Heroin and Cornflakes

Currently in the United States, around 47 million people – including 9 million children – have no health insurance.   The lack of coverage can be tied to about 45,000 deaths a year in the United States, say researchers from Harvard Medical School.

If you extend coverage, you can save lives,

states Dr. Steffie Woolhandler, a professor of medicine at Harvard.

Seems logical.

But does this statement hold true?

The problem in health care coverage is cost. Expenditures in the United States on health care surpassed $2.2 trillion in 2007, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980.

Since 1999, employer-sponsored health coverage premiums have increased by 119 percent, placing increasing cost burdens on employers and workers. With workers’ wages growing at a much slower pace than health care costs, many face difficulty in affording out-of-pocket spending (OOP).

The average family’s OOP rose in direct proportion to total medical spending and nearly twice as fast as did family income. The rates were notably high among low- and modest-income working families.(1)

Data from the Medical Expenditure Panel Survey (MEPS) showed altogether, an average of 18 million families per year—made up of 35 million individuals—faced OOP medical care costs that were high relative to their incomes.(2)

Are these rising health care costs justified?

Of a total $2.3 trillion spent on health care last year, $500 billion to $700 billion was spent on treatments, tests, and hospitalizations that did nothing to improve health. In fact new evidence suggests that too much health care may actually be killing folk.

According to estimates by Elliott Fisher, M.D., a noted Dartmouth researcher;

unnecessary care leads to the deaths of as many as 30,000 Medicare recipients annually.

He states previous studies have found that variation in medical care partly reflects the provision of unnecessary, expensive, and potentially harmful treatments. Often there are several possible treatment choices, each with unique benefits and risks.(3)

The care of vascular disease of the carotid arteries—the major vessels supplying the brain—is one example.  The disease results in plaque build up restricting blood flow to cerebral areas and possibly initiating a stroke. Every year, approximately 100,000 patients in the United States, most over the age of 65, undergo a carotid revascularization procedure. (4)

Until recently, the primary operation that could be performed to reduce the blockage (i.e., for carotid revascularization) was carotid endarterectomy, a surgical procedure in which an incision is made in the neck, allowing access to the carotid artery. Plaque is removed from the artery, and the incision is closed. It has been well established for almost two decades that endarterectomy is an effective measure for prevention of stroke in some patients. However, in the late 1990’s, a new technique began to emerge – the use of stents.

Unlike endarterectomy, carotid artery stenting does not require an incision in the neck. Instead, a catheter is placed in an artery in the arm or groin. A mesh cylinder—or stent—is then inserted into the carotid artery through the catheter. The stent is expanded with a balloon, flattening the plaque against the artery wall. Any loose plaque is caught and removed from the artery by a filtration device that is placed above the stent during the procedure.

There were few stent procedures performed in 1998: just 0.1 per 1,000 Medicare beneficiaries. By 2007, there were 0.6 stent procedures performed per 1,000 beneficiaries, with a peak in 2006 of 0.8 per 1,000. These trends suggest that stenting is being used increasingly as a substitute for endarterectomy (Philip P. Goodney, MD, MS et al).

Trends in the treatment of carotid atherosclerosis between 1998 and 2007 indicate that there is no general medical consensus regarding the best course of action. For example because of the perception that patients in their eighties and nineties are at increased risk, clinicians have recommended that these patients receive alternative treatments such as stenting. However, recent studies have shown this is not necessarily the case.

“Age alone should not place patients in the high-risk category for carotid endarterectomy,” states Steven Katz, MD, FACS, and Amy Bremner, MD, of the Huntington Hospital, Pasadena, CA, and the Keck School of Medicine, Los Angeles, CA.

“As the elderly population surges, it is crucial to identify strategies that can potentially limit the devastating consequences of stroke and its impact on the health care budget. Our study shows that carotid endarterectomy remains the treatment of choice in patients 80 years of age and older with substantial blockage of the carotid arteries.”

If this is the case, why push new techniques onto patients?

One likely factor, suggest the Dartmouth project, for developing programs like carotid stenting, is they can be highly profitable. They also suggest that some types of medical care are supply-sensitive; that is, the use of some procedures depends in large on the available supply of medical resources, such as the number of hospital beds, MRI scanners, or catheterization suites (the rooms where carotid stenting procedures are performed in a hospital). People who live in regions with high supplies of hospital beds, specialists, and testing facilities tend to be admitted to the hospital more often, have more specialty consultations, and undergo more tests than residents of regions with lower capacity.

Resulting in increased payments.

Current payment policies are such that surgical procedures, especially newly introduced ones, tend to have relatively high profit margins for hospitals, creating an incentive for hospitals to establish programs such as carotid stenting. It seems quite possible, the authors suggest, then, that the hospitals that have been most aggressive in developing stenting programs might also be more likely than other hospitals to turn to stenting for the treatment of cerebrovascular atherosclerosis.

