Monday, October 31, 2022

In Europe, health care does not bankrupt people. And universal coverage means they get the care they need.

A recent note from a friend of a friend:

Here we are in the Pyrenees foothills outside Perpignan [France]. An hour away from the closest ER. X was in the hospital with afib [atrial fibrillation, a heart rhythm disturbance] before we left for France in July and I’m worried about being so isolated. So in Sept he seemed disoriented for a few moments and I was worried so called the French version of 911. I just told them what was going on and they connected me directly with a doctor. They sent an ambulance. The EMTs thought he was OK after checking. But just in case, they SENT A HELICOPTER WITH A DOCTOR from Perpignan. Who also thought he was probably OK. But to be safe they took him by helicopter to Perpignan, arriving in nine minutes. They kept him overnight and let him go the next morning. He’s fine. I had to call them three weeks later to ask for a bill. They emailed it to me. It was itemized: ER, helicopter, two cardiologists, several imaging tests, overnight stay. Total price (for the uninsured): 249 euros.’

Wow! How much is a Euro? Must be like 10, or 100, times as much as a dollar, right? Um, no. Actually, with its recent fall the Euro is just about exactly $1. So $250 for all that? Unbelievable! In fact, if the Euro was worth $100, it would be $25,000, which would still be a lot less than the cost would have been in the US. If you could get that kind of care!

Indeed, that was the situation for this same family earlier…

‘Five years ago X had another chronic problem which has mercifully since been totally fixed. We came here, it started up, and we ended up with five ER admissions, six weeks in private rooms, 3 specialists, transfusions, intensive care, many tests, IV antibiotics etc etc etc. Total bill: about 20,000 euros over 6 weeks. Then back to [hometown in US], one night at [university hospital]: same price.’

What is going on here? It really is unbelievable! Except what is unbelievable, to people in France, or most of Europe, or most countries in the wealthier part of the world, is that we would find their out-of-pocket cost of care surprising. Everyone thinks, to some degree, that what they know, what their world consists of, is pretty much normative, that it is the same for kind of the same people everywhere. In fact, even when they intellectually know that it is not true, it is still one’s instinctive reaction, to think that what is normal for you is normal. Luckily for the French, what is normal for us in the US, in regard to the cost of healthcare, is not normal for them. And, of course, unluckily for us. And this is not a recent change.  It wasn’t even new back on January 21, 2012, almost 11 years ago, when I wrote ‘One thing to NOT worry about: paying for health care -- in France. Or for decades before that. In that piece, I wrote about going to see the film Le Havre and noted that in it a really poor person spends weeks in the hospital and the one thing no one is worried about is the cost. This could never be true in the US.

Doesn’t this upset you? Don’t you think something is wrong here? What is going on????

Sorry.  Of course it does. But, you know, it must be costing someone a lot of money, even in France, or wherever. All that health care, all those hospitalizations, all those tests, do not come cheap.

No, they don’t. But they don’t have to be so expensive. There is incredible markup on the bills and amount paid in the US. Not that anyone actually knows what the price is, or that there is any consistency to it.  US hospitals do have a Master Price List (like “one gall bladder surgery, $X) but it rarely is what is either billed or paid. These hospitals have deals cut with large insurers on how much they will be charged, and pay, on behalf of their customers. Medicare, the government insurance system for the aged and disabled, sets its own rates as to what it will pay (and the private insurance rates are usually expressed in “multiples of Medicare”). Really the only people who might be charged the “list price” are those who are uninsured and poor, those least likely to be able to pay it – although very few of us could pay those amounts! The couple who wrote about their experience in France is obviously well enough off to have spent that time in France, and to have paid their bill, but just being reasonably well off is far from sufficient to be able to pay hospital bills out of pocket.

Let us be entirely clear and simple: The reason US health care costs so much is profit. It is that everyone, everywhere along the line, is taking a cut. The insurance companies, right from the start, huge profits (and salaries to their executives). Hospital systems, huge markups (and salaries to their executives). Pharmaceutical companies, huge markups (and salaries to their executives). Doctors also, especially in some specialties. I could give lots of examples of those specialties with the highest income/work ratios. It is not because we use “too much health care” – indeed, it is really unlikely that any of us (unless a billionaire or a head of state) could have gotten the care that X did in France, and they did that just “routinely”, because it was what they thought was medically the right thing to do.

