Ir-rationing Health Care

There are a number of treatments for early-stage, slow-growth prostate cancer. These treatments range from “watchful waiting” — not treating the cancer at all, but just keeping an eye on it — to surgical removal of the prostate gland, to high-tech proton radiation therapy using a proton accelerator. The costs for the various treatments range from a few thousand dollars to hundreds of thousands of dollars.

However, there is little evidence that the more expensive treatments are any more effective than the cheap ones, including watchful waiting. Indeed, for an older patient, watchful waiting makes sense, as there is a high probability he will die of other natural causes before the prostate cancer becomes a problem for him. On the other hand, younger patients, meaning men under the age of 65, might benefit from more aggressive treatment. But which more aggressive treatment?

At the New York Times, David Leonhardt interviews some prostate cancer specialists and finds there is widespread skepticism that the new, expensive, state-of-the-art treatments work any better than older, less expensive treatments.

“No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, “We’re not sure how good any of these treatments are.” When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, “Watchful waiting.”

Naturally, the health care industry is pushing the more expensive treatments.

And in our current fee-for-service medical system — in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients — you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data. A new proton treatment center will open Wednesday in Oklahoma City, and others are being planned in Chicago, South Florida and elsewhere. The country is paying at least several billion more dollars for prostate treatment than is medically justified — and the bill is rising rapidly.

This takes us back to the issue of private insurance companies. Or, should I say, the the medical-industrial complex, which includes private insurance companies? I’ve ranted for years that our system is very good at one thing — creating profitable health care products. Medical treatments that make somebody a lot of money somehow get paid for. But any part of the health care system that can’t be made profitable is allowed to rot.

So, there are billion-dollar investments being made to build prostate cancer proton treatment centers that may or may not be any more successful than older radiation therapies that doctors have been using for years. Or, more successful than doing nothing at all, for that matter.

Meanwhile, just as one example, the nation’s emergency rooms are crumbling into decay. Emergency rooms do not make a profit. They have very high overhead because they have to be ready for, well, emergencies. And many people who use emergency rooms can’t pay the bills. So many hospitals are closing or cutting back or downsizing emergency rooms.

(And the practice of using emergency rooms as default “free” clinics for the poor and uninsured not only adds to the burdens on emergency rooms; it is also probably the least cost-effective way anyone could think of to provide last-ditch health services to the poor and uninsured, which is another big reason our nations spends so much on health care.)

Anyway — it appears that if somebody is making money off a particular gizmo or course of treatment, the health insurance industry manages to find room in its heart to pay for it. However, the private insurance companies routinely refuse to cover people who have even minor “preexisting conditions” and drop customers whose ailments are money-losers.

Put another way, if current trends continue, the day will come when the medical-industrial complex will simply refuse to provide treatments that aren’t making a profit for some part of the medical-industrial complex. And consider that conservatives not only want to kill government-led health care reform; they want the private insurance and other parts of the health-care industry to be even more unregulated and unwatched than they are now, and the government “safety nets” to be dismantled, on the theory that the “free market” fairy will solve our problems, even though there is no place on earth in which 21st-century medical care is being delivered by a “free market” system.

Leonhardt’s interviews show us that when it comes to health care, “profitable” and “effective” do not necessarily find their way into the same ball park. Weirdly, “profitable” and “cost-effective” are not necessarily fellow-travelers, either. That’s because the medical-industrial complex does not make a profit from curing you; it makes a profit from what it call sell to you, whether it cures you or not. And if two treatments are shown by studies to be equally effective, the industry will push the one that provides the higher profit.

Let’s go back to our gentlemen with early-stage prostate cancer. “You have cancer” has got to be among the worst pieces of news anyone ever gets. “You have cancer, but let’s not treat it” doesn’t sound much better, and I understand why some patients would push their doctors into providing some kind of treatment. Leonhardt says a Swedish study on treatment effectiveness recommends removal of the prostate gland for men under age 65. Such surgery can result in sexual dysfunction, however, so I understand why men may want another option. So doctors say, well, there is this new proton-therapy treatment …

One of the reasons the medical-industrial complex gets away with scamming us is that doctors themselves often do not know which treatment is most effective. There is remarkably little effectiveness testing going on. “Drug and device makers have no reason to finance such trials, because insurers now pay for expensive treatments even if they aren’t more effective,” Leonhardt writes. So the doctors often have little else to go on but what the sales reps tell them. And some doctors are as keen to boost their revenue streams as anyone else in the complex.

