Health – Page 56 – artdiamondblog.com

Health Care Costs Continue to Increase

Source of graphic: online version of the NYT article cited below.

(p. C1) The cost of living keeps going up, but the cost of healthy living is going up even faster.

A widely followed national survey reported yesterday that the cost of employee health care coverage rose 7.7 percent this year, more than double the overall inflation rate and well ahead of the increase in the incomes of workers.

The 7.7 percent increase was the lowest since 1999. But the average cost to employees continued an upward trend, reaching $2,973 annually for family coverage out of a total cost of $11,481.

Since 2000, the cost of family coverage has risen 87 percent while consumer prices are up 18 percent and the pay of workers has increased 20 percent, the survey noted. That is without counting the cost of deductibles and other out-of-pocket payments, which have also been rising.

For the full story, see:

MILT FREUDENHEIM. "Health Care Costs Rise Twice as Much as Inflation." The New York Times (Weds., September 27, 2006): C1 & C7.

Source of graphic: online version of the NYT article cited above.

“An Image Was Worth a 1,000 Statistical Tables”

Artistic vision of germ-laden hand. (This is not the photographic image mentioned below, and used as a hospital screen-saver.) Source of image: online version of the NYT article cited below.

(p. 22) Leon Bender noticed something interesting: passengers who went ashore weren’t allowed to reboard the ship until they had some Purell squirted on their hands. The crew even dispensed Purell to passengers lined up at the buffet tables. Was it possible, Bender wondered, that a cruise ship was more diligent about killing germs than his own hospital?

Cedars-Sinai Medical Center, where Bender has been practicing for 37 years, is in fact an excellent hospital. But even excellent hospitals often pass along bacterial infections, thereby sickening or even killing the very people they aim to heal. In its 2000 report “To Err Is Human,” the Institute of Medicine estimated that anywhere from 44,000 to 98,000 Americans die each year because of hospital errors — more deaths than from either motor-vehicle crashes or breast cancer — and that one of the leading errors was the spread of bacterial infections.

. . .

. . . the hospital needed to devise some kind of incentive scheme that would increase compliance without alienating its doctors. In the beginning, the administrators gently cajoled the doctors with e-mail, (p. 23) faxes and posters. But none of that seemed to work. (The hospital had enlisted a crew of nurses to surreptitiously report on the staff’s hand-washing.) “Then we started a campaign that really took the word to the physicians where they live, which is on the wards,” Silka recalls. “And, most importantly, in the physicians’ parking lot, which in L.A. is a big deal.”

For the next six weeks, Silka and roughly a dozen other senior personnel manned the parking-lot entrance, handing out bottles of Purell to the arriving doctors. They started a Hand Hygiene Safety Posse that roamed the wards and let it be known that this posse preferred using carrots to sticks: rather than searching for doctors who weren’t compliant, they’d try to “catch” a doctor who was washing up, giving him a $10 Starbucks card as reward. You might think that the highest earners in a hospital wouldn’t much care about a $10 incentive — “but none of them turned down the card,” Silka says.

When the nurse spies reported back the latest data, it was clear that the hospital’s efforts were working — but not nearly enough. Compliance had risen to about 80 percent from 65 percent, but the Joint Commission required 90 percent compliance.

These results were delivered to the hospital’s leadership by Rekha Murthy, the hospital’s epidemiologist, during a meeting of the Chief of Staff Advisory Committee. The committee’s roughly 20 members, mostly top doctors, were openly discouraged by Murthy’s report. Then, after they finished their lunch, Murthy handed each of them an agar plate — a sterile petri dish loaded with a spongy layer of agar. “I would love to culture your hand,” she told them.

They pressed their palms into the plates, and Murthy sent them to the lab to be cultured and photographed. The resulting images, Silka says, “were disgusting and striking, with gobs of colonies of bacteria.”

The administration then decided to harness the power of such a disgusting image. One photograph was made into a screen saver that haunted every computer in Cedars-Sinai. Whatever reasons the doctors may have had for not complying in the past, they vanished in the face of such vivid evidence. “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior,” Leon Bender says. “But when you present them with good data, they change their behavior very rapidly.” Some forms of data, of course, are more compelling than others, and in this case an image was worth 1,000 statistical tables. Hand-hygiene compliance shot up to nearly 100 percent and, according to the hospital, it has pretty much remained there ever since.

