Tell-A-Vision for the 21st Century
The Debate on Health Care Policy Reform
~ an exercise in pseudo-journalism
Day #2, Continued from yesterday’s post
What American should (but don’t) know about health care in the US:
Exactly what kind of ‘status quo’ is this medical dynasty fighting so hard to preserve and protect? Certainly not one that is either cheaper or safer!
The Facts ~ Quality of Care:
The US spends 50% more than any other country in the world, and yet we rank a lowly 19th in preventable mortality. An estimated 100,000 Americans die prematurely each year due to inadequate or inappropriate care; an additional 100,000 people die from medical errors & hospital-acquired infections, and 20,000 more men, women and children die needlessly because they didn’t have health insurance – that’s nearly a quarter of a million unnecessary deaths.
On September 11th, 2001, the loss of 3,000 American lives was seen as a tragedy of such magnitude that we went to war to be sure it didn’t happen again. However, every year we quietly accept a death toll from a broken health care system that is 73 times greater than the 9-11 disaster. In the eight and half years since, almost 2 million Americans –1,870,000 to be exact — have died from toxic healthcare system syndrome.
My mentor and midwifery partner ~ California Licensed Midwife Donna Driscoll with her first granddaughter
One of those fatalities was a highly-trained health professional and close friend of mine for 30 years. My colleague was the victim of a treatable condition that made health insurance unavailable to her. Without access to the necessary medical care until it was too late, she died tragically and unnecessarily, one more statistic in the collateral damage of a health care system that is neither healthy nor caring.
The US vs. Other Developed Countries: Compared to Australia, Canada, Germany, New Zealand and the UK, the United States ranks last, or next-to-last, on quality of care, access to care, efficiency, equity, and healthy lives. Measuring 37 different parameters, with a possible 100 points, the U.S. scored only 65. Its overall performance did not improve from 2006 to 2008. The Commonwealth Fund’s National Scorecard on health care performance for 2008 found “disturbing” evidence that the health system is performing worse than two years ago in nearly every category measured. Authors of the National Scorecard used words such as “squander” to describe an unconscionable level of wasteful care, inefficient systems, failure to treat preventable conditions and unproductive spending, especially on administrative costs.
Poor quality included:
v Avoidable hospitalizations
v Inappropriate, wasteful, or fragmented care
v Disproportionately expensive administrative costs
v Illogical variations in quality and cost of treatments
v Failure to make appropriate use of new information technology
“Without a new national policy, millions more U.S. residents are on a path to becoming uninsured or under-insured. … Rising costs put families, businesses, and public budgets under stress, pulling down living standards for middle as well as low-income families”. [National Scorecard – 2008]
They estimated that lowering administrative costs for insurance could save up to $100 billion a year. According to the National Scorecard, if the U.S. health system achieved the benchmark levels of performance identified in other cost-effective systems, it would produce measurable benefits in terms of health, patient experiences, and money saved. For example:
v 100,000 fewer people would die from causes that could have been prevented by good care.
v Save an estimated $102 billion per year if the US achieved the levels of the best performing countries.
v Save $51 billion a year by lowering administrative costs of health insurances to the level found in Germany which, like the U.S., has a blended public–private health system.
v Save at least $12 billion a year by reducing readmissions or reducing hospitalizations for preventable conditions for the Medicare patients
Maternity Care for Healthy Women:
The economic impact of maternity care for healthy women with normal pregnancies (70-80% of total childbearing population) accounts for 25% of our national health care budget or 4% of the GDP. Maternity care is the #1 occasion for hospitalization and the largest category of expense for both private insurers and the federal Medicaid programs. Hospital charges for mothers and babies far exceed any other single condition. [Milbank Report: Evidence-Based Maternity Care, 2008] This money mainly pays for the routine use of obstetrical intervention on healthy women.
Recent surveys of birth practices in the U.S. identified a 99% medicalization rate, with an average of seven medical and surgical interventions per new mother. For seven out of new mothers, childbirth included a major surgical procedure – episiotomy, instrumental delivery or Cesarean section. [Listening to Mothers Survey, 2002, 2006, www.ChildbirthConnection.org] The US is currently spending 3% of its total GDP to unnecessarily medicalize a healthy population, while those with life-threatening medical needs continue to go untreated.
