Public Health, Abortion and Childcare: US far behind other countries

On October 3, I wrote about the viciously restrictive Texas (anti-) abortion law, The Texas Abortion Law is contrary to women, to science, and to human values. Texas is not the only state with such restrictive laws; in my own state, Arizona, a very restrictive abortion law has been passed by the legislature and signed by Republican governor Doug Ducey that makes it a crime for a doctor to perform an abortion on a woman “just” because it has a genetic defect (including those incompatible with life, or worse, yet, compatible with a short life full of suffering). While a US district court judge has enjoined the law, Arizona’s attorney general, Mark Brnovich, has asked the judge to allow him to continue to enforce that law while his appeal is pending. That could mean, of course, felony convictions for physicians. This follows the Supreme Court, in a “shadow docket” ruling, declining to invalidate that law despite a prior US Court of Appeals ruling that did so.

These actions by Republican-controlled states are all predicated on the assumption that the Supreme Court will soon invalidate Roe v. Wade and take away any Constitutional protection for women seeking, or doctors or others providing, abortions. This may well happen with a case on the agenda for this year challenging Mississippi’s draconian law virtually outlawing abortion. That this is a distinct possibility is because of the success of the Republican party and Sen. Mitch McConnell in ensuring that The Former Guy, Donald Trump, was able to appoint 3 justices to the Court, first by preventing President Obama’s nomination of Merrick Garland (the current US Attorney General) on the specious grounds that it was the last year of his term (while there were over 9 months left), and then going ahead and then entirely hypocritically approving the nomination of Amy Coney Barrett just a week before the election, which Trump lost. Thus we have a Supreme Court with 6 Republican justices of which Chief Justice John Roberts, Jr., is the least reactionary – but no longer a swing vote. Many, including Coney Barrett (referred to by NY Times columnist Maureen Dowd in her recent piece “The Supreme Court v. Reality” (Oct 9, 2021) as “Lady Handmaid’s Tale” for her advocacy for some of the repugnant and misogynistic practices described in Margaret Atwood’s book and the later TV series, strongly opposed to abortion. It is, of course, worth remembering that large majorities of the American people favor retaining the rights in Roe v. Wade, and that in some circumstances (such as rape and incest and a threat to the life of the mother) that support is overwhelming. Not, however, on GOP legislatures or on the Supreme Court.

Much of the support that exists in the US for overturning Roe v. Wade, and in general opposition to abortion, justifies itself by claiming abortion is murder, that they are only advocates for helpless fetuses, whom they call “babies”. There are undoubtedly many in their ranks who are consistent in their opposition to killing, opposing the death penalty and war (the late Joseph Cardinal Bernardin of Chicago comes to mind, and perhaps the current Pope Francis), but the vast majority of them, including all these legislators and SCOTUS justices, are not. And, indeed, their concern for babies and children only extends back from birth to conception, not forward from birth. We got you to there, they effectively say, but then you’re on your own. Or your parents are. This country is the meanest, using the word in both its senses, unkind and stingy, of all wealthy countries in providing support for infants, children and their parents. No box of baby necessities as in Finland (available for sale in the US, but provided by the government in Finland) . No requirement for parental leave. No guarantee of health insurance coverage, not to mention adequate coverage. No support for childcare. This one is the subject of a dramatic graphic included in the NY Times demonstrating how much countries in the Organization for Economic Cooperation and Development spend per child on early childhood care. The mean is $14,436. The second-lowest, Israel, is $3,327. Hungary spends twice that, Lithuania is over $8,000 and Slovenia over $11,000. The “poor” US comes in, as in virtually all measures of caring for its people, last, at $500. Well, you know, it costs a lot to provide care for its least needy; for the billionaires who need tax cuts.

This, of course, does not bother the majority of the Supreme Court. They are not looking for consistency. They are looking for two things: 1) to enact their political agendas, and those of the Presidents who appointed them, and 2) to have people ignore #1 and lash out at people who point it out, painting themselves as victims.

Meanwhile, thing as better on the health front in the small Central American nation of Costa Rica, as described by surgeon and health care pundit Atual Gawande in the New Yorker (‘Costa Ricans Live Longer Than We Do. What’s the Secret?’, August 23, 2021). In a country with a “per-capita income is a sixth that of the United States—and its per-capita health-care costs are a fraction of ours—life expectancy there is approaching eighty-one years. In the United States, life expectancy peaked at just under seventy-nine years, in 2014, and has declined since.” This latter fact has been described in great detail in recent years, particularly in the work of Anne Case and Angus Deaton (in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and discussed by me in Rising white midlife mortality: what are the real causes and solutions?, Nov. 14, 2015). Costa Rica, in 1970, had an infant mortality rate of 7%. By 1980, it was only 2%. “In the course of the decade, maternal deaths fell by eighty per cent. Part of the change is due to improvements in access to medical care, a characteristic of middle-income countries such as Costa Rica as well as most (obviously excepting the US) upper-income countries.” This points to the second big reason, and the focus of Gawande’s article, the emphasis on public health, on the health of communities, on interventions (and spending money) on things that improve the health of all people, in great contradistinction to the US focus on providing medical care for individuals.

