Physicians often gravitate to cost control proposals that do not involve their own role and changing their practices, whereas policymakers may propose solutions that will not significantly reduce costs. In assessing cost control proposals, 2 criteria are fundamental. One criterion is that 2% growth in health care costs over growth in GDP amounts to $52 billion a year; serious proposals are aimed at reducing the growth in health care costs to 1% over GDP growth. Consequently, anything short of $26 billion in savings is not credible. A second criterion is that cost control proposals should transform the delivery of care and lead to improved quality as well as patient and physician satisfaction.

Malpractice Costs.. Physicians frequently cite malpractice premiums and the cost of defensive medicine as drivers of high costs. A recent Congressional Budget Office (CBO) analysis estimated that a package of reforms consisting of a $250 000 cap on noneconomic damages, a $500 000 cap on punitive damages, reducing the statute of limitations (1 year for adults and 3 years for children), and implementing fair-share liability could reduce malpractice premiums by 10% ($3.5 billion per year) and reduce defensive medicine for the entire health care system by 0.3% ($7 billion), for a total savings of approximately $11 billion or 0.5% of national health care spending per year.^3​ No reliable data indicate that other malpractice reforms would generate cost savings.

Importantly, more than 30 states have instituted similar caps and limits. If these measures have reduced costs, they are insufficient to counter other factors increasing costs. In addition, physicians in those states, such as California, do not seem to indicate that the practice environment is better. There is little research on the effects of malpractice caps on quality, although 1 study cited by the CBO suggested that caps lowered the quality of care.⁴ This suggests that limits on malpractice liability would not likely both reduce costs and improve quality.

Insurance Company Profits. Another proposed cost control mechanism focuses on the profits of insurance companies. In 2010, the combined profits of the 5 largest insurers—Wellpoint, United, Aetna, Humana, and Cigna—increased substantially, reaching $11.7 billion.^5​ It may be worthy to reduce these profits, but in the scheme of $2.6 trillion in national health care spending, this amount constitutes just 0.5% of total spending.

Drug Costs. In 2010, the United States spent $262 billion on prescription drugs, 10% of total health care spending.¹ There is a worrisome trend that new drugs and biologics costing tens of thousands of dollars per year do not provide cures, but achieve only modest disease benefit. One approach to cost savings is drug reimportation, which would allow brand-name drugs sold at lower prices in Canada or other countries to be imported into the United States. Assuming the logistical and supply problems were solved, the CBO estimated that reimportation could save approximately 1% of drug costs, an insignificant $2.6 billion.^6​

Another approach might be to substitute generic drugs for brand-name drugs. Between 2004 and 2009, use of generic drugs increased substantially from 57% to 75% of all prescriptions.⁷ Despite this change, costs for health care and for prescription drugs have both increased by approximately 25% during those years. By increasing generic prescription levels to 100%—an unrealistic level—CBO estimated that an additional $900 million could be saved for Medicare Part D in 2009.^8​ Of the $502 billion spent on Medicare in 2009, this would amount to a savings of less than 0.2%. The US Department of Health and Human Services recently concluded that increased savings from expanding generic use “are likely to be small relative to total spending on drugs”⁷—not to mention total health care costs.

“The Million Dollar Baby.” Many physicians believe the US health care system expends excessive amounts on so-called “million dollar babies”—patients who spend long periods in intensive care units and require tracheostomies, gastrostomy tubes, and myriad other interventions. However, an analysis of nearly 20 million commercially insured patients revealed that only 255 patients had consumed more than $1 million each on health care expenditures in 2010. Extrapolating to the entire health care system suggests these patients use 0.5% of all health care costs. Even if all costs attributed to care of these “million dollar babies” could be eliminated, there are not enough of such patients to significantly reduce health care spending. Expanding this group to patients who consume more than $250 000 in health care expenditures each per year would translate into 6.5% of health care costs. But how can these high-cost patients be identified before they get treatment? Furthermore, it would not seem possible to curtail the health care services such patients receive without raising the charge of “death panels.”

Some may suggest that even if each of these individual cost control measures does not save much money, all together the savings might begin to approach $15 or $20 billion. Maybe. However, there are no specific policies that would enable saving money on the care of “million dollar babies” and the probability of policies that would foster adoption in other areas is remote. More importantly, none of these 4 cost control approaches would transform the delivery of care and generate higher-quality care more efficiently. Malpractice reform based on caps to damages has the suggestion of lowering quality, reimportation of drugs and reducing insurers’ profits lower prices but do not affect the delivery of care or quality, and money saved on the “million dollar babies” cannot be anticipated.

Where Are the Cost Savings?

Where is the money in health care? Approximately 10% of the population consumes about 64% of health care expenditures. Who are these patients? “Chronic conditions were closely linked to high expenditure levels: more than 75% of high-cost beneficiaries . . . had one or more of seven major chronic conditions . . . 42% had coronary artery disease, 30% had congestive heart failure, and 30% had diabetes.”^9​ Another reason to focus on these patients is to improve quality—they use the majority of health care services.

There are 2 important aspects about their health care spending and quality of care. First, one estimate suggested that as much as 22% of all health care expenditures is related to potentially avoidable complications such as hospital admissions for patients with diabetes with ketoacidosis or amputation of gangrenous limbs or of patients with congestive heart failure for shortness of breath due to fluid overload.¹⁰ Thus, reducing avoidable complications by 10% could save more than $40 billion per year.

Second, reducing unnecessary medical care for chronically ill patients is about improving tertiary prevention. While some efforts to improve tertiary prevention have failed, others have succeeded. Development and dissemination of additional approaches are needed. Successful efforts seem to entail instituting at least 4 common changes: (1) installing electronic health records and using them to track patients’ health status and physician performance, as well as using decision supports to increase adherence to treatment pathways; (2) using the information for more intensive interactions between patients, caregivers, and clinic staff, including use of care coordinators, 24/7 access, interventions to increase medication adherence, specialized clinic services for recurrent problems of patients with chronic disease such as anticoagulation clinics; (3) reducing use of specialists, and when specialists are involved using those who are more efficient; and (4) providing services not traditionally covered by fee-for-service reimbursement, such as e-mail, wireless monitoring to increase medication adherence, home evaluations to minimize falls, lifestyle interventions to improve nutrition and exercise, and transportation services for office visits. Cumulatively, the savings appear to occur through fewer hospitalizations, emergency department visits, and lower use of specialist services.