For the full commentary, see:

STEPHEN J. DUBNER and STEVEN D. LEVITT. "FREAKONOMICS; Selling Soap." The New York Times Magazine (Section 6) (Sunday, September 24, 2006): 22-23.

(Note: ellipses added.)

The screen-saver at Cedars Sinai Hospital. Source of image: http://freakonomics.com/pdf/CedarsSinaiScreenSaver.jpg

Gym Classes Promote Sports, Not Healthy Exercise

Here is more evidence that public school physical education classes should be turned over to private sector firms like "24 Hour Fitness."

Ms. Jackie Lund, who is quoted below, is the President of NASPE, which the article identifies as "an association of fitness educators and professionals. Note well that she as much as admits that fitness is not the purpose of gym classes.

Researchers report that in the typical high-school gym class students are active for an average of 16 minutes.

The report by Cornell University researchers also found that adding 200 minutes more of physical-education time a week had little effect. (See the report.)

"What’s actually going on in gym classes? Is it a joke?" asked John Cawley, lead author of the study and a professor of policy analysis and management at Cornell.

. . .

The rest of the extra gym time is likely spent being idle — most likely standing around while playing sports like softball or volleyball that don’t require constant movement, Mr. Cawley said.

. . .

. . . , Ms. Lund says merely counting how many minutes students are moving may not be a fair measure of a gym class. "It’s not supposed to be aerobics class. The activity level is going to vary depending on the sport they’re learning," she said.

For the full story, see:

"High-Schoolers Get Scant Exercise in Gym Class." Wall Street Journal (Weds., September 20, 2006): D4.

(Note: the online version of the article has the title: "Is High-School Gym Class An Exercise in Futility?")

(Note: ellipses are added.)

World Health Organization (WHO?) Endorses DDT

Source of graphic: online version of the WSJ article cited below.

The World Health Organization, in a sign that widely used methods of fighting malaria have failed to bring the catastrophic disease under control, plans to announce today that it will encourage the use of DDT, even though the pesticide is banned or tightly restricted in much of the world.

The new guidelines from the United Nations public-health agency support the spraying of small amounts of DDT, or dichloro-diphenyl-trichloroethane, on walls and other surfaces inside homes in areas at highest risk of malaria. The mosquito-borne disease infects as many as 500 million people a year and kills about a million. Most victims are in sub-Saharan Africa and under the age of 5.

For the full story, see:

BETSY MCKAY. "WHO Calls for Spraying Controversial DDT To Fight Malaria." Wall Street Journal (Fri., September 15, 2006): B1.

Against Malaria “DDT Works in Weeks or Months”

Recently I highlighted hedge fund philanthropist Lance Laifer’s efforts to fight malaria in Africa. Here is a letter-to-the-editor of the Wall Street Journal, in which a distinguished physician strongly endorses Laifer’s advocacy of the use of DDT against malaria:

Impoverished Africans should be grateful to philanthropist Lance Laifer for his effective outreach to reduce the tragic, needless toll of malaria in sub-Saharan Africa ("Malaria’s Toll" by Jason Riley, editorial page, Aug. 21). For his attempt to focus complacent Americans, Mr. Riley also deserves thanks — such clarity is obviously desperately needed, as even with all the publicity accorded to the ravages of malaria, someone as educated and intelligent as Mr. Laifer remained blithely unaware of this scourge until last year.

Both Mr. Laifer and Mr. Riley note the lack of attention given by official organizations to the more widespread use of DDT as a malaria control method, despite its long and honorable history for this use. Even with his money and other resources, Mr. Laifer has been unable to persuade Africans to utilize DDT. African exporters legitimately fear economic repercussions from wealthy Western trading partners, who continue to demonize this lifesaving insecticide despite the lack of evidence of DDT’s adverse health effects in humans.

