Saturday, July 30, 2011

Second in the Series

The second suggestion on health care reform included in the Commonwealth Fund report to the National Governors Association, as reported by former Vermont governor James Douglas in the May 23 issue of Modern Healthcare, was as follows:

“Care coordination and disease management. Chronic illnesses account for the overwhelming majority of health care costs. Those with a chronic disease must be identified and treated. Diabetes is the first chronic condition that some states have addressed, as there’s a real opportunity for successful intervention and cost savings.”

All true, but identifying and treating chronic diseases is done by providers, not by states, and the question is: if they are not doing it satisfactorily now, what will it take to get them to?

So far, nobody wants to talk about that. Until that changes, progress will be slow.

Friday, July 29, 2011

Health Expenditures and Longevity

Steve Wenner sent me a graph he had come across showing for a number of Western countries and Japan life expectancy on one axis and per capita health expenditures on the other. The results for each year from 1970 to 2008 were plotted on a line along the graph.

The US line was well below that of all the other countries. Wenner’s conclusion was that “we are paying and arm and a leg and not getting much for it.”

I don’t agree fully with that, but before commenting I will say that we pay too much – more than we need to – and that it is past time that we should do something about it.

Having said that, my first comment on Wenner’s remark is that in comparison with the other countries shown, I believe the US population has by some considerable proportion more poor and culturally challenged people concentrated in places like Appalachia, certain parts of the south, and large cities. Violence, teen-age pregnancies, drug abuse, obesity and other destructive life-style behaviors among these groups skew the longevity numbers unfavorably.

My second comment is that it is easy to exaggerate the relationship between health care and longevity. The main determinants of longevity are things like clean water, sanitation, immunizations, nutrition, and living practices. Health care has an effect on longevity, but much less than is commonly assumed.

Finally, I would point out that our spending for health care buys more than longevity. Here are a few of them:

- Care available when and where we want it.
- As much care as we want.
- Free choice of providers.
- Care provided in modern, comfortable, well equipped facilities.
- Care provided by competent, courteous, highly trained and well-paid staff.
- Easy access to specialists, diagnostic tests, and treatments.

The changes needed to get cost down and quality up will pinch on these things somewhat but not, to my mind, in any serious way. But so far we have not been willing to consider even that.

Friday, July 15, 2011

A Series of Observations

In the process of catching up on my reading, I came across an article by James Douglas, a former governor or Vermont (Modern Healthcare, May 23 2011). Douglas was chairman of the National Governor’s Association in 2009. He opens the article by relating his decision to focus during his chairmanship on “Improving our system of delivering healthcare to the American people.” The concern expressed by Douglas was “that the rapidly rising cost of health care was outstripping the ability of the states to afford it.”

A report prepared for the NGA by the Commonwealth Fund suggested five areas for state-based reform.

I found the list intriguing, partly for its contents, but also for what was left out – thus speaking to the reasons why the cost issue is proving so difficult.

It led me to think about doing something I’ve never done before, which is to do a series of postings on a particular theme, one on each of the five suggestions.

Here is the first one:

“Quality Improvement. Ultimately, this is what it’s all about. We need to ensure that all Americans get the care they need when they need it. A study concluded that one doctor in six ordered a test that had already been done and one in four provided treatment that was unnecessary. We need to define quality, measure it, provide the IT support to assure its delivery, and pay for it appropriately.”

All of that is well and good, but it doesn’t address the cost problem and doing all the suggested things won’t by themselves improve quality. Only the providers can do that.

Douglas and others like him are clearly reluctant to address the issues of provider organization, behavior, and performance. But until they do, nothing much is likely to happen.

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