Cesarean surgery is the number one operating room procedure in American hospitals – 1.3 million a year – equal to the number of students that graduate from American colleges every year. Today, the Cesarean surgery rate in the US is 31.4% — triple the evidence-based rate — with no additional reduction in either maternal or newborn mortality. Because of this or in spite of it, maternal death rates in the U.S. were higher than in 33 other countries in 2005 and have risen the last 3 years in a row.
In 1977, the maternal mortality rate (MMR) was 10 deaths per 100,000; in 2007, MMR was 14. Despite the increase in maternal deaths, many in the obstetrical profession are promoting scheduled elective C-sections as the new standard of care for healthy women. Elective Cesarean delivery is associated with a 3.5 fold increase in maternal mortality. [“Postpartum Maternal Mortality and Cesarean Delivery” Catherine Deneux-Tharaux, MD, MPH, et al; 2006]
$$$ Healthcare Cost and its Consequence
In 2007 Price-Waterhouse-Coopers estimated that we wasted $1.2 trillion dollars of the $2.2 trillion spent on US health care – that’s 55 cents of every dollar.
The Commonwealth Fund’s 2008 Scorecard on Health Care Performance warned that: “…. the U.S. health system is on the wrong track.” Spending more money is not the answer. An important study reported a negative relationship between the amount of money spent on health care and its outcomes – more money was associated with higher use of Rx drugs and procedures and poorer outcomes as measured by morbidity, mortality and cost-benefit ratio.
Catching-up on half a century:
Health care costs in 1950 were about 4 percent of the GDP. In 1966, the year Medicare and Medicaid went into effect, it was about 5.5 percent. By the early 1970s it had risen sharply to 7.2 % ($69 billion) as a result of the cost plus/fee-for-service billing in the 1965 Medicare legislation. This sudden increase in cost was seen as an economic “healthcare crisis” which generated Herculean efforts to hold the line.
Despite this, costs continued to increase and by 1980 were 9.4% of GDP ($230 billion). The medical sociologist and author Paul Starr described this explosive growth in health care cost in his 1982 book The Social Transformation of American Medicine as something that “… cannot be indefinitely sustained, regardless of the administrations in Washington; other sectors of the economy will not support it”.
But apparently the other sectors of the economy were helpless in the face of this run-away freight train. According to the Bureau of Labor Statistics, the fastest growing occupations are concentrated in the health care industry. By 1998 health services became larger in GDP terms than the entire federal government. Per capita healthcare spending increased 28-fold between 1960 and 1998.
As of 1998 was 4.3 times the amount spent on national defense. By 2007, the $2.2 trillion HC expenditures in the US were nearly 17 % of GDP. By 2017 spending is expected to reach $4.3 trillion or 20 % of GDP, while health care spending accounts for only 10.9 % of GDP in Switzerland, 10.7 % in Germany, 9.7 % in Canada and 9.5 % in France, [National Coalition for Health Care – nchc.org]
A prime example of the irrationality of our system is the way the US regulates and prescribes drugs. According to a paper published in October 2008 in the Archives of Internal Medicine:
“FDA approval does not require that a drug be compared with alternative treatments; it only has to be safe to use and better than a placebo. Nor … does a pharmaceutical company have to show that a drug’s effectiveness justifies its price.”
More Bang for the Buck? Randall Stafford, MD PhD, Stanford Prevention Research Center; funded by the Agency for Health Research and Quality; published in the Archive of Internal Medicine 10-27-2008]
Health Insurance: For-profit insurance companies spend 10% to 30% of total premiums on administrative costs (overhead plus advertising, executive salaries and bonuses), versus just 3% for the Veteran Administration and Medicare. This per capita spending on administrative costs is six times more than economically-similar health care systems in Western Europe. A significant part of the unproductive cost for the 1,300 private insurers is spent cherry-picking healthy adults, while denying coverage to those who have genuine medical needs.
Workplace Disincentives: For employers, the fastest growing business expense is health insurance, which was projected to overtake profits for many businesses by 2008. On average, premiums for employer-sponsored health insurance in the United States have been rising four times faster than workers’ earnings since 1999.