That, of course, is the other part of this story. It is not just that the charges and costs to the individual were so much less than what they would have been in the US. As a physician friend pointed out “The dollars and cents issue is important. But freeing the medical community to just do the right thing is immeasurable.” Think about that. At each stage, from the person’s wife calling French 911, to the EMTs who came, to the doctors who decided to airlift him to the city, to those who cared for him in the hospital, the decisions that they made were medical, what, in their judgement, was the best for the health of the person/patient. At no point did the cost of the care enter into their decision. Well, I take that back. It may have. But what did not enter the decision was “what kind of coverage does this particular person have? Does it pay enough? Does it cover what we want to do? Have they met their deductible? Can they afford the copay?” This is what you would want for your own health care, and it is absolutely what doctors and other health professionals want to be able to do. Once there was a joke (what today would be a meme) that before doing a procedure the doctor would do a “wallet biopsy”. Today, it is more often the hospital, and it is more likely an “insurance biopsy”. This is crazy.  It is crazy. It is unacceptable. And more important, it is unnecessary.

And the cost of health care per capita is much LESS in France, just as the quality of care is higher (as I cited from the Commonwealth Foundation in my last blog post, Premiums are up, people are dying and insurance companies are making out like the bandits they are, October 25, 2022). Indeed, it is less than half the per capita cost in the US. And in France, that includes everyone; no one is without coverage.

Of course, not foreigners, like those visitors from the US, who had to pay their whole bill themselves with no insurance.  All $250 of it.

Tuesday, October 25, 2022

Premiums are up, people are dying and insurance companies are making out like the bandits they are

In “Medical debt ruined her credit: 'It's like you're being punished for being sick'”, on NPR October 6, 2022, reporter Aneri Pattani covered the story of Penelope Wingard of Charlotte, NC, and others who had their credit ratings ruined as a result of the cost of medical care. This is bad, but is not as bad as the fact that they could no longer receive medical care. Wingard tells the reporter that "My hair hadn't even grown back from chemo, and I couldn't see my oncologist." After all, the doctors and hospitals want to be paid. In response to pressure from breast cancer advocacy groups, North Carolina had passed a law that temporarily granted Medicaid to breast cancer patients like Ms. Wingard. But then it ran out. As did her money. And her medical treatment. And her credit score plummeted.

What is the worst part of this story? For Ms. Wingard, it is both that she is broke and has no credit, and that she can no longer get treatment for her cancer. For many of the rest of us, it may be that something like that could happen to us or someone we love. For all of us, it is the remarkable fact that we find it unremarkable, that someone could go broke from their medical bills and lose their ability to buy necessary things on credit, and then not even be able to get their needed medical care. It is just the way it is, we think. Awful, and it happens all the time.

Except it is not just the “way it is”. Only here. It is not this way in any other wealthy, or most middle-income, countries. They all have universal health insurance that covers everyone for medically necessary care. Mostly they have had it for many decades. What is remarkable to most people in those countries is that we could possibly think that such a thing is unremarkable, if not exactly “OK”, is the “way it is”, and we are willing to tolerate it. This was the message from the PBS documentary by T. R. Reid “Sick Around the World”, aired in 2008, and covered by me, along with its 2009 follow-up “Sick Around America”, in ‘"Sick Around America": A little bit sickening’, August 5, 2009. In the earlier show, Reid interviews political and health leaders in 6 countries and asks, among other things, how many people in their country go bankrupt from medical debt. In that post, I quote the then-president of Switzerland, ‘a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”‘ Then, and now as we approach the end of 2022, it should be one in the US, and yet we get stories like those of Ms. Wingard. These issues affect many Americans, and as usual are worst for those who are most disadvantaged.

It is “the way it is” in the US because we have chosen to make it so. Actually, it is our politicians who have chosen to make it so, blocking any effort to implement a universal health insurance program, from the 1920s to the time of Harry Truman in the late 1940s (when the AMA was the big opponent), to the 1960s when Medicare and Medicaid were passed and seen as the forerunners of such a program, to the current day. Why? Because of the powerful interests of those who are making money off our current health system, insurance companies and hospitals and other delivery systems (often vertically integrated) and pharmaceutical and device makers, who give lots of money to politicians and wield a lot of clout. They are not only making lots of money in an ostensible “free market” system, but in particular from government programs that they collect public money from. Don’t buy the false idea that “privatization” reduces costs; “administrative costs” are <3% in traditional “government” Medicare but upwards of 15-20% in Medicare Advantage. What privatization does is increase profit!

And, not content with making a lot from Medicare Advantage (a private, for-profit operation that our politicians should not allow to use the name “Medicare” – indeed, there is a bill in Congress now to prevent it – write your representative!), they further game the system by “upcoding”, paying folks whose job it is to make sure that every potential diagnosis and complication is recorded to maximize the amount of (your tax dollar) money that they collect from Medicare. Sometimes this is legal, if outrageous, but insurers are certainly not unwilling to push the legal envelope for more money (‘Cigna received millions of Medicare dollars based on invalid diagnoses, lawsuit claims’, ABC News October 17, 2022 -- and ‘millions’ is an underestimate). And it is assuredly not just Cigna that is guilty; while insurance premiums for Americans have increased 200% in the last decade, United HealthCare last year reported $24B ($24,000,000,000) in profit, more than ever before, an obscene amount, and a completely unabashed example of the fact that what is called the “healthcare” industry in the US is just an enormous profit center for the corporations that control it.