Public health in the US is grossly underfunded, as has been apparent since the beginning of the COVID-19 pandemic. Well, it has long been apparent to those who thought about those things. The emphasis in the US is on individual medical care, and this is what is discussed by those who have power and those who fund them, and of course the mass of journalists and pundits.This is a failure of those who should be providing accurate information, but it is also the fault of our people’s willingness to deny a problem until it is right in their face. Many Americans do not even take the preventive measures that are easily available to them (the COVID vaccine, for some reason, comes to mind) and many others are unable to avail themselves of screening and early treatment because of a lack of money or decent health insurance and so end up in extremis and grateful for whatever invasive, expensive, and often unlikely-to-be-successful medical care is available. But, as I have said before, it is less common for people to wake each morning and be thankful that they don’t have cholera because they have clean water.

It is not that the American people are stupid or have the wrong values. If a large majority support Roe v. Wade, and much larger majority believes everyone has the right to health care and that we should have a universal health insurance system. And a huge majority (about 88% including 77% of Republicans) believe that drug costs are too high, that the reason is that drug companies make too much money, and that Medicare should be able to use its clout as the nation’s biggest insurer to negotiate drug prices. Also, while we’re on it, that all children should have an excellent education, and that childcare and parental leave are truly important priorities.

But we don’t have that. We don’t have the “Finnish baby boxes”, and we don’t have universal health insurance, and we don’t have requirements that all health insurance cover everything needed, and we don’t have childcare or parental leave or excellent education for all our children or a decently supported and effective public health system or even the ability of Medicare to negotiate drug prices. Of course the poster child for opposing this latter while her constituents favor it is my senator from Arizona, Kyrsten Sinema, who has gotten a lot of money from the pharmaceutical industry. Do we think that is part of it??

The only solution is to vote them out. Make supporting public health and universal health care and affordable drugs more important to re-election than opposing abortion rights.

Drug and device makers: Obscene profits and kickback -- a big part of why our "healthcare" costs so much

 

Drug companies are greedy parasites. This is well-known to everyone. Even the shock troops of the Republican right know about and decry it.

The drug companies start with the capitalist model – sell something at a profit – and take to an extreme: make as much profit  as possible no matter who it hurts (as long as it doesn’t hurt them).

They have a great business plan: people need their medicine, they (or mostly their insurance companies, including government insurers Medicare and Medicaid) are willing to pay for it, even if truculently, and they’ll pay whatever is asked.

While we are all shocked periodically by stories of individual dramatic greed, such as Mylan and its CEO Heather Bresch jacking up the price of EpiPen® to over $600 (Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, Sept 3, 2016) or Martin Shkreli and his company Turing brazenly raising the price of Daraprim® from $13.50 to $750 (Drug prices and corporate greed: there may be limits to our gullibility, Sept 27, 2015), the fact is that this is the standard business model of pharmaceutical companies. Think of colchicine, an anti-gout drug first used by ancient Egyptians at least since 1500BC, having its price jacked up from $4/mo to $5/pill (VISA and colchicine: maybe the banks and Pharma really ARE in it for the money!). 

Or, to get to one of the biggest scandals of all, the price of insulin!  Should there be anyone who does not know, insulin was one of the most important drugs ever discovered. Unlike the newest drugs that I have recently discussed, which sell for thousands (or tens of thousands) of dollars a month, insulin is not for a niche market. It is for diabetes, one of the most common diseases. For people with Type 1 diabetes, who produce no insulin of their own, it is simply an absolute requirement for life. For the larger group of people with Type 2 diabetes, it is often a critical part of controlling their disease. It was discovered by Canadians Banting and Best in the 1920s, who sold the patent to Eli Lilly and Co. for -- $1! (Not sure if that was a US or Canadian dollar.) This drug – the impact of which is HUGE – now is over $100/month for the cheapest generic forms if you have a coupon, and, depending upon the formulation, can be hundreds!

So, we have predatory pricing on products people absolutely need for their lives. Check.

We have outrage among millions of people of all political stripes. Check.

We have the ability to control these prices, starting with the largest payer in the US, Medicare. Check.

We have done what we can, as a government and a society, to address this issue. Um, uncheck. Nope.