The Role of Physicians

For physicians to know “where the money is” and the availability of some successful models for reducing costs has 3 implications. First, physicians must be the leaders and must stop looking to drug companies, insurers, or someone else to initiate and achieve cost savings.

Second, physicians have the responsibility to redesign care delivery to emphasize more tertiary prevention and avoid unnecessary complications. Although this will be hard work, only effective physician leadership can ensure successful redesign.

Third, physicians know well that such care redesign cannot occur without payment reform. Rather than complain about the payment system and reimbursement rates, and the problems of accountable care organization regulations or bundled payment regulations, physicians need to take the initiative. They need to develop and propose bundled payments or suggest revisions to the new regulations on accountable care organizations that will facilitate the redesign of care and tertiary prevention.

Deficit pressures are making cost control inevitable. It will only be successful if physicians stop looking to others to find solutions and focus on approaches that improve the care for patients with chronic illnesses.

Author Information

Corresponding Author: Ezekiel J. Emanuel, MD, PhD, Office of the Provost and Department of Medical Ethics and Health Policy, University of Pennsylvania School of Medicine, 122 College Hall, Philadelphia, PA 19104 (zemanuel@upenn.edu).

REFERENCES

. Recession contributes to slowest annual rate of increase in health spending in five decades. Health Aff (Millwood). 2011;30(1):11–22, pmid:21209433.Free Full Text

. The Long-Term Outlook for Health Care Spending. http://www.cbo.gov/ftpdocs/87xx/doc8758/MainText.3.1.shtml. Accessed November 30, 2011.

. Selected CBO Publications Related to Health Care Legislation, 2009-2010: Effect of Proposals to Limit Costs Related to Medical Malpractice (Tort reform). http://www.cbo.gov/ftpdocs/120xx/doc12033/12-23-SelectedHealthcarePublications.pdf. Accessed November 30, 2011.

. Evaluation of Options for Medical Malpractice System Reform. http://www.medpac.gov/documents/Apr10_MedicalMalpractice_CONTRACTOR.pdf. Accessed November 30, 2011.

. HCAN Analysis Shows Health Insurers Pocketed Huge Profits in 2010 Despite Weak Economy. http://healthjusticenetwork.wordpress.com/2011/03/04/hcan-analysis-shows-health-insurers-pocketed-huge-profits-in-2010-despite-weak-economy/. Accessed November 30, 2011.

. H.R. 2427: The Pharmaceutical Market Access Act of 2003, CBO Cost Estimate: November 19, 2003. http://www.cbo.gov/ftpdocs/48xx/doc4852/hr2427.pdf. Accessed December 7, 2011.

. ASPE Issue Brief: Expanding the Use of Generic Drugs: December 1, 2010. http://aspe.hhs.gov/sp/reports/2010/GenericDrugs/ib.pdf. Accessed November 30, 2011.

. Effects of Using Generic Drugs on Medicare’s Prescription Drug Spending. http://www.cbo.gov/doc.cfm?index=11838. Accessed November 30, 2011.

. The high concentration of US health care expenditures. Research in Action. 2006:19. http://www.ahrq.gov/research/ria19/expendria.pdf. Accessed November 30, 2011.

. Building a bridge from fragmentation to accountability: the Prometheus Payment model. N Engl J Med. 2009;361(11):1033–1036, pmid:19692682.Find Full-TextCrossRefMedline

The study, released on Wednesday by the 34-nation Organization for Economic Cooperation and Development, or OECD, said Americans pay more than $7,900 per person for healthcare each year — far more than any other OECD country — but still die earlier than their peers in the industrialized world.

The cost of healthcare in the United States is 62 percent higher than that in Switzerland, which has a similar per capita income and also relies substantially on private health insurance.

Meanwhile, Americans receive comparatively little actual care, despite sky-high prices driven by expensive tests and procedures. They also spend more tax money on healthcare than most other countries, the study showed.

An “underdeveloped” U.S. primary care system is plagued by shortages of family doctors and high rates of avoidable hospital admissions for people with asthma, lung disease, diabetes, hypertension and other common illnesses.

U.S. survival rates are the world’s highest among breast cancer patients and the second highest, after Japan, for people with colorectal cancer – due in part to effective early screening, the study showed. The study also said Americans experience generally good acute hospital care.

“It’s a very, very mixed pattern,” said Mark Pearson, head of the OECD health division. “You get a very high quality of care for your money in some areas. Very poor quality, compared to other countries, in other areas.”

The quality and cost of the $2.6 trillion U.S. healthcare system are at the forefront of a rancorous national political debate over how to regulate and pay for treatment, particularly for the poor and elderly.

The 2010 U.S. healthcare reform law, which seeks to control costs over time by altering incentives for doctors and other providers, faces a constitutional challenge in the Supreme Court, and Republican presidential candidates on the campaign trail have called for its repeal.

LESS CARE, MORE MONEY

Federal spending on Medicare and Medicaid, the government programs for the elderly and the poor, is also a leading target of efforts to narrow the yawning U.S. fiscal deficit.

The OECD said U.S. public spending on healthcare reached 8 percent of the economy versus a 7 percent OECD average in 2009, the latest year for which comparison figures are available.

A forum of developed nations set up to foster global development, the OECD said U.S. life expectancy of 78.2 years ranked 28th – just behind Chile’s and well below the average of 79.5 years among member nations.

The growth in U.S. life expectancy over the past half century is also below average, gaining only 8.3 years since 1960 compared with an 11.2-year OECD average.

The United States was ranked fourth from the bottom for premature mortality, which focuses on deaths among younger people. The measure, which reflects dangers posed by violence, accidents and environmental hazards, puts America behind all others save Hungary, Mexico and Russia.

