Monday, November 23, 2009


The current mammogram controversy is yet another example of ignorant, unthinking people going crazy about something they don't understand. Most critics of the new U.S. Preventive Services Task Force guideline do not understand that our system has finite resources. They also don't understand that there is no such thing as saving a life. There is only delaying death. Also not mentioned in any of the articles I am reading is that breast cancer mortality rates are usually only measured for five years.

The new guideline says that the recommendation for mammograms should be once every two years starting at age 50. This replaces the recommendation for annual mammograms starting at 40. They found that only 1 in 1900 mammograms for women in their 40s delayed death. This may save $2 billion per year and result in maybe 600 undelayed deaths. That means the old guideline resulted in spending about $3.3 million dollars per delayed death. I don't know the life expectancy of breast cancer survivors, but for the sake of more math, let's say that all of these deaths were delayed by 40 years. That's over $83,000 dollars per year of life, just spent on mammograms! Keep in mind that these women will continue to incur more health care costs over those 40 hypothetical years, too, and I am not considering quality of life.

The British system refuses to pay for drugs that cost more than $45,000 per quality-adjusted life year (QALY). Medicare limits hospice spending to about $22,000 per year (if I read that right). These measures are necessary to protect the whole system from going bankrupt, as our system is destined to by 2017 unless we make drastic changes. These measures also help ensure that the system's finite resources are being used where they can do the most good.

Think about how much good could be done with that $2 billion per year. I guarantee that we could save far more than the breast cancer's 24,000 (my certainly too-high hypothetical estimation) life-years by spending it somewhere else. I bet that $2 billion could be easily spent to save 100,000 life-years or more. Critics of the new guidelines are selfish and short-sighted, and would rather hang on to their anecdotes of women whose deaths were delayed while sentencing thousands of other people to a lack of care due to insufficient resources. These costs also keep insurance premiums high, pricing working poor out of comprehensive insurance.

Women considered high risk due would still be recommended for mammograms before 50. There is some talk about how black women would be disadvantaged by the new guideline because they tend to have earlier and more aggressive cancers, and of course that would be taken into account by informed doctors making recommendations. The task force guideline is based on aggregate information for the national population.

Mammograms have been oversold, and our country as a whole would be better off following the new guidelines. We need to make our entire system more efficient and cost effective (not the same as cutting the total cost, just demanding better results for our money) for it to be sustainable and good for the people of our country.

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Friday, November 13, 2009

Stupak Inconsistency

I recognize that my ideas on health care, coming from my educational and work background, would have been far more interesting and useful to readers two years ago. Now we are deluged with health care information, and Congress is churning out thousands of pages of bills and amendments, which is too much for me to process and evaluate. There are great resources out there, such as Ezra Klein's blog, NPR, and so forth. I am trying to find my utility.

Anyhow, for today, a hot topic is that the Republicans just realized that they've been paying premiums to Cigna for 18 years that cover abortions, and they're going to stop. They say that abortion is evil. Enough Americans agree with that that some Democrats jumped on board and we got the Stupak amendment. Here's a quote from the site I linked to above:

"The Stupak amendment, named for sponsor Bart Stupak (D-Mich.), was adopted by the House before it passed the health care bill on Saturday night. It prohibits a government-backed health care plan from offering abortion services and bans the use of federal subsidies for individuals to buy into health care plans that provide abortion coverage. "

The ridiculousness of this, as was pointed out by Ezra Klein (I don't know that I would have caught this), is that the government heavily subsidizes health insurance plans that cover abortions. It does this by not taxing employer-provided insurance. People who get insurance from work are getting cheap insurance in part because of the government's decision not to tax the insurance costs as income (and also because of negotiating leverage depending on the employer's size).

I pay for my insurance individually. This means that I pay taxes on my income, then spend my income on insurance. I can still afford insurance because I have a very basic plan and I am not "poor". Many people who do not get insurance from work are poor and need more comprehensive insurance plans. Many of these people need government subsidies in order to have insurance. We already know that it is important to insure everyone to keep costs down because the uninsured get expensive ER care instead of cheaper basic care and prevention. The Stupak amendment is only hurting poor people's ability to choose insurance plans that cover abortion. This group is easily the most important group to provide that choice to.

Obviously, deontologists who think abortion is evil will try to make abortions impossible, even though unwanted pregnancies lead to all kinds of personal and societal problems such as child abuse, neglect, mental illness, delinquency, and crime, which all cost the people involved and our whole country billions of dollars, happiness, and function. So why aren't these same Stupak supporters clamoring to end the tax exemption on employer-provided insurance that covers abortions?

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Tuesday, November 3, 2009

Uwe Reinhardt Highlights

NPR interviewed Princeton health economist Uwe Reinhardt. Reinhardt does a good job clearly and concisely explaining concepts. There is a lot more than gets covered in the interview, but this is good. Here is a summary:

* People are generally individually selfish, and need active leadership to coordinate for the good of the group.

* The current health system hides too much information (costs and quality), so we can't make good decisions about what care to get or how much to pay for it, which leads to high prices for mediocre outcomes.

* Prices are different for people based on what can be negotiated, not costs or benefit.

* Government-imposed standardized prices work well in Maryland and Europe.

* Care providers are paid way too much for giving treatment and tests. This is a huge incentive to perform unnecessary procedures and prescribe unnecessary drugs. They are generally not paid based on outcomes (hidden from consumers).

* A public health insurance option would be able to negotiate good prices.

* The free market screws over poor people by relocating care providers (in addition to pricing out insurance for those who don't qualify for Medicaid).

* The private insurance system requires a ridiculous amount of nonstandardized paperwork that raises costs and takes resources away from treating patients.

So, what are some ways we can use this information to make our system better? I think it's clear that we need a way to track outcomes by doctor and clinic, and make costs transparent. Outcomes can easily be tracked if we had a unified system (single payer), which would lead to paying providers for outcomes instead of for giving unnecessary treatments. A single payer would also negotiate good prices that make the system more sustainable, and vastly reduce costs and wasted time due to paperwork. Government intervention is necessary in order to make care accessible to the poor, since the free market only provides incentives to abandon them. Unselfish, compassionate changes that are good for the whole country will have to be made by the government because individual actors are selfish.