In fact when Congress passed the Medicare Drug Plan, (MMA, Part “D”) in 2003, it specifically forbade Medicare from negotiating drug prices. Good deal for the drug companies! Guaranteed payment and no ability for the purchaser to negotiate the price! Where can you or I get that deal? Nowhere, of course. We do not have huge piles of $$ for paying Congressmen. Every time the drug manufacturers suggest that they need their profit to pay for Research and Development (R&D), we need to note how much MORE they spend on Marketing (including lobbying and contributions). It is also worth noting that contrary to their propaganda, MOST drugs are not developed in the US. It is the large plurality, but Japan and Western Europe also contribute a lot. (see, e.g., Light and Lexchin Pharmaceuticals as a market for “lemons”: Theory and practice and Pharmaceutical research and development: what do we get for all that money?, also for another take US Pharmaceutical Innovation in an International Context) More important, perhaps, is that most of the basic (high-cost, high-risk) research is funded by you, the taxpayer, through National Institute of Health (NIH) grants; drug companies most often buy the patents only after the original research shows promise.

Of course, in recent years, there has been a change. In labeling. Some expenditures that used to be included as marketing are now included as R&D. Not that the amount that they spend on lobbying, political contributions, marketing to physicians, and direct marketing to consumers has changed. And of course we have the FDA approving incredibly expensive and profitable drugs against the recommendations of their scientific panels (FDA approves Alzheimer's drug against the recommendation of its scientific panel. Be very concerned, June 21, 2021). This is corruption, this is your government selling you down the river to increase the profits of an industry that everyone, justifiably, hates.

And then, of course, we need to consider the device makers. You know, the companies that make stuff that is stuck into your bodies by surgeons, from artificial hips to cardiac defibrillators. Just to make sure that they do not continue to fly under the radar, getting cover from the excesses of the drug manufacturers. This is important; unlike drugs, if it turns out that your  implant  is not the best choice, or is not working well, or is really inferior, or is harming you, it is not as easy to just stop and put a new one in. That artificial hip? They opened you up, cut out the top part of your thigh bone (femur), and part of where it inserts into the pelvis (ilium) and put in this new hardware. Replacing it is a big deal. So getting the best one available is important. Usually, this decision is left up to the surgeon. So how do you get surgeons to use your device if you are a device manufacturer? Marketing! Telling them how great it is! Showing them testimonials from other surgeons!  Oh, yes, and, of course good old kickbacks, paying them for using your product! This is reported on in a recent piece in Medscape, “Device Makers Have Funneled Billions to Orthopedic Surgeons Who Use Their Products”, June 17, 2021. That is how you wanted your surgeon to choose the new part that is going to replace part of your hip, or spine, or knee, right? Bribery?

Of course, it is not listed as bribery on the companies’ balance sheets, and I’m sure that the individual surgeons do not report it on their income tax under “kickbacks”. Back in 2012, surgeon and writer Atul Gawande, in an article in the New Yorker called “Big Med” (discussed by me in Quality and price for everyone: Bigger may be better in some ways, but not all, Aug 24, 2012) reported on an effort in a Harvard-affiliated hospital to standardize the hardware used by orthopedic surgeons. Rather than having each surgeon pick their own favorite and having the hospital have to stock several – or sometimes more than 10 – versions of, say, an artificial hip, a committee researched the quality and the hospital stocked 1 or 2 of the best, and each surgeon had to use them. This improved outcomes. There was no suggestion that the surgeons were, at that time, getting kickbacks, but it is certain that the manufacturers whose products were not chosen were not happy about it.

It is not hard to see why the American people distrust the healthcare system, and the hugely profitable drug and device industries that supply it, and the healthcare “providers” – hospitals – that deliver it, and, sadly with news like these kickbacks, even the doctors and other clinicians caring for them. And I haven’t even gotten into  (today) the insurance companies! As in so much else, it often appears that both our major political parties are the parties of Corporate America, although one is at least making some efforts to limit those corporations. The other is, like the drug companies, totally shameless.

It is not hard, but it is sad. And worse, destructive to our health, as individuals and as a society. 

The Administration closes the National Guideline Clearinghouse: Bad for our health!

The Department of Health and Human Services (HHS) has closed the National Guideline Clearinghouse (NGC), which was housed in its Agency for Health Research and Quality (AHRQ), by pulling its funding. If one goes to the NGC website, it actually says that there is no longer funding for it. The NGC provided a major resource for consensus information, and closing it is a tremendous loss, not only for the physicians and other medical providers who depended upon its recommendations, but for the health of the American people. It is also, sadly, a loss for the patients of physicians and other medical providers who did not heed, and even opposed the existence of these guidelines. This is because  they will now have the cover that comes from the absence of the NGC when they do things that are not supported by the best evidence available.

Wait, wouldn’t my doctor want to use the best evidence available? Can’t I depend on her/him doing this? Do I have to become a medical expert?

You – we would all – hope that our doctors would use the best evidence available. This is not necessarily the newest stuff, for the obvious reason that it is new, and thus less tested. Frequently, when a test or intervention is new, it looks good, but later, when more people have been exposed to it and more data are available, negative information may emerge. (Sometimes this is because serious side effects may appear to a new drug because so many more people are using it; sometimes it is the result of straight-up fraud, as in the case of Theranos – see The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 2, April 22, 2018.) Conversely, the oldest tests and treatments are not necessarily the best either – a doctor who does not keep up after his or her training is also going to be way behind.