Pearson said researchers believe national mortality rates increasingly reflect the quality of healthcare, though more than half of the equation is still believed to lie with other indicators including lifestyle and diet.

Americans have fewer doctors and hospital beds, make fewer doctor visits, go to the hospital less often and stay for shorter lengths of time than about three-quarters of the other OECD countries.

But the United States is at the front of the pack when it comes to costly medical procedures including knee replacements, MRI and CT scans and tonsillectomies.

And it is consistently at the top of the cost chart for a number of procedures including caesarean sections, which are almost twice as expensive in the United States as in Germany.

Pharmaceuticals also cost about 60 percent more than in a range of European countries.

Pearson said one reason prices are higher in the United States is that the healthcare system lacks what other countries have: an effective government mechanism that acts to keep prices down.

“That’s simply not there in the U.S. system. So it’s a structural defect,” he said.

[Kaiser Health News] This story was produced in collaboration with POLITICO Pro.

During the health care debate, the Mayo Clinic, the Cleveland Clinic, Geisinger Health System and Intermountain Healthcare were repeatedly touted as models for a new health care delivery system.

Now, they have something else in common: All four have declined to apply for the “Pioneer” program tailor-made by the Obama administration to reward such organizations.

“When the poster boys ask that the posters be taken down, you have a problem,” says Michael Millenson, president of Health Quality Advisors LLC. The lack of participation, he says, suggests that “somebody messed up”: either the government didn’t make the rules appealing enough, or “when push came to shove, the big players didn’t want to play by the rules.”

The four health systems are considered the most promising models for “accountable care organizations,” a new approach to delivering health care services that rewards doctors and hospitals for providing high-quality care to Medicare beneficiaries while keeping costs down. The ACO provision became one of the most highly anticipated elements of the health care overhaul, and providers embarked on a frenzied race to join in as quickly as possible.

But when the proposed regulation for the program was announced in March, excitement fizzled.

Hospital and doctor groups complained that the program created more financial risks than rewards and imposed onerous reporting requirements. The American Medical Group Association, which represents nearly 400 large provider organizations, responded with a letter to CMS warning that more than 90 percent of its members would not participate because of the reporting requirements and financial disincentives. In particular, the proposed rule would impose penalties for ACOs that do not achieve savings.

In response, HHS announced the Pioneer program in May, promising it would “provide a faster path for mature ACOs” like the Mayo Clinic that would allow the high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk. HHS estimated that the Pioneer program could save Medicare as much as $430 million over three years.

CMS has been tight-lipped about how many health systems applied for the program and has declined repeated requests for the information by Kaiser Health News. The deadline to apply was Aug. 19.

The Advisory Board Company, a hospital consulting firm, estimates that between 30 and 50 organizations have applied for the Pioneer program, based on informal surveys of clients and conversations with Innovation Center employees, said Chas Roades, Advisory Board’s chief research officer. CMS hoped to have 30 health systems participate in the Pioneer program.

Daron Cowley, a representative for Intermountain, says the health system decided not to apply because “the ACO regulations fell short of the goals that had been set, especially as it pertains to institutions that already are organized to coordinate care.”

Geisinger and some of the other leading organizations decided to remain in the Physician Group Practice Demonstration instead for another two years — continuing an earlier integrated care Medicare pilot that has a similar structure to ACOs and shares many of the same goals.

Jeff Ruggiero, a lawyer at Arnold & Porter and general counsel to the Queens County Medical Society in New York, says others are waiting to see what will be included in the final ACO Shared Savings regulation, expected to be released this month, and may apply to become ACOs under those rules. Others are choosing to form ACOs with private payers rather than Medicare.

Ruggiero says the “lack of clarity is creating some less-than-expected participation in the Pioneer program,” as health systems take a wait-and-see attitude. He adds that with such a timeline, few providers will be able to meet the January 2012 launch of the Shared Savings Program. CMS is “going to have to allow for some kind of rolling participation,” he says.

Susan DeVore, president and CEO of Premier, a performance improvement alliance that has 77 integrated health systems that aspire to become some form of ACOs, says eight member organizations applied for the program. With so many new integrated care models launching, she says, the number isn’t surprising. Members “are not slowing down, backing up or stopping the development of the capabilities to deliver integrated care in their communities,” she says.

Instead, she explains, they are choosing among the many options for forming integrated systems, including the Pioneer and Shared Savings Program, the Physician Group Practice Demonstration, medical homes and arrangements with private payers.

CMS Administrator Don Berwick said this week that he expects CMS will announce the Pioneer ACOs before the Shared Savings program launches in January.

Here is a partial list of applicants, confirmed by Kaiser Health News, for the ACO Pioneer program:

* Tucson Medical Center in Arizona
* Monarch HealthCare in Orange County, Calif.
* Norton Healthcare in Louisville, KY
* Banner Health (multiple states)
* Mountain States Health Alliance (multiple states)
* Fairview Health Services in Minnesota
* Hackensack University Medical Center in New Jersey
* Montefiore Medical Center in New York
* IntegraNet in Houston, Texas
* HealthCare Partners in California
* Advocate Health Care in Illinois
* Crystal Run Healthcare in New York
* Texas Health Resources
* Park Nicollet in Minneapolis, Minn.
* Detroit Medical Center in Michigan
* Henry Ford Health System in Michigan
* North Texas Specialty Physicians in Fort Worth, Texas

Christopher Weaver contributed to this report.

The standards, which also guarantee free coverage of other preventive services for women, follow recommendations from the National Academy of Sciences and grew out of the new health care law.

“These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need,” said Kathleen Sebelius, the secretary of health and human services.

The requirements apply to insurance in years starting on or after Aug. 1, 2012. They take effect in January 2013 for insurance plans that operate on the basis of a calendar year.

Supporters of the new requirement said it would go a long way toward removing cost as a barrier to birth control, a longtime goal of advocates for women’s rights and experts on women’s health. But the requirement does not immediately help women who have no health insurance.