A critical part of President Obama’s health care proposal is called “comparative effectiveness research (CER).” CER is not, as the Right claims, a plan that would allow the government to countermand a doctor’s decisions based on cost-effectiveness studies. The common claim on the Right that CER is about rationing is a lie. The point behind CER is to fund the kind of effectiveness testing that is not being done now and provide that information to doctors and patients, so that doctors and patients can make more informed decisions about what course of treatment to pursue. (See also what Dr. Howard Dean says about CER.)

Of course, if CER becomes government policy, all those billions of dollars being invested to build proton accelerators to treat prostate cancer might not bring much of a return, which brings me to my last point.

Whenever I publish something about health care I get comments claiming that the private, for-profit health care industry is always better than “the government,” all we need is tort reform, blah blah blah, or that government (as opposed to the health insurance industry?) shouldn’t be involved in health care decisions. I agree with the latter; the government shouldn’t be involved in health care decisions, but nobody is saying otherwise.

The mendacious anti-reform talking points repeated ad nauseam by the dittoheads of the Right are generated by a network of right-wing think tanks and other organizations that exist solely to influence public opinion. This network is very good at getting their propaganda uncritically parroted throughout mass media and the Internet, repeated over and over until it becomes “common knowledge.” And in many cases the deep pockets funding those think tanks are also heavily invested in the medical-industrial complex. And round and round it goes …

17 thoughts on “Ir-rationing Health Care

  1. Awesome post. It clarifies a key big-picture issue quite painlessly.

    When drug companies first were permitted to run TV ads for prescription medications, I noticed immediately that Big Pharma has a real talent for inventing ailments, or hyping negligible ones, just because they’ve got a drug that has such-and-such effect on the human body. All of a sudden, restless leg syndrome and toenail fungus are the scourges of the land. As George Carlin once said, “If you nail together two things that have never been nailed together before, some shmuck will buy it!” True, also, of molecules.

    My point is, pretty much every participant in the medical-industrial complex knows that Marketing is king. We need more widely-disseminated, clear explanations like this post, to counter the M-IC’s noise machine.

  2. The rise of the Medical-Industrial complex (MIC), and its free market fairy (I like that term) quest for profit, parallels the rise of the Military-Industrial complex. Both treat citizens like children in the way they try to pull the wool over our eyes, and lead us around. Both make claims like we need proton accelerators to “keep us well” or we need expensive weapon systems to “keep us safe”. Almost never is it discussed what their definition of “well” or “safe” really means.

    For years, I’ve subscribed to alternative medical publications like Alternatives (and others), where many anecdotes can be found showing how expensive therapies are pushed by the MIC when cheap, simple, and often more effective ones are available (and ignored). It’s not uncommon for the FDA for example to ban useful alternative therapies that are widely available in other countries, simply because their acceptance here would undermine an MIC profit center. My belief is the FDA would ban vitamins and supplements if they could – it’s almost that bad.

    Because of the failure and expense of the MIC, alternative therapies have been rising in popularity for years. There are few things as good as the MIC when it comes to traumatic or acute care, and the best doctors are now versed in both the MIC approach as well as various alternative approaches. Obama’s CER would be a great step forward in this area.

    Going back to the weapon systems analogy, at what point does giganticism finally be seen as madness. Consider the evolution of warplanes, and how a single B2 stealth bomber costs around $2 billion (when all related costs are factored in). Yeah, a stealth bomber (like a proton accelerator) provides certain tactical advantages, but at such absurd cost. In health care, it’s especially insane given all the more basic needs that go completely wanting.

    This is what happens when a system is optimized around making money, instead of serving people. The free market fairy should be recognized for the demon it really is.