And guidelines are, of course, guidelines, not laws – they are meant to guide the practitioner to help make the best decisions by summarizing and presenting the evidence, for the whole population and for significant “sub”-populations. For example, older people may have a greater benefit from – or be at greater risk of harm from – a certain treatment than younger people. This could be from a different physiology (kidneys, for example, don’t function as well at cleaning out poisons in older people) or from a different risk/benefit profile (perhaps a bad outcome usually takes longer to appear than the life expectancy of a person; a 20-year lag time for something bad has a different meaning for a 50 year old than an 80 year old).

Not all guidelines have the same strength of evidence behind them. Sometimes the evidence is very strong, coming from multiple randomized controlled trials (RCTs) that are consistent with each other; at the other extreme, they can come from the opinions of a group of experts in the field who are gathered for the purpose of creating a guideline. However, in any case, the guidelines presented should be those for which the strongest evidence exists. The website for NGC still has available the inclusion criteria for the guidelines that used to exist there. The physician is always able to do something different if the recommendation is for some (good) reason not appropriate for a particular patient. But s/he should know, or be able to find – on the NGC, say – what the guidelines are for a particular course of action (test, treatment, etc.). Until just recently, they could. Not now. Which raises the question: why is it gone?

I, of course, do not know the answer, so am forced to speculate. There is some cost to maintaining the guidelines and doing the research, and many people do not like cost, but so much more is being spent on arguably less important things (if one considers the health of the people important; I do). Some people, versions of libertarians, do not like anything that even suggests government mandates, but I know few libertarians who advocate suppressing the truth. Some people are not surprised at any actions taken by the current administration and its executive departments, particularly those that seem to take on science, as has happened with climate change and the use of fossil fuels, but those seem, ultimately, to be based on money and the opportunity for profit. Thus, destroying pristine areas for fossil fuel exploration (the Arctic, the tar sands) and transport (the Keystone pipeline), as well as of the world’s climate from burning them, makes people money. Rich and powerful people.

So maybe that is where we should look for the closure of NGC. The fact is that if there are guidelines there is a rebuttable presumption that, barring differences in the individual patient that are relevant, they should be followed. If the evidence shows that a particular diagnostic test or a treatment (drug, device, etc.) is usually better, it is going to hurt the pocketbooks of the manufacturers of alternative drugs or devices or tests. And it can also hurt the pocketbooks of actual doctors if they make their money doing something that is no more effective than, or even less effective than, doing something cheaper or easier – especially if that is done by someone else. Sometimes the issue is standardization; it saves money for a hospital (and can improve quality) if only one or two types of, say, artificial joints are used. But this hurts (obviously) the manufacturers of the other brands, and perhaps is a negative for those surgeons who have learned how to use the non-preferred brands (see Atul Gawande, “Big Med”, New Yorker, August 13, 2012). It is even a bigger issue when the evidence demonstrates that the costly surgical option doesn’t work, or doesn’t work as well as, a much cheaper non-surgical option that exists. Well, then, you are threatening someone’s income – just like renewable energy threatens the income of companies that produce and sell fossil fuels.

But would doctors actually do such a thing? Resist a cheaper and more effective alternative because it would cost them money? You betcha. Not always, of course, and not all doctors, but it has happened. “In the late 1990s,” the New York Times observes in its excellent editorial on the subject,  “when it [AHRQ] endorsed nonsurgical interventions for back pain, the back surgeon lobby waged an attack that resulted in huge funding cuts and placed a permanent target on the Agency for Healthcare Research and Quality (A.H.R.Q.), the agency that houses the database.”[1] They attacked the existence of the Agency because they didn’t like (REALLY didn’t like, since it would hit them in the pocketbook!) the evidence.

Yup. It happened. I remember it. It was shocking to me (I must have been more naïve!). I lived in San Antonio at the time, and a San Antonio congressman, Henry Bonilla, was leading the charge against AHRQ, to the embarrassment of the non-back-surgeon San Antonio medical community. But they were, and are, a rich and powerful lobby. And they are still doing thousands of surgical interventions for back pain of the type that AHRQ recommended against in the ‘90s. And making a lot of money on it. Maybe you had such a procedure? Did it help? I hope so. If you are trying to decide, for this or any other complicated treatment (surgery, cancer treatment, etc.) and wanted to know what was recommended for your problem, you could have gone to the NGC website and looked it up. Not now.

One issue with the evidence, of course, is that it depends upon what research was done, and on what populations. And diagnostic and treatment plans that make money for doctors and hospitals are only of use to them if they get paid, and paid well, so they are less likely to be done to poor and uninsured or underinsured people. Maybe this is one time when not having good insurance is a health benefit!

But it shouldn’t be. We should all be covered for necessary diagnosis and treatment. And whether providers or manufacturers can make money should not be a criterion for recommending it. And now we have less access to finding out what the recommendations are.

