Better outcomes for patients ignored

I posted this to the National Journal Healthcare blog this morning:

I waited to write this blog because I was hopeful that someone would comment on the July 2, 2009 New England Journal of Medicine article, “The Effect of Medicare Part D on Drug and Medical Spending.” What Zhang, Donohue, Lave, O’Donnell, and Newhouse reported was that “Groups that had no or minimal drug coverage before the implementation of Part D had reductions in other medical spending that approximately offset the increased spending on drugs, but medical spending increased in the group that had more generous previous coverage.”

These findings bring to the forefront the reality of our health care system - just because you do the right thing for a person’s best health does not mean that it will reduce cost or have the same effect for everyone. We can all agree that it is better to take medicine than to have “other medical spending” because it means that you are able to manage your disease. This was the outcome for those who had the least coverage before Medicare Part D. For those who had more coverage the findings are harder to interpret.

In the same way that Medicare Part D was the right choice for patient health, expanding health insurance coverage to all, including preventive care coverage, is the right thing to do now. But we must be honest. Just because it is the right thing to do does not mean it will save money.

The key point is that health care is complex and deserves more than sound bites especially because it is about life, death, and the difficultly in measuring the quality of life.

Health Care Costs: More than Dollars

I posted this to the National Journal Healthcare blog this afternoon:

Today’s New York Times article ”In Health Reform, a Cancer Offers an Acid Test” is the type of analysis and discussion that makes me shudder when I think of how easy it is to misuse the findings from proposed comparative effectiveness research when the focus is just cost. The Times has a chart comparing the average cost of the five types of treatment for prostate cancer. What is lacking is how each procedure impacts the life of the person receiving the treatment.

I propose that all those considering health care reform remember to take the perspective of the patient and health consumer. For each procedure what needs to be included as part of any cost or effective analysis there is also a new measure that takes into account consumer’s assessment of PAID (pain, absence from work, invasiveness of procedure, and disability.) for each procedure under consideration. Patients need more information but it is more than just cost of the procedure.

Reading between the lines

There has been much hubbub about the New Yorker article comparing El Paso to McAllen and virtually nothing about Richard Cooper’s article, ”States With More Health Care Spending Have Better Quality Health Care: Lessons About Medicare.” (December 4, 2008 Health Affairs – Web Exclusive). It is easy to understand why.

The New Yorker analysis resonates to the mythology that pervades thinking about health - that there is great variability in costs of health care because in some areas physicians are not doing what is good treatment but rather taking actions that will only increase their income. The suggestion is made that where there are high Medicare costs it is because there is much waste and the suggestion is stretched to explain all the waste in health care.

Cooper’s analysis however looks at all health spending instead of the slice represented by Medicare data. Cooper finds that, “Medicare spending per enrollee correlates poorly with total health care spending per capita.” He takes it one step further with the data he presents to state that regional variation in Medicare is not a valid measure of how well the health care system is working.

My question is simple - then why do we keep using Medicare data the way we do?

Best Outcomes for All

I just finished the first edits on my book (look for it in early 2010) and am so glad that I will be able to write my blog again. The best part about writing a new book is that it is an opportunity to look across sectors and see what is on the horizon that will shape our health and well being. In many ways the new developments left me hopeful. At the same time it became clear that it was time to rethink some of the terms used by the health cognoscenti.

Let’s begin with discarding the conceptual framework of ED (not the one of blue pill fame) but as in “Elimination of Disparities” a term which over the past decade has had increased popularity. Too often ED became the new code for addressing the health care needs and concerns of Hispanics, African Americans, Asian Americans, Native Americans, and other communities.

The research that ensued documented the differences in care and treatment. With ED too many made the assumption that the best treatment would be the same for all. I knew that was a mistake because too often the goal of equal treatment did not sufficiently focus on outcomes.

There are differences among individuals and the best health care for a non-Hispanic woman in Minnesota may not be what is best for a Latina in Santa Fe. If fact, there is a growing body of evidence that the Latina is less likely to practice unhealthy behaviors like smoking and is likely to live longer that the woman in Minnesota.

As we enter one of the most robust debates we have had on health care, the need should not be to standardize treatment but to design systems that achieve the best outcome for all (BOA). The goal should be “Best Outcomes for All”; not on the average but at the individual level. That is something we can all get behind.

Saving money is not always good news

It will be refreshing when I go to a meeting and people present data in a way that tells the full story. Take the recent thrown around fact that we have spent less money on Medicare Part D than had been projected. Isn’t it great that we saved billions of dollars? The reality is that half of the savings come from the failure to enroll all of the modest income persons who are eligible for extra help in paying for their medicines. While the savings may sound good, the challenge remains to enroll all those eligible in a program that helps them get the medicines they need.

Hispanics Have Highest End-of-Life Costs

A study published this week in the Archives of Internal Medicine found that in the last six months of life cost for care for Hispanic patients ($31,702) was 60% higher than for non-Hispanic white ($20,166) patients. I have been there at the end-of-life for four people who were very close to me. If the costs are higher for Hispanics than for non-Hispanics whites I would say it is because no one took the time to talk to the patient and the patient’s family.

Hispanics are the group least likely to have a regular source of care. This means we are also less likely to have a relationship with a provider who understands our wishes on end-of-life issues. Ensuring the dignity and comfort all people deserve at the end-of-life is one more reason why health reform is so important. Hispanics must have access to health care providers who can understand their patient’s language and cultural values and can support families in their decisions about end-of-life care. It’s a simple matter of quality of care.

Five Popular Health Care Myths in 2009

In my latest post to the National Journal Healthcare Blog, I identify five popular health care myths in 2009.

Early Death Means Health Care Savings

While there is much agreement about the need for health care savings we also need to agree on how we define good health services and outcomes.  CBO Director Elmendorf’s comment below needs our careful consideration:

"Even if successful, measures to reduce smoking and obesity—two factors linked to the development of chronic and acute health problems—might not have a substantial impact on health care spending for some time.  In the long term, spending on diseases caused by poor health habits could decline substantially, but the impact on federal costs would also have to account for people living longer and receiving more in Medicare benefits (for the treatment of other diseases and age-related ailments) as well as other government benefits that are not directly related to health care (including Social Security benefits)."

--Douglas W. Elmendorf; Director, Congressional Budget Office 

   Testimony before the Senate Finance Committee

   February 25, 2009