You want to know why we spend 2-3 times as much as any other wealthy country on “healthcare” and yet have so much poorer outcomes, shorter life expectancy, greater infant mortality, higher rates of “deaths of despair”? (‘Mirror, Mirror 2021: Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries’, Commonwealth Fund). This is the reason: the money is going to corporate profit, not your health care! If it were going to your healthcare, our outcomes would be better. But then they would not be making so much money, and donating so much of it to our (or maybe it is “their”) politicians.

Oh, maybe you thought that was the end. That insurance companies are raising our premiums, denying needed healthcare to sick people, making billions of dollars in profit, and corrupting our political system to ensure that it continues, was bad enough. And convincing you to shrug your shoulders and think “it’s sad, but that’s the way it is” when someone gets very sick, maybe dies, and goes bankrupt in the process. But, you know, that’s not enough for them. There is one more step: convincing you – and probably more important, the politicians – that it is not their fault that US health care costs so much. It is not the $24B in profit made by United. It is not the scamming of Medicare done by Cigna, or the entire Medicare Advantage and Direct Contracting Entities (DCE) programs that funnel public money into their pockets. No, no, it is YOU! As Wendell Potter, a “reformed’ health insurance executive, reports in ‘Corporate health insurance consultants blame high medical costs on our "bad habits" and "overuse" of system’ they say it is OUR fault for using too much care. Like, you know, going to the emergency room with chest pain, and sometimes it isn’t a heart attack (bad you!). Or, like Ms. Wingard, wanting to be treated for cancer. Or maybe even going to the emergency room when we are only sick, not dying, because we can’t get an appointment for the doctor.

It's not true, by the way. Europeans are hospitalized more frequently, have longer lengths of stay, and use the doctors at least as often. Their outcomes are better, especially when the health of the entire society is considered (we have a way of fudging this by only considering those people who were actually able to get care), and they pay a lot less. No, it is the profit and “administrative costs” of the health insurance companies and healthcare corporations.

Apparently buying into the idea of “incrementalism”, our politicians for the last 60 years have given us limited programs to help limited groups of people, at least somewhat. Seniors, disabled people, sometimes children, sometimes programs like the North Carolina one that paid for Ms. Wingard’s cancer treatment specifically because it was breast cancer (until, of course, it didn’t). This is NOT the way to go to get universal health care. The ACA (Obamacare) included the option for states to expand Medicaid to the less-than-desperately-poor and some did and folks in the other states are getting sick and dying.

No. We need a universal, comprehensive, EVERYBODY in, NOBODY out, health insurance system, government run or tightly regulated so there are not obscene profits. Like improved and expanded Medicare for All. Now.


Saturday, October 8, 2022

TikTok, NyQuil, vaccines, the frontal cortex, and making wise decisions: something we all need to do better

FDA warns against cooking chicken in NyQuil”, the title of an article from Family Practice News, and reprinted by MDEdge, may seem a little “Hey, what? Why would the FDA have to issue a warning about this?” It certainly caught my attention. I don’t claim to be a gourmet, or conversant with all the ways recipe books have to cook chicken, but I certainly never heard of using NyQuil. But, then again, I don’t spend a lot of time on TikTok. I read a bit more and caught the key phrases that largely explain why this is an issue, “adolescent” and “TikTok challenges”. Aha. It is not a celebrity chef who has been suggesting that we cook our poultry in a liquid designed to treat the symptoms of colds, and that includes a variety of drugs to treat pain (acetaminophen), suppress cough (dextromethorphan) and decrease sniffles (doxylamine, an antihistamine), which all are concentrated and made more toxic by cooking them down. It is, rather, morons on social media. Or how about the “One chip challenge”, which has led to hospitalizations of children eating a chip made with peppers with 400 times the capsacin (thus hotness) of jalapenos?