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[1]By the way, how did Fox News cover this story? I could only find one link, to Fox Vegas, which used the CNN coverage, which was quite critical of the elimination of NGC. National Fox didn’t seem to think it worth covering.

Maternal mortality in the US and UK: Why do we tolerate paying so much more for so much worse outcomes?

Last year, ProPublica, in association with NPR, published Why Giving Birth Is Safer in Britain Than in the U.S. In typical journalistic style, it starts by grabbing your attention with a case report of a woman in England who almost died of post-partum hemorrhage, but did not. The lesson is presumably that she did not because the physicians, midwives, and others attending her followed a rigorous set of established protocols for addressing post-partum hemorrhage that are implemented nationally in the UK.

Of course, there is a possibility that this individual woman could have died, or had to undergo more invasive surgical procedures further down the protocol’s algorithm, but the real point is that, overall, the system is working. The evidence is in that the maternal mortality rate (deaths/100,000 women delivering) is 8.9 in Britain, while in the US the rate in 2015 was 25.1, three times that of the UK! What makes this more dramatic is that the disparity has developed only since 1990; until then the maternal mortality rates in the US and UK had been declining in parallel since the 1950s.

The article cites several reasons for this difference. One, a very important one, is that the UK collects data on maternal mortality nationally and develops guidelines based upon this data which are implemented nationally. In contrast, the US collects data at best by state, or even by hospital, and

There is no federal-level scrutiny of maternal deaths, and only 26 states have an established committee (of varying methodology and rigor) to review them. Nor do all U.S. hospitals routinely examine whether a death could have been avoided. Procedures for treating complications such as preeclampsia, and for responding to emergencies such as hemorrhage, vary from one doctor, hospital and state to the next.

This is true despite the fact that the methods used by the British to collect and analyze this data were developed in the US. While there has been a well-documented 30-year effort to improve quality and to reduce preventable deaths (a category into which most maternal mortality falls) in the US, led by such organizations as the Institute for Healthcare Improvement (IHI) and embraced by such other organizations as the American Hospital Association (AHA), National Center for Quality Assurance (NCQA), the Joint Commission for the Accreditation of Healthcare Organizations (TJC), the National Academy of Medicine, and on and on, no compulsory national approach to this problem has developed. This reflects a common, and often knee-jerk, opposition to centralized approaches to almost everything, even when they have been determined to have an important effect on reducing death. It is actually parallel to efforts within hospitals to standardize care, to require, for example, all surgeries to go through a series of prescribed steps (“timeouts”) before operating, or limiting the number of different devices implanted to those needed by different types of patients rather than by the preference of the individual surgeon (for an interesting discussion, see A. Gawande, “Big Med”, New Yorker, August 13, 2012). That is, it is effective where it has been done, but it is not mandated to be done everywhere and comprehensive national data is not even collected.

Another big part of the successful UK approach to the reduction of maternal mortality has been collecting detail on what happened and why; this goes beyond “there was a death”, or “there was a death from hemorrhage”, or “there was a death from sepsis”, to identifying why it happened, particularly if the reason was something that is relatively easily addressed. Marian Knight, head of MBRRACE-UK, the group that collects the data and makes the guidelines, says

It’s all very well to know a woman died of sepsis, but to know that she died of sepsis because nobody measured her temperature, as they had no thermometers on the postnatal ward, that’s where the instruction Put a thermometer on your postnatal ward might make a difference. It’s not just the what, it’s the why.

Can you believe that there might be post-partum units where there is no thermometer? Apparently it has happened. And having a rule that it must be present is a way of preventing it from happening again.

There are at least three other important dimensions. One is that, as the report states, “These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy.”  This is not a big surprise.  Poor women, minority women, rural women, and uninsured women do much worse, and are much more likely to die from complications of delivery. It is the familiar song in the US, as in so many areas, of health and of every aspect of society. Is it not true in Britain? The article goes on to say

In the U.K., while inequalities persist when it comes to serious complications, according to 2012-2014 data, there is no statistically significant difference in mortality rates between women in the highest and lowest socioeconomic groups. All British women have equal access to public medical services, including free care and prescriptions from pregnancy through the postpartum period.

This also has two components; the greater equity of the quality of healthcare delivered to all segments of the population, a result of having a national health care system, and less disparity in the “social determinants of health”, the actual quality of the lives of people (women, in this case) before they access care. Especially for rural women, some of the problem the lack of an adequate number of health professionals. Over 20 years ago, family medicine residencies in Texas were surveyed and only a small percent of residents were interested in providing rural obstetric care, but no OB/Gyn residents were! This has not improved; while a recent study published by Tong, et al., in Family Medicine (Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care) found that 22% of FM residents planned to deliver babies, they cite his 2012 study that showed that only 9.1% of FM residency graduates were delivering babies 1-10 years out into practice despite an intention to do so of 24%, comparable to the current study.