Any other surgical procedures that are unnecessarily promoted?

A panel of gynecologists reviewed the records of 497 women who were told to have a hysterectomy. In 367 cases—70 percent—the panel found that the surgery was not needed.(5)

Recommendations, in force since the early 1990’s, that gynecologists try less-invasive treatments first, have had little effect on the number of surgeries being performed around the country. Even today, one in three women has had a hysterectomy by age 60, and one in two by age 65, according to Ernst G. Bartsich, M.D., clinical associate professor of obstetrics and gynecology at Weill Cornell Medical College in Manhattan. (6)

Any more problems due to errant human decision making?

Overall, an average of 195,000 people in the USA died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002, according to a  study of 37 million patient records that was released by HealthGrades, the health care quality company. (7)

The HealthGrades study finds nearly double the number of deaths from medical errors found by the 1999 IOM report “To Err is Human,” with an associated cost of more than $6 billion per year.

“The equivalent of 390 jumbo jets full of people are dying each year due to likely preventable, in-hospital medical errors, making this one of the leading killers in the U.S,”

Says Dr. Samantha Collier, HealthGrades’ vice president of medical affairs.

Are these deaths evenly distributed throughout the U.S.?

According to a Medicare analysis, there is a wide variation in death rates between the best hospitals and the worst.

At 5.9% of hospitals, patients with pneumonia died at rates significantly higher than the national average. With heart failure, 3.4% of hospitals had death rates higher than the average, and 1.2% of hospitals were higher when it came to heart attack.

A separate USA TODAY analysis of the data found that patients have higher death rates at hospitals in the nation’s poorest and smallest counties, compared with those in larger, more affluent areas.

Death rates in hospitals in counties with fewer than 50,000 people rank 1 to 2 percentage points higher than their most-populated counterparts, a significant difference. A similar pattern emerges at hospitals in counties where the median household income falls below $35,000 a year.

Therefore the opening statement by Dr. Woolhandler does not necessarily equate that there are going to be fewer deaths if health care coverage is extended.

It would appear we have poor folk dying because they cannot afford health care treatment; folk dying who can afford treatment but don’t receive the best treatment; and people,who can afford the best treatment, dying because in some cases its not necessarily needed.

Incredible.

Clearly something has be done to cut costs and reduce preventable deaths.

But what?

One idea on the table is to reward doctors and hospitals, not just for how many procedures they perform, but how well their patients fare.(8)

How are doctors and hospitals presently rewarded?

Doctors and hospitals are generally funded by payments from patients and insurance plans in return for services rendered.

Even in today’s recessive monetary climate, most hospital executives can still expect salary increases; although they will likely not see increases as high as in the past. The average salary increase for health system and hospital executives was 3.5 percent in 2009, down from 4.0 percent in 2008, according to Integrated Healthcare Strategies, a health care human resources consulting firm.

The 2009 median base salary for a health system CEO is $657,000, according to Integrated Healthcare Strategies. The median salary for an independent hospital CEO is $434,500, and the median salary for a subsidiary hospital CEO is $300,000. It is important to note, though, that salaries vary greatly, beginning at around the low six-figure range and increasing upwards to a million dollars.(9)

What about doctors?

Salaries vary by degree with family doctors earning up to $ 150,000, and general surgeons over $200,000.

Any other costs related to doctors?

To become a physician, students spend four years in medical school. Graduates then spend three to seven years training as residents, usually treating patients under supervision at a hospital. Residents work long hours for $35,000 to $50,000 a year.

Medicare, which provides health care to the nation’s seniors, also is the primary federal agency that controls the supply of doctors. It reimburses hospitals for the cost of training medical residents.

The government spends about $11 billion annually on 100,000 medical residents, or roughly $110,000 per resident. The number of residents has hovered at this level for the past decade, according to the Accreditation Council for Graduate Medical Education.

How many qualified physicians are there in the U.S.?

Currently there are 7,569 hospitals nationwide where you may encounter one of the nation’s 819,000 physicians and surgeons; 77,000 occupational therapists; 182,000 physical therapists; or 94,000 respiratory therapists. (10)

Outside that, there are 1.8 million nursing, psychiatric and home health aides.

The annual revenue for hospitals in 2003 was an estimated $536.3 billion; up 6 percent from 2002. Major sources of revenue were private insurance ($204 billion; up 8 percent), Medicare ($167 billion; up 2 percent) and Medicaid ($65 billion; up 7 percent).

That’s a lot of dollars being made.

Is there an alternative system on the horizon that could replace these management, professional, and related occupations resulting in cost reduction?

Maybe the answer is to be found in the thoughts of  Craig Mundie, chief research and strategy officer at Microsoft. He says world population growth means low-cost technologies must become accessible for billions of people.

