Thought du Jour

Another great health care article by Dr Atul Gawande.

The subject [of health care for the terminally ill] seems to reach national awareness mainly as a question of who should “win” when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we can’t afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But they’re debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper. ….

In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.” ….

The hard question we face … is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives. ….

Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. …. The lesson seems almost Zen: you live longer only when you stop trying to live longer.

Atul Gawande, “Letting Go”, The New Yorker, 2 August 2010.

HT Clive Crook.

Atul Gawande (1965-) is a journalist, a staff surgeon at Brigham and Women’s Hospital (Boston), Associate Professor of Surgery at Harvard Medical School and Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health.

We are not getting any younger. Death is certain, even if its timing is not. You will benefit from reading Gawande’s long essay, and also – in case you missed it – a recent essay by another author, on the same subject:

Katy Butler, “What Broke My Father’s Heart”, New York Times Sunday Magazine, 20 June 2010.

Medical journalist Atul Gawande has posted his commencement address to graduates at Stanford’s School of Medicine. His message? The system of care – how components fit together – is a major determinant of the cost and effectiveness of medicine, irrespective of the excellence of individual drugs, devices and specialists.

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. ….

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. ….

Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says.

Atul Gawande, “The Velluvial Matrix”, The New Yorker News Desk, 16 June 2010.

HT to The Browser.

New research from the United States suggests that we can expect increased consumption of medical services as a result of healthcare reform, because privately owned hospitals are more willing to care for insured patients than for uninsured patients.

Over one-quarter of nonelderly adults in the United States lacked health insurance during at some point in 2007. A large body of research documents a strong association between insurance status and particular patterns of health care utilization. The uninsured are less likely to consume preventative care such as diagnostic exams and routine checkups. They are more likely to be hospitalized for conditions that – if treated promptly – do not require hospitalization. ….

But would the uninsured behave differently if they had health insurance?

[...]

Most studies cannot determine whether the large differences in healthcare utilization between the insured and the uninsured are due to insurance status or to other unobserved differences between the two groups. In this paper, we exploit a sharp change in insurance coverage rates that results from young adults “aging out” of their parents’ insurance plans to estimate the effect of insurance coverage on the utilization of emergency department (ED) and inpatient services. Using the National Health Interview Survey (NHIS) and a census of emergency department records and hospital discharge records from seven states, we find that aging out results in an abrupt 5 to 8 percentage point reduction in the probability of having health insurance. We find that not having insurance leads to a 40 percent reduction in ED visits and a 61 percent reduction in inpatient hospital admissions. The drop in ED visits and inpatient admissions is due entirely to reductions in the care provided by privately owned hospitals, with particularly large reductions at for profit hospitals. The results imply that expanding health insurance coverage would result in a substantial increase in care provided to currently uninsured individuals.

Michael Anderson, Carlos Dobkin and Tal Gross, “The Effect of Health Insurance Coverage on the Use of Medical Services”, NBER Working Paper 15823, 20 February 2010.

An ungated version of the paper can be downloaded here.

I was surprised to see that loss of insurance decreases visits to hospital emergency rooms. Conventional wisdom is that emergency rooms are the medical services of choice for the uninsured. Larger – and related – questions are “What is the effect of insurance on visits to a doctor’s office or clinic?” and “What is the effect of insurance on health status (outcomes)?” The researchers ignore both questions, but NHIS data displayed in appendix 10 reveal no discontinuity by age in reported visits to “a doctor or other health care professional at a doctor’s office, a clinic, an emergency room, or some other place”. This suggests that the uninsured might be substituting visits to doctor’s offices and clinics for more expensive visits to hospitals. More analysis is needed. This is not a definitive study of the effect of insurance on the use of medical services, but it raises interesting questions and could stimulate further research.

Via Paul Krugman, The Heritage Foundation – a conservative Washington, DC think tank – back in 2003 proposed reform of the US healthcare system that is remarkably similar to the legislation passed last Sunday by the House of Representative. Stuart Butler, Vice President for Domestic & Economic Policy at The Heritage Foundation, supported universal health care coverage in order to

Provide support to people to obtain health care based on their need, not where they happen to work, or their eligibility for welfare, or their military record, or their age. Enable individuals and families to use this support to enroll in a seamless system of coverage according to their choice.

The central public policy objective of a health care system is to use public funds in an efficient and economical way to enable every household to obtain at least an acceptable level of health care services and protection from large financial burdens associated with ill health. Whether a US resident is able to count on that commitment should not depend on their current circumstances. Moreover, resources should be used as efficiently as possible to provide help those who need it most to obtain coverage. That requires us to overhaul current subsidy methods to target funds more efficiently and to achieve horizontal equity between similar people.

An important step towards that would be to overhaul the tax treatment of health care, gradually ending the regressive tax exclusion for employer-sponsored health insurance and replacing it with a more progressive subsidy. That is the logic behind the various refundable tax credit proposals in numerous proposals for addressing uninsurance. These proposals would increase the subsidy to lower-income households relative to upper-income households.

Stuart Butler, “Laying the Groundwork for Universal Health Care Coverage”, Testimony given March 10, 2003 before the Special Committee on Aging, United States Senate.

The only difference between this 2003 proposal, and the legislation passed last Sunday, is that Butler (and THF) prefer a federalist approach: “Congress would establish goals for universal coverage” and provide funding for states to reach those goals. Otherwise, Obama’s conservative reform legislation reads as if it were drafted by The Heritage Foundation.

The Heritage Foundation nonetheless has been consistently critical of the efforts of Democrats to reform health care. See, for example, here and here and here.

The final bill gets many things “right” from a conservative perspective (dropping the public option, for example, and preserving consumer choice except for  abortion), so it is odd that there is not a word of praise from The Heritage Foundation on any aspect of the reform.

[E]ven if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this [Senate] bill [passed by the House on Sunday] will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003.

Uwe E. Reinhardt, “Wrapping Your Head Around the Health Bill”, Economix, 24 March 2010.

GW Bush’s “Medicare Modernization Act”, according to the actuaries of Medicare, will add more than $1 trillion to the federal deficit over the next ten years.

Uwe E. Reinhardt teaches economics at Princeton University.