Or maybe they’re not morons; maybe they’re smart folks with an agenda, although the agenda is likely to simply be getting more views and becoming more of an “influencer” than intentionally trying to poison our young people. Although the impact can be the same. One question is “why do people (especially young people) get so ‘influenced’ that they do crazy, stupid things?” Actually, it’s easier to answer for young people. They have a biological, developmental excuse. Contrary to what we learned decades ago (or in the last millennium!) about brain development, that no new neurons grew after birth, the development of the brain is not complete until the mid 20s. And the last part of the brain to completely develop is the frontal cortex, which is associated with both executive function and judgement. Judgement is very different from intelligence or knowledge; it is the ability to integrate knowledge and come up with a wise plan of action. It is why a young adult or late teen, otherwise both very smart and even very knowledgeable, can often do something that seems, well, stupid. “Why did you drive into that crowded intersection? What were you thinking?” “Thinking?”…

Addressing this issue (helping learners to know how to integrate knowledge into a wise plan of action) is one of the key goals of education; and in my experience, in medical education. It is important, in making a diagnosis or deciding upon a treatment, to think critically, and this is not necessarily a skill that comes naturally. Before electronic medical records (EMRs) came into being, I would encourage learners to write the important laboratory and x-ray results in their chart notes, on the theory that in going from their eyes to their hands it would go through their brains and significant results that needed further investigation or action would trigger those brains to follow up. Now with EMRs, it is possible to block and paste all those results and insert them into the physician’s note, which does not have the same effect. It does make the notes a lot longer, but that in itself serves no purpose since the results could be seen elsewhere in the chart.  The goal was not to have them in the note (easy with cut-and-paste) but to have awareness of them in the physician’s brain. The traditional “SOAP” note includes “Subjective” (what the patient relates), “Objective” (what is found by physical, lab, imaging examination), “Assessment” (how the physician integrates that information into a decision on what is the most likely diagnosis or diagnoses, and what are the alternatives), and “Plan” (what are we going to do now to clarify the diagnosis and/or treat?). Assessment is by far the most important part; it is the part that requires that the data, relatively easily available, interact with the physician’s knowledge and experience. It is also, unsurprisingly, the one most often lacking in quality and thoroughness. It is, indeed, the one that require the most out of the frontal cortex.

The bigger question is not about adolescents and young adults, whether training in medicine or not, and why they cannot distinguish between a “challenge” that is a gimmicky fundraiser for a good cause (e.g., pouring ice water on your head so people will contribute money for ALS research) and one that is idiocy (e.g., cooking chicken in cold medicine). After all, we train children to irrationally believe things (Santa Claus, the Easter Bunny, parents are omniscient, good guys always win) so it is understandable that aspects of this may persist for a while. The bigger question is about adults. Why do they find it so easy to believe what should be obvious nonsense, and act on it, and have it determine not only what they do in a mildly risky manner (chicken and NyQuil, incredibly hot chips) but in their work, their relationships with others, their beliefs in the world around them, how they vote, and how that affects our world.  

Vaccines, for example, work to prevent disease both in the individuals who receive them and the communities of which they are a part. They are good. They are one of the few things (along with surgery) that healthcare workers can actually do to/for people that enhances their health, as opposed to making recommendations, whether for diet/exercise or giving small pieces of paper, which have to be taken somewhere and, with money, redeemed for medicines that have to actually be taken. But there  is still a lot of vaccine skepticism. Some of it is political; being skeptical of COVID vaccines has become de rigeur for many Republicans and conservatives and this has bled into distrust of other vaccines. But it also a belief of many who think of themselves as liberal, and are economically well off. It is just as wrong and dangerous. We read now that vaccine reluctance is now moving into people’s views about vaccinating their pets; we may soon face not only outbreaks of measles in children but rabies in dogs!

I understand and have written about the fact that all doctors are not always correct, that they sometimes are motivated by interests other than those of their patients’ health (their own financial interest or that of the corporation they work for), and that asking questions is good. But the dangerous irony is the same people who are suspicious of “mainstream medicine” are often far too willing to accept unproven and unlikely alternatives. Because something is recommended by those who are not mainstream physicians does not make it correct; in fact it is often quackery.

People often adopt behaviors, or either eat or eschew certain foods, or take supplements, that they believe will make them healthier. Maybe they do help. No one thing is going to make you healthy; there are too many factors affecting health. People usually choose those consistent with what they already believe and are things that they feel that they can do (thus the popularity of supplements; you don’t have to do anything hard like change your lifestyle). Unfortunately, people often think that doing the things they like or believe in or find easy cancels out other things – “if I take supplement X (or eat a lot of Y but no Z), I don’t have to do A or stop doing B!”

Near the end of Herman Hesse’s novel “Siddhartha”, the protagonist meets his childhood friend Govinda when they are both old men. Siddhartha shocks Govinda, a devotee of the Buddha, by saying that wisdom cannot be taught. Knowledge can be taught, he says, but wisdom must be acquired by the person themselves. I do not think we need less knowledge, but we do need more wisdom.

I’ll share some knowledge: Don’t cook your chicken in NyQuil. And get vaccinated, get your children vaccinated, get your pets vaccinated.

I’ll also try to share some wisdom: Because you want something to be true does not make it true. And if something seems too good to be true, it probably is.

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