And where is the Gates Foundation’s massive resources in this ongoing struggle to save a half-billion from sickness and millions from death? This organization asserts its devotion to reducing the toll of TB, AIDS and malaria — yet none of its funding is aimed toward the cheapest and most effective way to deal with malaria: increased indoor spraying with DDT. Maybe Warren Buffett can persuade his friends Bill and Melinda to target their contributions where they will do the most good, in the shortest time, for the most people. Malaria vaccines are many years away — DDT works in weeks or months.

Gilbert Ross M.D.
Executive and Medical Director
American Council on Science and Health
New York

For the source of the letter, and for other letters, see:

"Malaria Kills Millions — We Have the Cure." Wall Street Journal (Mon., August 28, 2006): A13.

“DDT Saves Lives, Environmentalists Take Lives”

Connecticut hedge-fund trader, and malaria-fighting activist and philanthropist. Source of image: online version of the WSJ article cited below.

Inside of a year, and working with George Ayittey of the Free Africa Foundation, Mr. Laifer’s efforts have spawned five "malaria-free zones" in Ghana, Nigeria and Kenya. Expansion to Ivory Coast and Benin is in the works. He adds that he has the financing to roll out additional zones this year but — ever the searcher — first wants to assess what’s working and what isn’t. If all is going well, "next year I see us doing something like 100 villages."

Mr. Laifer says a future focus will also be DDT, the pesticide used by Americans and Europeans in the 1940s to win domestic fights against malarial mosquitoes. Indoor spraying of DDT is by far the cheapest and most effective way to control the disease. One South Africa province employing DDT saw malaria infections and deaths drop 96% over a three-year span.

Yet Rachel Carson-inspired environmentalists have convinced many public health agencies that the chemical is dangerous. African nations, fearful that lucrative European and U.S. markets might ban their agricultural exports, make do with less-effective DDT substitutes. Though DDT, like any chemical, can be harmful in high doses, there’s no evidence that using it in the amounts needed to combat malaria has any ill-effect whatsoever on humans.

Mr. Laifer’s been unable to spray DDT in any of his malaria-free zones. "It’s the best thing in our arsenal," he says. "We have a prodigious supply, it’s cheap and we know it works. Our world leaders need to legalize DDT, and people in America need to get mad about this. . . . We need to have people walking around with signs that say, ‘DDT saves lives, environmentalists take lives.’"

For the full commentary, see:

JASON L. RILEY. "Malaria’s Toll." Wall Street Journal (Mon., August 21, 2006): A11.

(Note: the ellipsis is in the original.)

Distorted Incentives in Medicine

Source of book image: http://www.harpercollins.com/books/9780061130298/The_End_of_Medicine/index.aspx

The problem right now, as Mr. Kessler sees it, is that we fight the "big three" — cancer, stroke and heart attack — with treatment rather than early detection. Cancer cells and blood-vessel plaque can be handled much more easily in the early stages, but we spend most of our money on the later ones. More than 80% of health-care dollars are paid by insurance companies and the government, and neither is especially interested in detecting disease when it first appears. Doctors, regulators, researchers and payers of all kinds are locked into what Mr. Kessler calls — a bit ungenerously — the "cholesterol and cancer conspiracies."

A complicated system of mutual dependency distorts the incentives. "The FDA is like the FCC and Big Pharma is like the regional Bells" is what Mr. Kessler hears from Don Listwin, a former Cisco executive who now heads the Canary Foundation, a Silicon Valley-based effort to promote preventive medicine. In other words, in medicine as in telecom, the big players end up exploiting regulations more than opposing them, if only to preserve their monopolies. The Food and Drug Administration — understandably but narrow-mindedly — wants "cures" for cancer and other diseases. Thus tens of thousands of chemicals are screened, only a handful make it even to Phase I trials, and by the time a new drug is approved a billion dollars has been spent. Even then the new drug may help only 10% of patients.

Yet if someone were to invent a device with a wide, preventive usefulness — say, a nanotech implant that would spot the proteins that indicate the first minute presence of cancer — it would have to go through the same process of billion-dollar testing. Since the government and insurance companies are reluctant to add anything to their repertoire of coverage — and since such a device would be targeted at the much broader pool of people who are not sick — research might well stall in its earliest phases for lack of reimbursement-funding.