It is sure to reignite debate over the federal role in health care at a time when Republicans in Congress are trying to repeal the health care law signed last year by President Obama.

A major goal of the law is to increase the use of preventive services like mammograms, colonoscopies, blood pressure checks and childhood immunizations. The law generally bans co-payments, deductibles and other charges for preventive services recommended by expert professional organizations. The law directed federal health officials to pay attention to the health needs of women in particular when listing preventive services that must be covered.

The new standards require coverage of the full range of contraceptive methods approved by the Food and Drug Administration, as well as sterilization procedures. Among the drugs and devices that must be covered are emergency contraceptives including pills known as ella and Plan B.

Senator Richard Blumenthal, Democrat of Connecticut, said, “These guidelines will save countless dollars and lives, and send a hugely powerful message about the importance of women’s preventive health care.”

Representative Lois Capps, Democrat of California, also praised the requirements, saying they would “ensure that women have increased access to the services they need to be healthy.”

The United States Conference of Catholic Bishops and some conservative groups, including the Family Research Council, have strenuously opposed any requirement for coverage of contraceptives.

Health plans offered by certain religious employers would be exempt from the requirement to cover contraceptive services. This provision is similar to the exemption for churches found in many of the states that already require coverage of contraception, federal health officials said.

Researchers have found that people who have coverage of preventive services, under Medicare or private insurance, use them much less than recommended. Federal officials said they would try to promote their use by publicizing the fact that wider, cost-free coverage is now available.

The National Academy of Sciences said the Obama administration had told its experts not to consider “the cost-effectiveness of screenings or services” in deciding which ones to recommend. Insurers expressed concern that coverage for some of the newly required preventive services could be costly.

Under the federal rules governing preventive services, insurers can use “reasonable medical management techniques” to control costs and promote the efficient delivery of care. The administration said Monday, for example, that an insurer could charge co-payments for brand-name drugs if a lower-cost generic version was available and was just as safe and effective.

In addition to contraceptive services for women, the government will require health plans to cover screening to detect domestic violence; screening for H.I.V., the virus that causes AIDS; and counseling and equipment to promote breast-feeding, including breast pumps.

Other preventive services that must be covered, without co-payments, include screening for gestational diabetes in pregnant women; DNA testing for the human papillomavirus as part of cervical cancer screening; and annual preventive-care visits. Such visits could include prenatal care and preconception care, to make sure women are healthy when they become pregnant.

In a report commissioned by the Obama administration, the academy’s Institute of Medicine said free contraceptive coverage was justified because nearly half of all pregnancies in the United States were unintended, and about 40 percent of unintended pregnancies ended in abortion. Thus, it said, greater use of contraception will reduce the rates of unintended pregnancy, teenage pregnancy and abortion.

Certain health plans that were in place on March 23, 2010, when Mr. Obama signed the health care law, may be able to avoid the requirement to cover preventive services for a while. But as time passes and insurers and employers modify their coverage, the number of plans entitled to such “grandfather status” is shrinking.

It has happened a few times in the U.S., and the opinion piece in Wednesday’s Journal of the American Medical Association says putting children temporarily in foster care is in some cases more ethical than obesity surgery.

Dr. David Ludwig, an obesity specialist at Harvard-affiliated Children’s Hospital Boston, said the point isn’t to blame parents, but rather to act in children’s best interest and get them help that for whatever reason their parents can’t provide.

State intervention “ideally will support not just the child but the whole family, with the goal of reuniting child and family as soon as possible. That may require instruction on parenting,” said Ludwig, who wrote the article with Lindsey Murtagh, a lawyer and a researcher at Harvard’s School of Public Health.

“Despite the discomfort posed by state intervention, it may sometimes be necessary to protect a child,” Murtagh said.

But University of Pennsylvania bioethicist Art Caplan said he worries that the debate risks putting too much blame on parents. Obese children are victims of advertising, marketing, peer pressure and bullying — things a parent can’t control, he said.

“If you’re going to change a child’s weight, you’re going to have to change all of them,” Caplan said.

Roughly 2 million U.S. children are extremely obese. Most are not in imminent danger, Ludwig said. But some have obesity-related conditions such as Type 2 diabetes, breathing difficulties and liver problems that could kill them by age 30. It is these kids for whom state intervention, including education, parent training, and temporary protective custody in the most extreme cases, should be considered, Ludwig said.

While some doctors promote weight-loss surgery for severely obese teens, Ludwig said it hasn’t been used for very long in adolescents and can have serious, sometimes life-threatening complications.

“We don’t know the long-term safety and effectiveness of these procedures done at an early age,” he said.

Ludwig said he starting thinking about the issue after a 90-pound 3-year-old girl came to his obesity clinic several years ago. Her parents had physical disabilities, little money and difficulty controlling her weight. Last year, at age 12, she weighed 400 pounds and had developed diabetes, cholesterol problems, high blood pressure and sleep apnea.

“Out of medical concern, the state placed this girl in foster care, where she simply received three balanced meals a day and a snack or two and moderate physical activity,” he said. After a year, she lost 130 pounds. Though she is still obese, her diabetes and apnea disappeared; she remains in foster care, he said.

In a commentary in the medical journal BMJ last year, London pediatrician Dr. Russell Viner and colleagues said obesity was a factor in several child protection cases in Britain. They argued that child protection services should be considered if parents are neglectful or actively reject efforts to control an extremely obese child’s weight.

A 2009 opinion article in Pediatrics made similar arguments. Its authors said temporary removal from the home would be warranted “when all reasonable alternative options have been exhausted.”

That piece discussed a 440-pound 16-year-old girl who developed breathing problems from excess weight and nearly died at a University of Wisconsin hospital. Doctors discussed whether to report her family for neglect. But they didn’t need to, because her medical crisis “was a wake-up call” for her family, and the girl ended up losing about 100 pounds, said co-author Dr. Norman Fost, a medical ethicist at the university’s Madison campus.