Average employee contributions to company-provided health insurance have increased more than 120% since the year 2000. In 2008, the employer-paid premium per year for a family of four was $12,700. If administrative costs for private health insurance are figured at the median rate, approximately $2,600 of that premium was administrative costs. For a government-administered insurance plan or not-for-profit coverage co-op group, the cost would be approximately $377.
Bankrupting the Insured: Two of every five Americans reported problems paying medical bills, up from 34% just two years ago to 41% in 2007. More than 50% of all bankruptcies in the US are the result of overwhelming medical debt. According to a Harvard University study, 68% of those who declared bankruptcy had health insurance.
About 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs. [www.NCHC.org] Since hospitals routinely bill insured patients at inflated rates ($24 for an aspirin) in order to cover the hospital’s losses for uninsured patients who can’t pay, medical bankruptcy is a form of double jeopardy. This Alice-in-Wonderland system is sending insured individuals into bankruptcy as a way to subsidize the uninsured.
Double jeopardy for the Uninsured: Hospitals are still permitted to bill uninsured patients at hugely inflated rates in many states. A $9,000 reimbursement for normal birth when billed to an insurance company becomes a $32,000 debt when billed to an uninsured family.
This occurs because uninsured patients are not protected by an insurance company’s ability to negotiate a cap on payments for a specified form of care. If uninsured patients can’t pay, their delinquent account is turned over to a collections agency, putting medically-indigent patients at risk for also having their credit ruined, making it harder to get or keep a job or qualify for rental housing.
Physicians: Physicians are the only health care professionals broadly licensed to perform or order medical, diagnostic and surgical procedures, thus exerting the greatest influence over the allocation of healthcare resources of any entity in the system. Of the 13,621 health care occupations, payments to physicians accounted for 20% of the total healthcare expenditure in 1998.
At that time, there were some 427,000 active physicians in the United States; by 2006, the number was 633,000. Based on national population, the availability of practicing physicians increased from 190 doctors per 100,000 people in 1980 to 268 doctors in 2000, which is one doctor per 373 people. [Ref # 25]
Corporate Medicine: Investor-owned, for-profit hospitals and out-patient clinics prescribe twice as many drugs, do twice as much lab work, order twice as many diagnostic tests (including high-ticket items such as MRIs) and use twice as many medical treatments and surgical procedures on each patient as their not-for-profits counterparts. This also doubles the rate of medical errors and hospital-acquired or drug-resistant infections.
However, investor-owned nursing homes and kidney dialysis units (2/3s of all dialysis) are paid by diagnostic code and so improve their profit margin through cost-cutting measures, such as a much smaller and less-educated staff and re-use of materials. This propensity for under- and over-treatment reflects decisions to put profits before patients and contributes to a 20% increase in mortality in investor-owned facilities. [A Second Opinion; Relman, MD].
Deregulation and Privatization: The most corrosive influence on healthcare in the late 20th century was the deregulation and privatization of hospitals in the 1980s and redefining medical care as a for-profit business. Small or non-profit hospitals were snapped up by conglomerates, thus replacing local control with national hospital chains.
By law, the prime directive of the corporate practice of medicine (or anything other business) is its fiduciary responsibility to shareholders and quarterly profits. In pursuit of these goals, investor-owned facilities and service-providers market themselves as a superior provider of safe and effective health care, while making treatment decisions based on profit-value to the system rather than therapeutic value to the patient.
Corporate medicine enjoys the benefit of government regulation when it prevents others from stealing it its assets or engaging in anything it deems to be ‘unfair’ competition, while it simultaneously rejects any form of regulation that would protect the vulnerable population it serves (the ill, injured and elderly).
Professionalism vs. commercialism: A recent example of how medical decision-making is influenced by a business agenda – in this case, hospitals and big pharma – revolves around the prescribing of Rx heartburn-indigestion drugs (Prilosec, Nexium, etc).
Between 50-70% of all hospital patients, regardless of admission diagnosis and without any history of ulcers (including nearly half the babies in the NICU), are being given these expensive drugs. [NPR June 2009] Unfortunately, patients receiving these drugs suffer an increased rate of pneumonia. Both drug companies and hospitals profit from the drug’s administration (hospital patients are billed the each time a drug is dispensed) and profit again from the prolonged and more expensive treatment required by patients who contracted pneumonia.