For the full review, see:

WILLIAM TUCKER. "Bookshelf; The Art of Navigating Arteries." Wall Street Journal (Tues., July 18, 2006): D6.

A full reference to the book reviewed, is:

Kessler, Andy. The End of Medicine: How Silicon Valley (and Naked Mice) Will Reboot Your Doctor. HarperCollins, 2006.

“Financial Incentives Can Change the Way Medicine is Practiced”

An angioplasty being performed in Eyria, Ohio. Source of photo: online version of the NYT article cited below.

Medicare patients in Elyria receive angioplasties at a rate nearly four times the national average . . .

. . .

. . . some outside experts say they are concerned that Elyria is an example, albeit an extreme one, of how medical decisions in this country can be influenced by financial incentives and professional training more than by solid evidence of what works best for a particular patient.

“People are rewarded for erring on the side of an aggressive, highly expensive intervention,” said Dr. Elliott S. Fisher, a researcher at Dartmouth Medical School, which analyzed Medicare data and found Elyria to be an outlier.

Medicare pays Elyria’s community hospital, EMH Regional Medical Center, about $11,000 for an angioplasty involving use of a drug-coated stent.

The cardiologist might be paid an additional $800 for the work. That is well above the fees for seeing patients in the office. And with the North Ohio doctors performing thousands of angioplasties a year — about 3,400 in 2004, for example — the dollars can quickly add up.

Some medical experts say Elyria’s high rate of angioplasties — three times the rate of Cleveland, just 30 miles away — raises the question of whether some patients may be getting procedures they do not need or whether some could have been treated just as effectively and at lower cost and less risk through heart drugs that may cost only several hundred dollars a year.

. . .

Experts know that changing the financial incentives can change the way medicine is practiced.

For example, Kaiser Permanente, the big health system that employs its own doctors, says its patients in Ohio, including some in Elyria, are slightly less likely than the national average to undergo the type of cardiac procedures the North Ohio Heart Center doctors perform so prolifically.

Kaiser’s cardiologists, who work on salary instead of being paid by the procedure, typically treat patients in that region at the Cleveland Clinic, where they have hospital privileges. And they follow established protocols about when a patient should undergo an angioplasty, when drugs might suffice and when bypass surgery might be the best resort.

“It’s not just individual doctors making up their minds,” explained Dr. Ronald L. Copeland, the executive medical director for Kaiser’s medical group in Ohio. With no financial reason to perform expensive procedures, the Kaiser doctors frequently choose to manage the patients’ heart disease with drugs only. “Our doctors have no disincentive to do that,” Dr. Copeland said.

. . .

For many cardiologists, the natural tendency when they see a patient with heart disease is to perform a procedure to try to clear arterial blockages. And patients, cardiologists say, tend to rely on their doctors’ judgment.

“It’s sort of like, you go to a barber and ask if you need a haircut,” said Dr. David D. Waters, chief of cardiology at San Francisco General Hospital, who is currently studying the effectiveness of different kinds of treatment for heart disease. “He’s likely to say you do.”

. . .

Experts say it can be difficult to detect cases in which doctors cross a medical line and are clearly performing unnecessary treatments.

“A lot of decisions are discretionary,” said Dr. Harlan M. Krumholz, a cardiologist and professor at Yale.

“It’s about where the thermostat is set,” he said, arguing that doctors in a particular geographic area tend to be unaware if the way they are treating their patients is markedly different from the practices of their peers in other areas.

Traditional measures of medical quality are not set up to detect whether patients are being treated too much, he said, unlike the kinds of safeguards that prompt credit card companies to call their customers to discuss unusual spending activity. “Right now there are no ‘smart’ systems in place,” Dr. Krumholz said.

In the absence of any real monitoring or oversight, doctors in most places, including Elyria, have few incentives not to favor the treatments that provide them the most reimbursement. Dr. Waters, the San Francisco cardiologist, said that the way physicians are typically paid — more money for more procedures — results in too many decisions to give a patient a stent.

“You can’t be paying people large sums of money to do things without checks and balances,” he said.

For the full story, see:

REED ABELSON. "In Ohio City, a Heart Procedure Is Off the Charts; SIDE EFFECTS; A Stent Epidemic." The New York Times (Fri., August 18, 2006): A1 & C4.