State intervention in obesity “doesn’t necessarily involve new legal requirements,” Ludwig said. Health care providers are required to report children who are at immediate risk, and that can be for a variety of reasons, including neglect, abuse and what doctors call “failure to thrive.” That’s when children are severely underweight.

Jerri Gray, a Greenville, S.C., single mother who lost custody of her 555-pound 14-year-old son two years ago, said authorities don’t understand the challenges families may face in trying to control their kids’ weight.

“I was always working two jobs so we wouldn’t end up living in ghettos,” Gray said. She said she often didn’t have time to cook, so she would buy her son fast food. She said she asked doctors for help for her son’s big appetite but was accused of neglect.

Her sister has custody of the boy, now 16. The sister has the money to help him with a special diet and exercise, and the boy has lost more than 200 pounds, Gray said.

“Even though good has come out of this as far as him losing weight, he told me just last week, ‘Mommy, I want to be back with you so bad.’ They’ve done damage by pulling us apart,” Gray said.

Stormy Bradley, an Atlanta mother whose overweight 14-year-old daughter is participating in a Georgia advocacy group’s “Stop Childhood Obesity” campaign, said she sympathizes with families facing legal action because of their kids’ weight.

Healthier food often costs more, and trying to monitor kids’ weight can be difficult, especially when they reach their teens and shun parental control, Bradley said. But taking youngsters away from their parents “definitely seems too extreme,” she said.

Dr. Lainie Ross, a medical ethicist at the University of Chicago, said: “There’s a stigma with state intervention. We just have to do it with caution and humility and make sure we really can say that our interventions are going to do more good than harm.”

While the findings may seem obvious, health economists and policy makers have long questioned whether it would make any difference to provide health insurance to poor people.

It has become part of the debate on Medicaid, at a time when states are cutting back on this insurance program for the poor. In fact, the only reason the study could be done was that Oregon was running out of money and had to choose some people to get insurance and exclude others, providing groups for comparison.

Some said that of course it would help to insure the uninsured. Others said maybe not. There was already a safety net: emergency rooms, charity care, free clinics and the option to go to a doctor and simply not pay the bill. And in any case, the argument goes, if Medicaid coverage is expanded, people will still have trouble seeing a doctor because so few accept that insurance.

Until now, the arguments were pretty much irresolvable. Researchers compared people who happened to have insurance with those who did not have it. But those who do not have insurance tend to be different in many ways from people who have it. They tend to be less educated and to have worse health habits and lower incomes, said Dr. Alan M. Garber, an internist and health economist at Stanford. No matter how carefully researchers try to correct for the differences “they cannot be completely successful,” Dr. Garber said. “There is always some doubt.”

The new study, published Thursday by the National Bureau of Economic Research, avoided that problem. Its design is like that used to test new drugs. People were randomly selected to have Medicaid or not, and researchers then asked if the insurance made any difference.

Health economists and other researchers said the study was historic and would be cited for years to come, shaping health care debates.

“It’s obviously a really important paper,” said James Smith, an economist at the RAND Corporation. “It is going to be a classic.”

Richard M. Suzman, director of the behavioral and social research program at the National Institute on Aging, a major source of financing for the research, said it was “one of the most important studies that our division has funded since I’ve been at the N.I.A.,” a period of more than a quarter-century.

In its first year of data collection, the study found a long list of differences between the insured and uninsured, adding up to an extra 25 percent in medical expenditures for the insured.

Those with Medicaid were 35 percent more likely to go to a clinic or see a doctor, 15 percent more likely to use prescription drugs and 30 percent more likely to be admitted to a hospital. Researchers were unable to detect a change in emergency room use.

Women with insurance were 60 percent more likely to have mammograms, and those with insurance were 20 percent more likely to have their cholesterol checked. They were 70 percent more likely to have a particular clinic or office for medical care and 55 percent more likely to have a doctor whom they usually saw.

The insured also felt better: the likelihood that they said their health was good or excellent increased by 25 percent, and they were 40 percent less likely to say that their health had worsened in the past year than those without insurance.

The study is now in its next phase, an assessment of the health effects of having insurance. The researchers interviewed 12,000 people — 6,000 who received Medicaid and 6,000 who did not — and measured things like blood pressure, cholesterol and weight.

The study became possible because of an unusual situation in Oregon. In 2008, the state wanted to expand its Medicaid program to include more uninsured people but could afford to add only 10,000 to its rolls. Yet nearly 90,000 applied. Oregon decided to select the 10,000 by lottery.

Economists were electrified. Here was their chance to compare those who got insurance with those who were randomly assigned to go without it. No one had ever done anything like that before, in part because it would be considered unethical to devise a study that would explicitly deny some people coverage while giving it to others.

But this situation was perfect for assessing the impact of Medicaid, said Katherine Baicker, professor of health economics at the Harvard School of Public Health. Dr. Baicker and Amy Finkelstein, professor of economics at M.I.T., are the principal investigators for the study.

“Amy and I stumbled across the lottery in Oregon and thought, ‘This is an unbelievable opportunity to actually find out once and for all what expanding public health insurance does,’ ” Dr. Baicker said.

They had just a short window of time. Within two years, Oregon found the money to offer Medicaid to the nearly 80,000 who had been turned down in the lottery.

As an economist, Dr. Finkelstein was interested, among other things, in whether Medicaid did what all insurance — homeowner’s, auto, health — is supposed to do: shield people from financial catastrophe. Almost no one had even tried to investigate that question, she said.

“It is shocking that it is not even in the discourse,” Dr. Finkelstein said.

The study found that those with insurance were 25 percent less likely to have an unpaid bill sent to a collection agency and were 40 percent less likely to borrow money or fail to pay other bills because they had to pay medical bills.

Dr. Finkelstein said she had thought that the people were so poor to begin with that they just did not spend very much out of pocket on medical care when they did not have insurance. “Yet look at the results,” she said.

Dr. Baicker interviewed people for Part 2 of the study and was impressed by what she heard.

“Being uninsured is incredibly stressful from a financial perspective, a psychological perspective, a physical perspective,” she said. “It is a huge relief to people not to have to worry about it day in and day out.”

