for the Cure, it seems, is no longer a breast cancer charity, but a pro-life breast cancer charity .” In real terms, Komen has taken away funding that supports breast cancer screening for 170,000 low-income women in 16 local Planned Parenthood affiliates. In the longer term this action raises questions about the political and ideological forces that help guide a successful organization like the Komen Foundation.
The Planned Parenthood decision, which was made “quietly” late last year, is not the only reason to question some of Komen’s motives and to wonder what motivates its backers. The organization, which created the hugely popular (and profitable) “Race for the Cure” runs and multi-day walks as well as the ubiquitous “pinkwashing” of products as varied as yogurt containers, running shoes and buckets of Kentucky Fried Chicken, has always been focused on marketing and fundraising. In fact, this is a primary focus of an organization like Komen; since 1992 the group has raised $1.2 billion to help support breast cancer research, free breast cancer screenings and to promote education about maintaining breast health.
But despite their support of research and under-served community programs (like the Planned Parenthood screening effort in Waco, Texas), it’s sometimes hard to justify Komen’s ends with their means—especially when it comes to corporate partners. As Barbara Brenner, past Executive Director at Breast Cancer Action, a grassroots advocacy group that doesn’t accept industry funding and focuses on determining environmental causes of breast cancer says, “Many of those products don’t do anything for breast cancer and some of them are actually bad for our health.” She mentions cars, cosmetics, alcohol, and fast food as key examples of questionable “pinkwashed” Komen partners. Read more…
In the last year, three of my close relatives were prescribed statins; the class of drugs used to reduce cholesterol levels in the bloodstream. All three of my relatives had elevated readings of low-density lipoprotein (LDL) cholesterol (the bad kind) but no other risk factors for heart disease. Two of these relatives (my sister and a brother-in-law) are in their 50’s, are not overweight, maintain relatively healthy diets and exercise moderately. The third, my mother, is in her late 70’s, exercises daily and is in very good mental and physical health. No diabetes, little family history of heart disease, none are smokers.
I am not a doctor, but because I’ve written about medicine and health care for so long, people sometimes ask me for advice about medical problems and medications; most of the time I demur. But when my family members asked me what I thought about them undergoing drug therapy—potentially for many years, if not decades, in order to bring LDL cholesterol down to a target level, it was difficult to keep quiet. That’s because despite the widespread, almost reflexive, practice for doctors to prescribe statins, there is scant hard evidence that lowering cholesterol levels in otherwise healthy people will keep them from developing heart disease and extend their lives. This is especially true for women and people of both sexes who are over 65.
Questions about the wisdom of treating patients solely to achieve an LDL target are particularly important right now. A committee (the Adult Treatment Panel or ATP IV) convened by The National Heart, Blood and Lung Institute is currently revising clinical guidelines for testing and managing cholesterol. These guidelines were last released in 2002 (updated in 2004) and state that “recent clinical trials robustly show that LDL-lowering therapy reduces risk for CHD [coronary heart disease]. For these reasons, ATP III continues to identify elevated LDL cholesterol as the primary target of cholesterol-lowering therapy. As a result, the primary goals of therapy and the cutpoints for initiating treatment are stated in terms of LDL.”
Since those guidelines were released, more and more of us have been put on cholesterol-lowering drugs—current estimates are that one in four Americans over the age of 45 takes a statin daily. Heavy marketing of drugs like Lipitor (newly available in a generic form), Crestor and Zocor (available as generic simvastatin) to consumers, along with a concerted effort by drug companies to sell doctors on the relative cholesterol-lowering benefits of these drugs resulted in $17.1 billion in health care spending on just statins alone in 2009. Current spending figures are thought to exceed $20 billion. Read more…
At the height of the debate over the health reform law, insurance companies spent tens of millions of dollars trying to defeat the legislation, warning that its provisions would raise premium costs and force Americans to abandon their current plans.
Instead, large insurers like WellPoint, Aetna and Cigna have seen profits and enrollment rise “to levels not seen since before the recession,” according to a new Bloomberg Government study . Just last week alone, United Health Groups announced that its fourth-quarter profits had risen 21%. And despite fears of a “government take over of health care,” private insurers have made significant inroads into the Medicare and Medicaid programs.
A recent piece entitled “Betting On Private Insurers” by the Kaiser Family Foundation, reports that about 30% of seniors are now enrolled in private Medicare Advantage plans, while 23% of Medicaid enrollees receive coverage through a private managed care organization. Another 15 million Medicaid recipients receive care through managed care plans that are a mix of private and public insurers.
What does this privatization mean for health care savings in the long term? First of all, private insurers have historically had higher overhead costs than government plans and, according to the McKinsey Global Institute, “Across the health system, we pay a price for this reliance on private insurance in terms of higher administrative costs.” These higher costs are reflected in premiums and in the case of Medicare Advantage, resulted in the government spending an average 14% more for seniors enrolled in private plans vs. the traditional fee-for-service program.
That’s where key provisions of the Affordable Care Act come in. By eliminating excess payments to Medicare Advantage plans, the government is hoping to save $136 billion in health care costs. And staring this year, large group insurance plans will have to devote 85% of what they collect in premiums on direct patient care or quality improvements. Individual and small group plans must spend at least 80% on care. That means only 15% or 20% (respectively) can be spent on non-care costs like overhead, executive salaries and marketing. Plans that do not meet those thresholds, called the medical loss ratio or MLR, must refund the difference to beneficiaries beginning in August of this year.