Another dimension is that the difference in maternal mortality reflects a greater focus on the health – and life -- of the pregnant woman in Britain, while in the US the focus is more on the health of the fetus and the newborn. This goes far beyond the issue of abortion, although the focus on children rather than women is one that is also characteristic of the anti-choice movement in the US. It is so deeply ingrained in our culture that even many health professionals (including midwives, doctors, and nurses) who see themselves as “pro-choice” and would never want to see a maternal mortality, are still more focused on the fetus and baby. It results in a practice, if not a belief, that considers the woman but a vehicle for producing a child.

Finally, there is cost, ironically but again unsurprisingly much higher in the US. Much higher. The total cost for a normal vaginal delivery in the US is about $30,000, and about $50,000 for a Caesarean section. In Britain, the cost for a normal vaginal delivery or planned Caesarean is about $2500, or less than 1/10^th the cost in the US, perhaps rising to $3400 for complicated cases (such as the one that leads off the article). Thus, the US charges far more, but has much worse outcomes for maternal mortality (as for many other conditions). This is not a side note; it is not just an interesting contradiction that our care costs more but has worse outcomes. And it is not by any means limited to pregnancy care or maternal mortality, but is present in our healthcare system at almost all levels and for most conditions. What ties these two components, cost and quality, tightly and inversely together, is that our “healthcare system” is only secondarily about delivering quality healthcare, and primarily about being a profit-making business.

So, that is the bottom line. The US has three times the maternal mortality rate of the UK despite charging ten times as much for delivery. The reasons are the absence of a national strategy to identify and remedy the causes of maternal mortality and the lack of a national healthcare system to provide the access necessary for women at risk. It causes the suffering and death to disproportionately affect those women who are already at greatest risk: the poor, minority, rural, and uninsured. The root cause is that our healthcare system is composed of poorly interconnected components, most of which are run as businesses to make money.

It is inequitable, and it is irrational from a health perspective if not from a business one. It causes unnecessary death and excessive cost, and seems to not be improving. It is not acceptable. We need to change it.

Integrated Health Systems and Cost: The Price is the thing!

When the Affordable Care Act (ACA) was being developed, much emphasis was put on the effectiveness of integrated health systems as a way to save money but still deliver quality health care. Many studies from various research centers had looked at cost to Medicare and found that places – usually smaller cities – with large integrated health systems spent less on Medicare without noticeable decrements to quality. These systems can have a single provider of both inpatient and outpatient care (such as the Mayo Clinic) or close collaborations, including shared electronic medical records (as in Grand Junction, CO). The presumption of policy makers creating ACA was that Medicare spending, which is much easier to track, would reflect overall spending. However, a recent article from the National Bureau of Economic Research by Zack Cooper, Stuart Craig, Martin Gaynor and John Van Reenen, The Price Ain’t Right? Hospital Prices and Health Spending on the Privately Insured, demonstrates that this assumption was incorrect. Reviewing overall costs in the 306 Hospital Referral Regions (HRRs, developed by the Dartmouth Atlas of Health Care) in the US, they discovered wide discordance between Medicare costs and overall healthcare costs. Indeed, many of the places that were highly-touted for lower-Medicare-costs-but-still-high-quality, notably Grand Junction, CO (which was, for example, cited as a success story by Atul Gawande in his June, 2009 New Yorker article “The Cost Conundrum”) have far higher than average costs overall. (Dr. Gawande has just had a new piece in the New Yorker discussing the implications of this new article.)

The New York Times coverage of this study, by Kevin Quealy and Margot Sanger-Katz, The Experts Were Wrong About the Best Places for Better and Cheaper Health Care (December 15, 2015), includes a terrific feature that allows interactive access to the data collected by Cooper and his colleagues. You can put in a town (really, HRR) and find out where it ranks in terms of both Medicare and private costs. Grand Junction, for example, while ranking 3^rd lowest of the 306 HRRs for per-capita Medicare spending, was the 42^nd most expensive for private insurance spending. Rochester, MN, home of the Mayo Clinic, is another city lauded for its low Medicare costs (14^th lowest), but its private spending is 10^th highest! McAllen, TX, cited by Gawande in 2009 for being #1 in Medicare spending (and now still #4) is only 140^th in private insurance spending. Tucson, AZ, on the other hand, while only in the lower middle (82^nd from the bottom) in Medicare spending, is 7^th lowest for overall costs. The Kansas City region, where I live, was atypically near the middle for both, 142^nd lowest for Medicare and 82^nd  lowest for private costs. New York City is high in both, but it is 2^nd for Medicare and 34^th (quite a bit lower) for private insurance. The map in the article depicts HRRs as low, middle or high for both Medicare and private insurance.