In an article published online for the June 16 issue of The American Journal of Public Health, scientists calculated the number of deaths attributable to each of six social factors, including low income.

To estimate the number of deaths caused by each factor, the scientists reviewed 47 earlier studies on the subject, combining the data in a meta-analysis. The studies were generally based on large national surveys like the National Health and Nutrition Examination Survey, a continuing study by the Centers for Disease Control and Prevention.

Then, using the pooled data, the researchers calculated the “population-attributable fraction” of deaths — that is, the number of deaths caused by living with a given social disadvantage.

Finally, they multiplied that fraction by the total number of deaths in the year 2000 to come up with a number of deaths caused by each of the six social conditions. The researchers then separated the contribution of each social factor.

“The methods we’re using are limited,” Dr. Sandro Galea, the lead author, acknowledged. “Any time you try to say that death is attributable to a single cause, there’s a problem — all deaths are attributable to many causes. But what we did is just as valid as what was done to establish smoking as a cause of death.”

“This is a very interesting paper,” said Roger T. Anderson, a professor of public health sciences at Pennsylvania State College of Medicine who was not involved in the study. “It’s simple and elegant, a very straightforward approach to looking at these kinds of data.

“It brings to the surface what the impact of social disadvantage is in terms of numbers of deaths, and the authors have done a very nice job of laying out the argument.”

The researchers used various criteria to define an adverse social condition. Low education, for example, was defined as not having graduated from high school. Poverty was defined as a household income of less than $10,000. A population in which more than 25 percent of people reported their race or ethnicity as non-Hispanic black was considered racially segregated.

The study also calculated the effect of an area’s overall poverty level, income differential and low social support.

For 2000, the study attributed 176,000 deaths to racial segregation and 133,000 to individual poverty. The numbers are substantial. For example, looking at direct causes of death, 119,000 people in the United States die from accidents each year, and 156,000 from lung cancer.

Social factors are not the same as diseases or accidents, but Dr. Galea argues that they are equivalent to a behaviors like smoking, and that, as with smoking, there is evidence of the mechanism involved. He said that the causal chain between, for example, poverty and death from heart disease has many well-established links.

Dr. Galea also said that poverty results in poor access to health screening, poor access to quality care for those who actually have heart disease, greater vulnerability to stresses associated with heart disease and a greater likelihood of engaging in unhealthy behavior.

“In some ways,” Dr. Galea added, “the question is not ‘Why should we think of poverty as a cause of death?’ but rather ‘Why should we not think of poverty as a cause of death?’ ”

If they had not smoked, 400,000 people each year would not have died, Dr. Galea said. Similarly, he said, if they had graduated from high school, the 245,000 people whose cause of death he attributes to low education would still be alive.

“This might be a useful lens to help focus our minds,” said Dr. Galea, who is the chairman of the department of epidemiology at the Mailman School of Public Health at Columbia University. “If you say that 193,000 deaths are due to heart attack, then heart attack matters. If you say 300,000 deaths are due to obesity, then obesity matters.

“Well, if 291,000 deaths are due to poverty and income inequality, then those things matter too.”

]]> http://www.bioethicsinternational.org/blog/2011/07/05/researchers-link-deaths-to-social-ills/feed/ 0 http://www.bioethicsinternational.org/blog/2011/07/01/high-mark-to-invest-475-million-in-west-penn-deal/ http://www.bioethicsinternational.org/blog/2011/07/01/high-mark-to-invest-475-million-in-west-penn-deal/#comments Fri, 01 Jul 2011 19:06:10 +0000 Lauren Rushing, BEI Intern http://www.bioethicsinternational.org/blog/?p=2446 [Post-Gazette] The boards that lead Highmark Inc. and West Penn Allegheny Health System have unanimously approved a “capital partnership” in which the area’s dominant health insurer will invest up to $475 million into the region’s second largest health system, including an up-front $50 million payment that will rescue Bloomfield’s West Penn Hospital from what would have been imminent closure.

The deal puts Highmark into the hospital business in a big way, and floats a life preserver to a hospital system that has been losing money each quarter, including a $22 million operating loss in the quarter ending March 31.

Executives from both Highmark and West Penn Allegheny called the partnership “a historic transaction for Pittsburgh,” one that will put WPAHS on sure financial footing, and will help maintain a viable option to the region’s largest hospital system, the University of Pittsburgh Medical Center, which controls more than half of the hospital beds in the region and many of its physicians, too.

“They are well-capitalized, and we’re not,” said David L. McClenahan, WPAHS board chairman, speaking of Highmark. “That’s putting it mildly.” In the decade since the collapse of the Allegheny Health Education and Research Foundation, whose bankruptcy eventually bore the West Penn Allegheny Health System, WPAHS has been persistently starved for capital, he said.

WPAHS wanted to remain independent, that was no longer an option, financially, he said. Had the deal with Highmark not materialized, WPAHS was preparing a budget that would have included the autumn closure of West Penn Hospital.

While the short-term goal of this partnership is to preserve a “fragile” Pittsburgh hospital system, the long term goal, said Highmark CEO and President Kenneth Melani, is the creation of a new model of health care, one that is outcomes based, with an integrated delivery and financing system.

“Health care services are becoming less affordable,” he said. “It’s important to have choice. It’s important to have a second system.”

He also said that while the Highmark-WPAHS partnership is the primary product of this deal, the two institutions will also work to strengthen relationships with other regional hospitals and physicians’ practices.

Also announced today, Christopher Olivia, president and CEO of West Penn Allegheny Health System, will step down from that position, effective immediately. He will take on a consulting position at Highmark, he said at the press conference this morning.

With Dr. Olivia’s departure, Dianne Dismukes has been named interim president and CEO. Ms. Dismukes last month was named executive vice president for hospital operations at WPAHS, replacing Dawn Gideon.

Following the signing of a tentative “term sheet,” Highmark “is immediately providing a $50 million grant to the WPAHS” to strengthen its West Penn and Forbes Regional hospitals “while assuring the continued delivery of quality medical services by the entire system.”