According to a McKinsey report, “Health administration costs represent $91 billion, or 14 percent of total [health care] spending above expected, due partly to the system structure, but also on account of inefficiencies and redundancies that exist within the system.” Lowering administrative costs should, in theory, reduce premiums and drive health care costs down. Read more…
The American College of Physicians recently released a new version of its thoughtful ethics manual, a 37-page document published in the Annals of Internal Medicine that provides guidance for its membership of 132,000 internists on issues as varied as whether doctors should participate in torture (they absolutely should not), use social media (carefully) and provide uncompensated care to the poor (yes, an unspecified “fair share’).
But despite the breadth of this publication and its ambitious attempt to guide the ethical practice of medicine, much attention has been focused on a single highlighted text box that urges doctors to actively confront the current crisis in health care by considering cost-effectiveness when providing care. The controversial box states the following:
“Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”
The manual instructs doctors to choose procedures and treatments that are backed up by “the best available evidence in the biomedical literature, including data on the cost effectiveness of different clinical approaches.”
To some doctors and medical ethicists this recommendation to practice “effective and efficient health care” and to be cognizant of limited resources is a bold and timely move by the ACP. Ezekiel Emanuel, a bioethicist at the University of Pennsylvania and one of the architects of Obama’s health care policy, writes in an accompanying editorial in the same issue of the Annals;
“Here is a professional society unafraid of advocating the principle of cost-effectiveness. These positions on efficiency, parsimony, and cost effectiveness constitute an important shift, if not in ethics then in emphasis.” Read more…
The health reform law in all its 2,000-plus page glory sets up a bevy of initiatives, specifications and several historic mandates all with the primary goal of making affordable and comprehensive health care available to most Americans. But what’s become increasingly clear is that this transformation is a work in progress, evolving and adapting as politics, a faltering economy and policy insights trigger tweaks, compromises and new approaches.
This is most apparent when it comes to determining what the legislation calls “essential health benefits” (EHBs)—minimum coverage standards that must be met by all new health plans offered to individuals and small employers both on and off the state exchanges. The health bill requires that these EHBs include coverage within 10 general areas; including emergency care, hospitalization, out-patient services, maternity and newborn care, preventive visits, mental health and substance abuse disorder services, pediatric services including vision and dental care, and more. The Affordable Care Act gave the Secretary of Health and Human Services the authority to flesh out the details of coverage within each of these areas and to “ensure that the scope of the essential health benefits … is equal to the scope of benefits provided under a typical employer plan.”
As Sara Collins, vice president for the Affordable Health Care Program at the Commonwealth Fund puts it, “Ideally, people choosing among plans [on state exchanges] will no longer have to worry about benefit variation across plans, but will be able to focus on how plans differ in terms of out-of-pocket costs and premiums.”
The problem is that coming up with a national EHB standard is far harder than it sounds. For starters, what one segment of the population considers “essential” is not the same for another. And of course there is the looming issue of cost; if benefits are too generous, states and the federal government—who both will subsidize some portion of the premiums for many Americans who utilize the exchanges—will simply not be able to afford to help all those who need it. Meanwhile, lobbyists for medical device makers, drug companies, the home health industry and other “stakeholders” have descended on Washington to make the case for including their products and services in the package of essential benefits. Advocates for autistic children, the mentally ill and cancer patients (just to name a few) have also put pressure on HHS and lawmakers to specify coverage for often-costly—yet beneficial—behavioral therapies, drugs and other services. Defining “essential health benefits,” according to the authors of a recent Institute of Medicine report that attempted to do just that “is a politically and socially charged endeavor.” Read more…
In the twisted logic of Congress, Rep. Paul Ryan (R-WI), who supports repeal of the Affordable Care Act, is now advocating transforming Medicare into a premium support plan that would look a lot like the health insurance exchanges at the heart of the ACA. Like the state-based exchanges, the new Medicare proposal, co-sponsored with Sen. Ron Wyden (D-OR), would give seniors a voucher to purchase their choice of private health plan. And like the ACA, “managed competition” is the goal in that participating plans must provide a minimum set of benefits and conform to other regulations that prevent cherry-picking healthy seniors and set limits on out-of-pocket expenses. In the Ryan-Wyden plan, there’s also (gasp) a public option—traditional fee-for-service Medicare—a key initiative that progressives had to sacrifice to get the ACA passed.
The details of this “bipartisan” plan are still not completely worked out and most pundits give the plan little chance of advancing before the 2012 elections. And so far Wyden is the only Democrat to publicly endorse this plan—the Obama administration denounced it outright; “We are concerned that Wyden-Ryan … would undermine rather than strengthen Medicare,” said spokesman Jay Carney. “At the end of the day, this plan would end Medicare as we know it for millions of seniors.” Another spokesman invoked Newt Gingrich’s 1995 statement that Medicare would “wither on the vine” when faced with competition from private insurers.
But despite the administration’s opposition, the proposal gives Republicans an alternative to Ryan’s House GOP budget plan that would have turned Medicare into a privatized voucher program, raised the age of enrollment to 67 and, according to the Congressional Budget Office, would have forced seniors to pay for up to two-thirds of their own care. So, in essence, the Ryan-Wyden plan is a way for the GOP to try and regain some of the support from older Americans that they may have lost by threatening to “change Medicare as we know it.”
This is a key turnaround for Ryan and his fellow conservatives, one that they have deemed a necessary evil. That’s because despite the fact that a vast majority of Americans see health care’s rising costs as a serious problem, a recent Washington Post-ABC News poll found that nearly 80 percent oppose cutting Medicare. This new proposal is a natural outgrowth out of the failed super-committee negotiations where similar ideas about “harnessing market forces” to cut spending by turning Medicare into a premium support program were discussed. In fact, the plan is very similar to one proposed recently to the deficit-cutting committee by Alice Rivlin, former director of the CBO and most recently, member of the President’s Debt Commission. Read more…
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