Source of graphic: online version of the NYT article cited above.

Perverse Incentives Lead to Useless Heart Surgeries

The old idea was this: Coronary disease is akin to sludge building up in a pipe. Plaque accumulates slowly, over decades, and once it is there it is pretty much there for good. Every year, the narrowing grows more severe until one day no blood can get through and the patient has a heart attack. Bypass surgery or angioplasty — opening arteries by pushing plaque back with a tiny balloon and then, often, holding it there with a stent — can open up a narrowed artery before it closes completely. And so, it was assumed, heart attacks could be averted.

But, researchers say, most heart attacks do not occur because an artery is narrowed by plaque. Instead, they say, heart attacks occur when an area of plaque bursts, a clot forms over the area and blood flow is abruptly blocked. In 75 to 80 percent of cases, the plaque that erupts was not obstructing an artery and would not be stented or bypassed. The dangerous plaque is soft and fragile, produces no symptoms and would not be seen as an obstruction to blood flow.

That is why, heart experts say, so many heart attacks are unexpected — a person will be out jogging one day, feeling fine, and struck with a heart attack the next. If a narrowed artery were the culprit, exercise would have caused severe chest pain.

Heart patients may have hundreds of vulnerable plaques, so preventing heart attacks means going after all their arteries, not one narrowed section, by attacking the disease itself. That is what happens when patients take drugs to aggressively lower their cholesterol levels, to get their blood pressure under control and to prevent blood clots.

Yet, researchers say, old notions persist.

”There is just this embedded belief that fixing an artery is a good thing,” said Dr. Eric Topol, an interventional cardiologist at the Cleveland Clinic in Ohio.

In particular, Dr. Topol said, more and more people with no symptoms are now getting stents. According to an analysis by Merrill Lynch, based on sales figures, there will be more than a million stent operations this year, nearly double the number performed five years ago.

Some doctors still adhere to the old model. Others say that they know it no longer holds but that they sometimes end up opening blocked arteries anyway, even when patients have no symptoms.

Dr. David Hillis, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas, explained: ”If you’re an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them they don’t need the procedure, pretty soon Joe Smith doesn’t send patients anymore. Sometimes you can talk yourself into doing it even though in your heart of hearts you don’t think it’s right.”

Dr. Topol said a patient typically goes to a cardiologist with a vague complaint like indigestion or shortness of breath, or because a scan of the heart indicated calcium deposits — a sign of atherosclerosis, or buildup of plaque. The cardiologist puts the patient in the cardiac catheterization room, examining the arteries with an angiogram. Since most people who are middle-aged and older have atherosclerosis, the angiogram will more often than not show a narrowing. Inevitably, the patient gets a stent.

”It’s this train where you can’t get off at any station along the way,” Dr. Topol said. ”Once you get on the train, you’re getting the stents. Once you get in the cath lab, it’s pretty likely that something will get done.”

For the full story, see:

GINA KOLATA. "New Heart Studies Question the Value of Opening Arteries." The New York Times (Sun., March 21, 2004).

Doctors Face Perverse Incentives and Constraints

Kevin MD’s blog provides an illuminating discussion of how hard we make it for good people to practice medicine. The case discussed involves an MD who is successfully sued for not performing a heart cath on a patient, even though two previous treadmill tests did not reveal any problems. (The heart cath procedure itself has a nontrivial risk of death and other serious complications.)

The discussion in the Kevin MD illustrates the difficult incentives and constraints faced by the conscientious physician. In terms of a patient’s health, a cost/benefit analysis may imply that a medical test should not be performed, but in terms of an MD’s income, and legal liability, a cost/benefit analysis may imply that a medical test should be performed.

Something is wrong with our reward structure and legal institutions, when MD’s who make the right medical call for the patient, are "rewarded" by earning less, and by increasing their chances of being sued.

Read the full discussion at:

http://www.kevinmd.com/blog/2006/06/liable-for-not-doing-heart-cath-on-49.html

For convenience, here is the opening entry in the discussion:

Continue reading “Doctors Face Perverse Incentives and Constraints”