So, what’s up? Were the experts trying to fool us? No, but the flaw  was the assumption that Medicare spending reflected overall spending. The data in this article demonstrates that it does not. It also reveals something about integrated health systems, especially those that dominate their smaller cities, given that some of the “top performers” for Medicare, like Grand Junction and Rochester, MN, were so high for private insurance. The integrated nature of these plans allows them to save money on patients by a variety of methods – they can be seen in ambulatory settings rather than in hospitals or ERs, and they share electronic medical record systems, and thus the information recorded therein, saving money by not having to repeat tests, x-rays, etc. This lower utilization is good for these health systems because Medicare is a relatively low payer, and because they can’t negotiate these rates – Medicare pays what it pays (it is a single-payer system, with minor regional variations). However, the same characteristic – being the dominant player in town – allows such integrated health systems to negotiate much higher rates with private insurers. Thus the mismatch; overall cost is a multiple of price for each service times the number of services delivered. These systems decrease the number of services for people insured by Medicare, for whom they cannot control the price (whether this does or does not decrease quality is a separate question) but they raise the price for services to people with private insurance. That places like Tucson and Kansas City have relatively lower prices for private insurance reflects the absence of a single large dominant system in those cities.

‘“Price has been ignored in public policy,” said Dr. Robert Berenson, a fellow at the Urban Institute, who was unconnected with the research’, in the Times article. Other health policy experts, such as Princeton’s Uwe Reinhardt, have been warning about this for decades. In the effort to pass the ACA, and please both providers and insurers, this point was in fact ignored, and it is the source of most of the common legitimate criticism of the ACA – that in many places decent health insurance policies bought through the health exchanges are unaffordable. With higher prices in these regions, insurers pass on the cost to their customers.  This is illustrated in the NPR story “Obamacare Deadline Extended As Demand For Health Insurance Rises” on December 18, 2015, which documents both the success of ACA measured by the large increase in the number of people signing up for coverage and their frustration at the frequently-high cost of this coverage. Of course, this is completely unrelated to the criticisms leveled at ACA by the Republican candidates for President and their allies in Congress, whose “solution” – abolish ACA – is Marie Antoinette-like. While the French queen is reputed to have said, in response to being told that the peasants had no bread, “then let them eat cake!”, Republicans, hearing that many people cannot afford health insurance on the exchanges even with subsidies, or get Medicaid in states (that they control) which have not expanded it, respond “let them pay out of their own pocket!”

The issues and solutions are clearly laid out by the reliably insightful Dr. Don McCanne is his “Quote of the Day” on this topic. A solution cannot come from a jerry-rigged program that allows either insurers or health systems or both to maximize their profit. It needs to come from a system that starts with price controls, most effectively by a single-payer system such as Medicare. There are, as he notes, still risks – mainly that health systems may under-utilize services when they cannot make profit, leading to lower quality of care. But we can guard against this both on the regulatory end, by measuring quality outcomes and holding providers responsible, and through the market because the incentive to not provide services to Medicare patients because they can be more profitably provided to the privately -insured (the “opportunity cost”) goes away.

The infatuation of both policy makers and providers for integrated health systems is not entirely misplaced. The potential savings from shared data and not repeating tests, and more importantly for caring for people in the most clinically appropriate setting (inpatient, ER, outpatient surgery center, primary care, long-term care) is a real positive feature of these systems. But to the extent that these providers are allowed to use their market muscle to raise prices to insurers which are passed on to beneficiaries, it becomes a real negative.

The key feature of a good health system is that it is not focused on balancing the financial interests of big insurers and big providers, but that it puts the benefits to patients, to the people’s health, first.

Payments for surgical complications: With a scalpel or a meat ax?

When you bring your car to a mechanic and there is a complication, when something goes wrong with the procedure they say they are going to do, you don’t expect to pay for it, at least if it is their fault, and if you know it. Say that in repairing one part of the engine, they cut a hose in another part; you wouldn’t expect to be financially responsible for fixing it. You’d think that they should absorb the cost, but of course it might unlikely that you would know whether the complication was their fault (sloppy work) or unpredictable, maybe a pre-existing problem that they hadn’t anticipated. On the other hand, if they fix your brakes or transmission and a few days later they fail, you do expect them to repair it for no cost to you.

The relationship between payment and surgical procedures done on your body in the hospital is more complex. First of all, just as with your car, complications happen. Sometime they are the result of “operator error”, whether mechanic or surgeon, but most of the time they occur with a predictable (but hopefully low) frequency. And, like with your car, some people have higher risk of complications because they are in worse shape. And one of (although certainly not the only) the predictors of being worse shape is, just as with cars, the age of the patient. Therefore, it is important to consider the risk (and potential seriousness) of complications and weigh it against the potential benefit from the surgery.