In health, it’s clear to me that there’s no way to translate the rich-world model to the rest of the world.

Even if all you sought to do was to take the current model of health in the US and recreate it for billions of people across the globe, it [the cost of health service delivery] would have to be cheaper.

The real key is to take a technological approach and focus on prevention rather than remediation.

He thinks information technology is clearly one of the main elements in making it possible to address the public at scale. In health care, technology can facilitate self-help as a component of ultimately lower-cost ways of delivering remediation.

One area his company is looking at is robotics.

We’re developing a robotic triage doctor, capable of learning and reasoning, which projects an avatar of itself onto a screen. It listens to patients and can make a diagnosis and recommend a course of treatment. It can already be effective in dealing with 16 of the basic world childhood diseases – but that’s just the tip of the iceberg.

We’ve been working with universities to find a way of taking a smart phone and plugging in a USB to make a basic ultrasound. This means millions of people who would otherwise have no access to hospital specialists and technology can have a basic ultrasound. This tells you things like whether a baby is in the right position and could help cut down on things like infant or maternal mortality, he says.

So if the information technology sector believes virtual doctors and self-help technology can help raise health standards in the developing world, why not in the United States?

The answer may lie in the NASA SUPERCOMPUTER ‘Pleiades’, which ranks among the worlds fastest. Among the scientific and engineering projects accepted for computer time on Pleiades at present are:

• Extensive simulations of large computational problems for future space vehicle design;
• Development of increasingly detailed models of large-scale dark matter halos and galaxy evolution;
• Running coupled atmosphere-ocean models to assess decadal climate prediction skill for the Intergovernmental Panel on Climate Change.

“The Pleiades supercomputer meets the demands of leading global research institutions like NASA for superior systems that help solve the world’s most complex research problems. The performance achievement on Pleiades will help NASA to make new discoveries ever faster,” said Richard Dracott, general manager of Intel’s High Performance Computing Group.

“Pleiades is even more impressive in the actual work it can accomplish,” said William Thigpen, Pleiades project manager at the NASA Advanced Supercomputing (NAS) Division at Ames. “Pleiades has become the agency workhorse, delivering over 275 million hours in its first year of production”. (11)

Pleiades was acquired to augment the space agency’s high-end computing requirements in supporting four key mission areas: aeronautics research, exploration systems, science, and space operations. The latest addition is focused on Earth science research.

Why can’t this technology be acquired to focus on the health care system incorporating information from bioinformatics and latest technologies such as Nano technology and daVinciSurgery techniques?

A control center could be created that linked an army of robotic doctors and surgeons throughout the U.S.

It has to be an improvement on the present system. The prestigious Institute of Medicine recently published a report that estimates only about half of what doctors do today is backed up by valid, scientific evidence.

The rest?

Many procedures and tests are based on medical tradition or on unproven and potentially faulty assumptions about how the body works.

Why can’t this super computer, that is capable of 275 million work hours a year, replace the amount of time it takes to train a doctor, at great savings?

It could work out the chemical imbalances that are instrumental in disease and send that information to robotic doctors – much like your computer automatically receives updates from Microsoft programs.  If a patient had the necessary equipment (a smart phone and UBS for example) to conduct self analysis, it could be interpreted by a robot doctor who could then advise on the best course of action.

Sounds plausible.

Any problems?

Ethics could be one.

Dr. Peter M. Asaro, HUMlab & Department of Philosophy & Linguistics, Umeå Universitet asks;

A robot is given two conflicting orders by two different humans. Whom should it obey? Its owner? The more socially powerful? The one making the more ethical request? The person it likes better? Or should it follow the request that serves its own interests best?

Humans face such dilemmas all the time.

Patients might well ask themselves this question when they learn that 94 percent of physicians have “a relationship” with the pharmaceutical, medical device or other related industries, according to a national survey of physicians published two years ago in the New England Journal of Medicine.(12)

Integrated Medical Systems, a research firm, estimates that pharmaceutical companies spend more than $20 billion annually marketing directly to doctors.

Dr. Peter M. Asaro says our overarching interest in robot ethics ought to be the practical one of preventing robots from doing harm, as well as preventing humans from unjustly avoiding responsibility for their actions.

Another problem may be the doctors, surgeons and CEO’s who find themselves out of a highly paid job.

However, as Craig Mundie points out;

In the future, we have to be able to do a better job for more people for less money.

And if that includes replacing expensive CEO’s and doctors with artificial intelligence, then so be it.  Perhaps then, the public will receive the service they deserve.

Related Article;

Death, Undertakers and the Environment

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Ann Margrain

Founder, ‘Heroin and Cornflakes’ blog.

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This entry was posted Wednesday, February 3rd, 2010 at 4:49 pm and is filed under general. You can leave a response, or trackback from your own site.