  3. I was curious about Israel’s health care system so I went to Wikipedia. “Health care in Israel is both universal and compulsory.” “The health care system in Israel is one of the most advanced in the world and is notable for its many achievements in medical research and universal public accessibility.”

    Not only Israel, but the entire western world long ago figured out how to provide health care for all citizens so our insistance that it can’t be done rings just a tad hollow. The health care industry can well afford and is giving $1 million/day to members of Congress so the chance that anything resembling what other countries are doing to insure health care for all is next to never.

  4. Not sure I follow/agree with your prostate cancer analysis, but agree wholeheartedly with your conclusion. It used to be summed up with the cynical observation that medicine will never “cure” cancer because there is too much money to be made treating it. Given your and several other comments reference to the military industrial complex, I always find it a wonder that the most vigourous “free market” defenders are always those folks who are feeding off the government teat. Even those red anti tax states tend to get more from the feds than they pay in taxes. The big winners with the prescription drug benefit for seniors? Big Pharma. One way or another the medical industrial complex will be the big winner of any reform that comes out of the current debate. After all they have the best politicians that money can buy.

  5. We need to get the government out of health care. Medicare for everyone! Hey, it works for me.

    Yeah, I know, Medicare is a government program, but that might make a great marketing strategy.

    I remember 100 years ago, a friend of mine defined a program as debugged when it crashed less often than the operating system and hardware it ran on. It’s like that for medical treatments. Many older people have a slow growing prostate or breast tumor that will kill them when they hit 105. Of course, the odds are that they aren’t going to hit 105. Treatment isn’t always a good idea, though I have no problem with treatment once the tumor starts causing function or aesthetic problems.

  6. I agree wholeheartedly. Incorporating a plant-based diet can also make a world of difference.

  7. The right-wing’s opposition to comparative effectiveness research is particularly galling in view of their previous support for Bush’s health “plan”, health care savings accounts, which supposedly would enable “consumer-driven” health care because we’d all be making our own decisions about what treatments to get.

    Assuming they all think that would still be a good idea, just HOW do they think we consumers are supposed to make decisions about which treatment to spend our hard-earned money on, if we don’t do research into what is most effective for the money? Is it more of that famous right-wing “going with your gut” thing or something?

    Of course, logical consistency is not something they worry about, which is how they can currently be complaining that private insurance will be put out of business by people all rushing into a public plan that won’t pay for a whole bunch of treatments that people want to have. (There would be no way for private insurers to get people to opt for their plans which WOULD cover the treatments people want, presumably? It’s confusing.)

    Lying scumbags, that’s what they are.

  8. For the past 4 years my wife and I been saving up all our medical and dental problems and making the journey to a Thai hospital where the care is excellent and the cost…just a fraction of what I would have to pay out of pocket in the US. For example, last November I had an Endoscopic balloon dilation for a condition known as dysphagia. The specialist in the US said the operation would cost me $2500. (His bill for the 15 minute consultation was $250.) I decided to wait until I got to Thailand and had it done in at Chulalongkorn public hospital…cost $100 including biopsy. (all I needed for ID was my US passport. No questions asked!!)
    7 months later I am happy to report that I am doing fine.

    Why do we have to travel half way around the world for a procedure that we could have done here in America. Cost.
    My wife and I are in our 60’s and self employed. Unlike most Americans who work for someone else who foots a large portion of their health care premiums, we pay 100% of everything. And at our age, the best policy we’ve been able to find so far is a Blue shield plan that costs $900 a month and has a $8000 deductible.

    So we are basically “self insured”

    America is divided into two groups. Those who have adequate health insurance and those who don’t. So in essense, we have a rationed healthcare system where those who can afford insurance get good medical treatment..and those who cannot afford it go without.

    I highly recommend any American who can’t afford US medical care to look into going overseas. Countries like Thailand, India and Singapore are gearing up to provide top notch medical care at a fraction of the cost in the US citizens like me who are either uninsured or underinsured.

  9. Norris — Wow, thanks so much for your comment. I’d heard of “medical tourism” but never heard directly from anyone actually doing it.