Highmark is making “a total financial commitment of up to $475 million over four years, including $75 million to fund scholarships for students attending medical schools affiliated with WPAHS, and to support other health professional education programs,” according to the morning’s press release.

Earlier this month, Dr. Olivia announced that WPAHS would open a regional campus of Temple University’s School of Medicine.

Throughout the morning, Highmark and West Penn officials took some verbal jabs at UPMC, noting more than once, for example, that WPAHS is the only local hospital system currently offering live transplants, as a result of having UPMC suspended those operations last month after a patient received a kidney from a donor with hepatitis C.

Officials from Highmark and WPAHS organizations (which are both non-profits) also tried to draw a distinction between WPAHS and UPMC, saying UPMC is not behaving like a not-for-profit community asset in the way that it tries to “maximize revenue” and put WPAHS out of business.

Highmark and UPMC relations have frayed in recent months as negotiations over a new reimbursement contract are at an impasse, with Highmark claiming that UPMC wants too much money, and UPMC saying that it cannot, and will not, sign a deal with an insurer that is now partner with a UPMC competitor.

The partnership’s framework will be fleshed out over the coming two months, and the organizations hope it will be approved within six months. Some aspects of the deal may need state approval.

“Ultimately, we expect the Department will be one of the regulators that has a role in reviewing and approving the proposed arrangement between Highmark and West Penn,” said Pennsylvania Insurance Department Commissioner Michael F. Consedine in a statement.

“However, no formal agreement has yet been signed and no filing has been submitted to the Department for its review.”

Cathy Stoddart, staff nurse at Allegheny General Hospital and an SEIU member and union leader representing the system’s 2,000-plus nurses, said the deal may prove beneficial for staff.

“I’m actually pretty excited,” she said. “To have our system have money is something that hasn’t happened in 11 years.”

Read more: http://www.post-gazette.com/pg/11179/1156765-100.stm#ixzz1QsjoQ4wP

Vehemently opposed by the Medical Society of the State of New York, the law passed last summer by a two-thirds majority of the Legislature and took effect in February. The legislation was written in collaboration with Compassion and Choices of New York, an organization that advocates for informed choices and greater physical and emotional comfort at the end of life.

The act, which I discussed in this column last August, states that when patients are found to have a terminal illness or condition, health care practitioners must offer to provide information and counseling about appropriate palliative care and end-of-life options. Patients or their surrogates are entirely at liberty to refuse an offer to discuss these options.

California passed a similar law in 2009, and other states are considering them. These measures promise to reduce the cost of care at the end of life, as well as the suffering often associated with it; palliative care is meant to reduce the severity of disease symptoms, pain and stress.

Although there are penalties for violation, it is not the specter of punishment that raises the hackles of some physicians. Rather, they say the new requirement interferes with how they choose to deal with their patients and does not take into account the nuances of a doctor-patient relationship.

In an article in The New England Journal of Medicine last month, Dr. Alan B. Astrow and Dr. Beth Popp of Maimonides Medical Center in Brooklyn wrote that they were troubled by “the law’s heavy-handed intrusion into the doctor-patient relationship.” They stated, “In asserting power over the way in which deep and troubling human questions should be addressed, the New York Legislature seems likely only to generate cynicism at the times when critically ill patients and their families are most in need of honesty, kindness and engagement.”

Another New York physician, Dr. Yashar Hirshaut, an oncologist at NewYork-Presbyterian/Weill Cornell Medical Center who also objects to the act, said in a letter to me that “the new law is going to have a direct negative effect on too many cancer patients.” He wrote that when he explained what the law required to a patient with a life expectancy of six months, her response was, “What, are they trying to kill me?”

How the Law Can Help

This law is not about ending a patient’s life. Rather, it is intended to make the end, when that end is near, as physically and emotionally painless as possible. The law is intended to spare terminally ill patients from futile medical interventions that can detract from the quality of their remaining days.

Despite their opposition to this legislation, Dr. Astrow and Dr. Popp acknowledged that “seriously ill patients and their families need accurate information about prognosis and treatment options; physicians’ repeated failure in this realm is clearly a public health problem that the profession should be required to address.”

David C. Leven, who heads Compassion and Choices of New York, said in an e-mail that “the law simply requires physicians to do what the authors say should be required of them. The profession has not addressed this public health problem. The Legislature did.”

While legislation may not be the ideal way to go about this, the fact is that too many doctors fail to inform their terminally ill patients about the risks of continuing aggressive treatments to the bitter end and the benefits of opting only for treatment of discomforting symptoms through palliative or hospice care.

Doctors are notorious death-deniers, often more reluctant than their patients to admit that it is pointless to pursue treatment that is medically futile. They either fail to mention hospice care or suggest it far too late — usually within a week of death, when hospice personnel have little time to get to know the patient and family and to provide the kind of care that can make for a graceful exit from this world.

Studies have shown that patients with a short life expectancy who choose hospice over continued treatment and last-ditch assists like ventilators and feeding tubes live not only better but, surprisingly, longer on average. Researchers also have found that surviving family members are less likely to experience prolonged depression and grief when their loved ones are spared grotesque medical interventions and receive only comfort care at the end of their lives.

Even knowing these facts, some patients are likely to choose to take advantage of anything and everything in the medical armamentarium that could conceivably grant them extra days, weeks or months of life. And such a choice is the prerogative of every terminally ill patient; the new law does not in any way deny that choice. It merely says that patients should be offered the chance to learn about the alternatives.

Nor does the law prohibit patients (or families) from changing their minds and requesting aggressive measures after an initial acceptance of palliative care.

Communication Skills Needed

Many physicians fear that merely broaching the subject of palliative care will strip terminally ill patients of hope. But I have to wonder whether offering unrealistic hope for a cure, or overly optimistic prognoses, isn’t more harmful to patients and their families. If patients are unaware that the remaining time is short, they may lose the chance to resolve important personal issues, say meaningful good-byes, and leave legacies or memories that survivors can cherish long after death.