Secondly, payment for surgery (as for all hospital activities, and to some degree all medical activities) is bewildering and incomprehensible to health economists, not to mention doctors and regular people. With your car, you get a bill for “parts” and for “labor”; if you think you’re overcharged, you go somewhere else next time. In medicine, and particularly in hospitals, “charges” for procedures are a largely mythical but definitely inflated number that bears only a little relationship to the costs the hospital incurs, and is almost never the amount that is paid. Different insurers (private, Medicare, Medicaid, “self-pay”) pay different amounts; big insurance companies can bargain down the rates that they pay, government programs such as Medicare and Medicaid set their rates, and the uninsured are the only ones who get a bill for the whole set of charges (of course, they can rarely pay them, but are often bankrupted or have their credit ruined in the process). (See Bargaining down the medical bills, March 15, 2009, or the experience of health journalist Frank Lalli trying to find out what his medicine would cost, “A health insurance detective story”, NY Times December 2, 2012, and covered in my blog post “Medicare: Consumer choice or choosing your poison? How about coverage for everyone?”, December 15, 2012.)

So, do hospitals make or lose money when there are complications to surgery? The answer is “it depends on who’s paying”. In a recent JAMA, Relationship Between Occurrence of Surgical Complications and Hospital Finances[1], Sunil Eappen and colleagues from the Harvard School of Public Health (including, as last and corresponding author, Atul A. Gawande, the surgeon whose New Yorker essays I have discussed several times) examined this question in a large hospital system in the southeast US whose “inpatient surgical payer mix (Medicare, 45%; private, 40%; Medicaid, 4%; and self-pay, 6%) was comparable to that of an average US hospital in 2010 (Medicare, 40%; private, 41%; Medicaid, 9%; and self-pay, 5%)”. Their study found that “…The financial effects of surgical complications varied considerably by payer type. Complications were associated with more than $30,000 greater contribution margin per privately insured patient ($16,936 vs $55,953) compared with less than $2000 per Medicare patient ($1880 vs $3629). In contrast, for Medicaid and self-pay procedures, those with complications were associated with significantly lower contribution margins than those without complications. As a result, the payer mix will determine the overall economics of surgical complications for a given hospital."

Definitions  of Costs and Margins  (from Eappen, et al.)

Variable costs: Costs that vary with patient  volume (ie, supplies and nurse staffing).

Fixed costs: Costs that do not vary with patient volume (ie, costs for the hospital building, utilities, and maintenance).

Total margin: Revenue minus variable costs and fixed costs.

Contribution margin: Revenue minus variable costs. These are revenues available to offset fixed costs.

This absolutely does not mean that in these hospitals, or any hospital, surgical complications are seen as desirable. It does mean that, when the complications happen, the hospitals make money (their “contribution margin” toward fixed costs goes up – see the box which I have reproduced from the article for explanations of terms) if the patients are privately insured or covered by Medicare and lose money if the patients are covered by Medicaid or self-pay. It provides another example of why hospitals see some patients as “more desirable” based upon their insurance coverage, and illustrates how flawed this system is.

The study by Eappen was done on data from 2010, and there have been some changes since then. Medicare no longer pays for the treatment of complications (surgical or medical) that it has identified as preventable and that did not exist on admission (such as new bed sores or blood clots). It will soon go further and not pay for readmissions to the hospital within a certain period of time, whether or not the readmission is for the same problem. So, to carry on the car analogy, not only will they not pay again if your brakes fail after they’ve been “fixed”, they also won’t pay if you have to bring your car back because it needs transmission work. The latter may be as inappropriate for people as for cars; with time multiple things break down, not always related. With a car, we may sell or junk it; with a person we usually try to treat it. Our high-tech medical system can often get a person from the brink of death to “well enough” to go home or a skilled-care facility, but the same problem or another recurs and requires readmission. And, of course, since this is Medicare, all of our patients over 65 covered by this program now become “less desirable”; it means that, even more than before, hospitals will compete for patients with private insurance coverage.

This is no way to fix the problem. The first step has to be to put everyone in the same boat, to have a universal health insurance system, so that no patient is “more” or “less” desirable from a financial standpoint based upon their insurance coverage. Second, hospitals should not be paid on a “per case” basis or have a charge structure that no one understands. They should not have to seek out “well-insured” patients to cover their actual costs (fixed and variable) or put aside money for purchase of new capital equipment. In Canada, hospitals receive a global yearly payment for operating costs (and capital expenses are considered separately), and can thus make treatment decisions based on best meeting the needs of the patient, rather than “readmissions good” (we make money) or “readmissions bad” (we lose money. It is rather parallel to capitated payments for physicians, which I have discussed (recently, for example, Gaming the system: Integration of healthcare services can just raise costs, not quality, December 1, 2012), allowing physicians to treat patients in person, by phone or email, with long visits or short, depending upon what is most appropriate rather than which has the greatest reimbursement.

Of course, like capitated payments to physicians, hospital global budgets need to be adequate to cover costs and incent efficient but effective performance. A well-designed structure for payment that minimizes “gaming” the system no longer works when it is grossly underfunded. An open and transparent system of funding is most likely to permit cost savings where appropriate and not “across the board” (which is almost always wrong); it encourages the use of a scalpel rather than a meat ax.

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[1] Eappen S, Relationship Between Occurrence of Surgical Complications and Hospital Finances, JAMA 2013;309(15):1599-1606.