    So in essense, we have a rationed healthcare system where those who can afford insurance get good medical treatment..and those who cannot afford it go without.

    Exactly what I’ve been saying for years. And you can find right-wingers who will argue that it would be a big mistake to go with a national health care plan, because if everyone has the same access to health care we’ll get waiting lines like in Canada. The logic of that always leaves me breathless.

  10. I did a bit of number crunching today– I haven’t seen any media mentioning this:

    The percentage of deaths due to swine flu in the US is 44% of the total swine flu related deaths worldwide.

    Mexico, for various unsurprising reasons, is 31%.

    The remaining 25% of all worldwide swine flu related deaths are scattered here & there (Canada 6%, Europe 4%, etc.).

    The US hasn’t even yet hit actual flu season yet. I just find it shocking that the US swine flu fatalities are so high, accounting for almost one half of all the fatalities world wide. Why is that? And why isn’t this being reported?

    I got my numbers from here:

  11. Very good post. Now go out and find out who the opponents of single payer are. Rent a HUGE sound system with ENORMOUS speakers, rent a flat bed truck and go to any opposition congress critters and crank the sound up to ten and have someone with a really irritating voice scream at 5 am, “single payer you son of a bitch” or daughter of a bitch if you have LA or AR for a state. This will accomplish more than any petition or calls or the other light weight nonsense that the libs propose.

    Fuck them, they weren’t drafted they sold their souls to be congress critters so waking them and the neighbors up is justified.

    A youtube of the first one will go viral, have fun and fuck them.

  12. The point behind CER is to fund the kind of effectiveness testing that is not being done now and provide that information to doctors and patients, so that doctors and patients can make more informed decisions about what course of treatment to pursue.

    Factually inaccurate, I’m afraid. It just isn’t being done in America now. The treatments paid for by the (British) NHS are determined by NICE – which runs based on the QALY (Quality Adjusted Life Year) and more or less only authorises them if the cost-benefit ratio exceds a certain threshhold (IIRC, 1 QUALY/£30,000).

    • Francis, we’re not talking about the same thing. Repeat after me:

      CER is not about determining a cost-benefit ratio.
      CER is not about determining a cost-benefit ratio.
      CER is not about determining a cost-benefit ratio.

      Now, go write that 500 times on a blackboard. Thanks much. If you want to understand CER, go read the Howard Dean interview linked.

  13. The spirit of Capitalism is competition. It’s a system where there must be a winner and there must be a loser. There must be the chance of failure, because it motivates people to achieve success. This is all well and good, until the consequences of failure are disease, and ultimately, death.

    Through this reasoning, I would suggest that medicine is incompatible with Capitalism. In fact, I have often wondered how people who practice medicine reconcile their hippocratic oaths with the tenets of scarcity that a for-profit enterprise demands. How does one withhold care in ANY circumstance? What is the rationalization?

    In response, I have gotten in the habit of withholding my money for healthcare. I pay, eventually, grudgingly, but not before I have recieved something with red ink on it. Yes, this does all sorts of damage to my financial status (a pointless, stupid game in and of itself) but if a person does not agree with how things work, I believe it’s his duty to disobey and challenge.

  14. The health-industrial complex is bankrupting America just as surely as the military-industrial complex bankrupted the USSR. By the time the USSR collapsed, 40% of their GDP was being consumed by their military-industrial complex. If current increases continue, within twenty years that’s going to be the USA — except we’ll collapse long before then, because we don’t have a totalitarian government to keep the lid on once medical treatment becomes unobtainable by the majority of Americans.

    – Badtux the Healthcare Economist Penguin

  15. Maha, go retake Critical Thinking 101.

    The QALY – the Quality Adjusted Life Year absolutely is a measure of Comparative Effectiveness. (There are others). And as such it requires Comparative Effectiveness Research, and in a fairly wide-ranging form.

    In order to assess the cost-benefit ratio of a form of healthcare you need to know the benefits, and the benefits relative to other treatment. And that is CER. (Assessing the cost is the easy part).

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