Few physicians trained more than a decade ago were taught how to communicate emotionally challenging information to their patients. But in recent years the medical literature and continuing education courses have sought to fill in this gap.

For example, Dr. James A. Tulsky of the Center for Palliative Care at Duke University Medical Center wrote in The Journal of the American Medical Association that “talking about treatment choices at the end of life does not necessarily rob patients of hope. Redirecting the patient’s goal toward realistic hopes and being present with compassion can serve as a powerful act in helping patients make decisions while maintaining a hopeful outlook.”

Dr. Tulsky advised that patients be told, in effect, to hope for the best but to prepare for the worst. Their goals can be broadened to include not just successful treatment, he suggested, but also the measures they want taken if they cannot be cured and advice on how to accomplish important tasks that might otherwise be left undone.

Terminally ill patients may fear not just death, but also that in choosing palliative or hospice care, they will be abandoned by their primary physicians. Disappearing doctors are all too common when curative treatment options are exhausted. If doctors truly want to preserve hope, they owe it to their patients to stick around until the end.

Neither Bishop’s sister, a longtime advocate for her (who works in the justice system) whom a court years earlier declined to make Bishop’s legal guardian, nor Bishop’s daughter were informed of her condition during her extended stay in New Hampshire’s state hospital — nor were they told when she was discharged. Instead, a fantasy relationship that Bishop had for years in her head, with no contact with the man, was her plan for support, even marriage, upon leaving the hospital.

The story of Linda Bishop’s multiple psychiatric hospitalizations, her misdemeanor (non-violent) offenses and time in jail, her abandonment of her teenage daughter, her assertion that she was not mentally ill and her refusal to follow any treatment plan, the lack of evidence that she could care for herself, and the self-imposed distance from her family was all too familiar to me and my colleagues working in public mental health, even if the details of her situation may vary in some ways from others. Recognized experts (and longtime colleagues) Drs. Tom Gutheil and Paul Appelbaum in 1979 (!) aptly called this type of tragedy “rotting with their rights on.”

Our laws stipulate that Bishop had to consent to provide information to her family, which she did not. Privacy violations would have been the consequence of the hospital contacting her family during the hospital stay or at the time of discharge. Bishop’s “right” to live where (and how) she wanted derives from legal rulings that stipulate a person’s right to live in what is called “the least restrictive setting.”

The letter of the law had been met. And the patient died.

Arguments have been made on the polar extremes of this dilemma. On one side are patient rights advocates who are stalwart about privacy and self-determination. In fact, legal organizations are present to defend these rights in state hospitals throughout this country. Considerable legal rulings now protect individuals from involuntary hospitalization and involuntary treatment by requiring court action to achieve both, with the exception of emergency situations. On the other side are advocates calling for increasing commitments of people with serious mental illness, including outpatient commitment (and requiring that those committed take psychiatric medications for their disorders), and longer hospital stays.

Never having been one for extremes, except maybe when it came to my playing sports, I believe there are viable middle grounds — even if difficult to reach.

For example, nine years ago the first Mental Health Court was established in New York City, under the remarkable (and continued) leadership of Judge Matthew D’Emic. There are now seven such courts in NYC, about 25 in New York State and approximately 200 around the country (not counting drug and domestic violence courts). A mental health court accepts referrals from other courts where there appears to be a mental illness complicating the crime. Court mental health specialists evaluate the person for a mental illness, and if present, the defendant can plead guilty (in New York State) and be “sentenced” to court ordered treatment under the supervision of the judge; other states may divert the person from jail, have charges held in abeyance pending completion of the treatment program, or other procedures according to local statute. This form of supervised treatment is typically for a year (the maximum sentence for a misdemeanor). More recently, there are mental health courts working with felons where the court ordered treatment can go on for years.

For example, outpatient commitment already exists in almost every state (this has been the case in New York State for over 10 years, instituted after Kendra Webdale was pushed before an oncoming subway train by a man with a psychotic illness). The law, Kendra’s Law, has been renewed twice, each time for five years. We don’t need more outpatient commitment (though some state statutes warrant updating); we need more outpatient treatment that works.

Which brings me to my main point: outpatient mental health services in this country don’t work very well, despite the dedicated people who work for them. The result is that early intervention and the provision of comprehensive, continuous, proven (evidence-based) treatments is being delivered to less than 20 percent (!) of people who need it. That means more than four out of five people are not getting what they need for their illness and recovery. Lack of good care coupled with lack of housing are the principal drivers for the clinical deterioration, chronic homelessness, use of jails and prisons as institutions to contain people with mental disorders, and suicidal and violent behaviors among those who are mentally ill. This country is in need of a mental health overhaul, as candidly portrayed in the President’s New Freedom Commission on Mental Health (December 2002; disclosure: the Commission’s chair was Michael Hogan, Ph.D., now Mental Health Commissioner for the state of New York, and my boss).

Mental health has treatments that work. It has mission-oriented professionals and provider organizations. But it lacks organization, accountability and financing that pays for what is accomplished rather than what is simply done. Sounds familiar? That’s because mental health care is part of health care, where the same issues apply in capital letters.

As this country grinds its way to a more responsive, and hopefully affordable, health care system, what can be done now? For one, mental health clinics can be held to specific standards of care and their licenses made dependent on delivering those standards. Measurement-based care can be introduced (and required) where improvement from mental illness is tracked just like we track blood pressure, blood sugar and lipids. Incremental financing reforms can better support evidence-based practices as well as outreach and engagement of those hardest to reach and retain in care. People in recovery from mental illness (called peers or consumers) can be made a part of the public mental health system so they serve as navigators and trusted persons for those wary of mental health care. And no one stands a decent chance of getting better from a serious mental illness without safe and reliable housing with access to quality health and mental health services.

Indifference is cruel and costly. We can make a difference. People can have their rights and their lives — and their families, too. That’s what health care, including mental health care, is really all about.

The opinions expressed herein are solely my own as a psychiatrist and public health advocate.

I receive no support from any pharmaceutical or device company.