October 16, 2017

Why Do We Need Health Insurance Anyway?

            Despite the seemingly endless barrage of articles stimulated by the equally endless efforts of the Trump administration to kill the Affordable Care Act, relatively little attention has been paid to why we need health insurance in the first place. Liberal Democrats assert that health care is a “right” and right-wing Republicans maintain that it’s a “privilege” and that the only business government has with health care is to facilitate the business of medicine. Some of the disagreement among the parties stems from differing assumptions about just exactly what health insurance is for. Is it to protect people in the event of catastrophe—a devastating car accident that results in multiple operations and an extended hospitalization, or metastatic cancer that triggers several rounds of chemotherapy, radiation therapy, and numerous hospital stays? Or is to maintain individual and public health—ensuring that people receive immunizations and cancer screening, along with treatment of high blood pressure and high cholesterol? We can begin to answer the question by looking at the example of one group in American society with universal coverage, the older population.
            Medicare (and its sister program, Medicaid, providing insurance coverage for poor people) went into effect on July 1, 1966, after what was effectively a 30-year battle. Franklin Roosevelt wanted the government to provide health insurance for everyone, but couldn’t make much headway with his idea; Truman campaigned actively for health insurance for all Americans, but his plan failed. Finally, after decades of wrangling, Congress and President Lyndon Johnson agreed to begin with those in greatest need: people who were either old, poor, or both. Medicare had the immediate effect of boosting the number of older people hospitalized—suddenly, they stopped neglecting that chronic cough that turned out to be lung cancer or decided to get medical attention for that stomach pain that proved to be an ulcer. The likely effect (though to be fair, it’s hard to disentangle the effect of Medicare from the effect of other concurrent changes) is that older people began to live longer—a lot longer. But what was really striking were the countless indirect ways in which Medicare promoted the health of the entire older population: for example, by promising to pay for effective technology, it stimulated the development of incredibly successful interventions such as the pacemaker and the artificial hip.
When we compare the health of Americans to that of their counterparts in other developed nations, we find, rather shockingly, that everyone else is generally better off than we are—if they are under 65. Among older people, the stark differences between the U.S. on the one hand and Europe, Australia, and Japan on the other hand vanish. The only plausible explanation is that older people in the U.S. all have health insurance, rendering them comparable to older people in other parts of the world.
            From a population perspective, ensuring that everyone has health insurance is desirable because health is desirable. Good health is like education: without it, we are not productive, creative, prosperous, or happy.  Health insurance is the means to assure good health, so just as public education is a means to a skilled labor force. Environmental regulations are the means to assuring a safer, more healthful country.
            From an individual perspective, health insurance is critical to well-being because it’s the gateway to good health. It’s simply not true that we can expect to stay perfectly healthy as long as we eat well, exercise, and lead a virtuous life. We never know when disease will strike, whether in the form of cancer or heart disease or a chronic neurologic disorder such as Alzheimer’s disease or multiple sclerosis. No matter how cautiously we drive, we cannot guarantee that a drunk driver won’t unexpectedly plow into us, causing no end of medical problems if we survive the crash. Nor can we expect that the cost of even routine medical care will be affordable: a plain x-ray, used to diagnose pneumonia and other lung conditions, typically costs hundreds of dollars when you add up the cost of the procedure and the cost of a radiologist’s reading. 
          Everyone needs basic medical care and it’s not just “catastrophic care” that is expensive. Hence, the rationale for covering each and every American isn’t just that health insurance only works when everyone shares the risk—though it is true that the only way to keep premiums manageable is for everyone, the sick and the healthy, to have coverage, rather than confining coverage to those who are known to be sick and are guaranteed to use huge amounts of service. The rationale for covering everybody is that health care is essential if we are to have enough energetic, healthy, educated workers to provide the services and the innovations that we all need, and the only way to make sure that everyone has access to health care is to provide insurance.
          Health care, and the insurance coverage to pay for it, isn’t a right, nor is it a privilege. But it is critical to promoting a strong, vibrant, capable citizenry.

October 08, 2017

Is Medicare Entering the 21st Century?

       The do-nothing Congress may be doing something. In the immediate aftermath of the Senate’s third and hopefully final failure to “repeal and replace” the Affordable Care Act, the Senate actually passed a health care bill unanimously. With little public fanfare, it approved CHRONIC (the Creating High Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017). This bill, if it is not eviscerated or rejected by the House, takes a few important steps in the right direction.
         As a useful summary in the Health Affairs blog explains, the bill supports changes in four domains: home based care, managed care, telehealth, and accountability. In the arena of home based care, the law extends the successful “independence at home” demonstration project for two years, increasing the number of participants from 10,000 to 15,000. This is a relatively small modest program that does something critically important for some of our sickest and most complex patients—it moves the nexus of care from the hospital and the office into the home.
         In the area of managed care, the law does something quite remarkable. It incentivizes further use of Medicare Advantage programs, a long-standing Republican objective since they see Medicare Advantage as a way of privatizing Medicare. But one of the ways it does this is to allow programs to expand benefits to include social supports and help with activities of daily living. It’s a tiny wedge that could signal the beginning of a recognition that social factors contribute to health. This is the message of the book, The American Health Care Paradox by Elizabeth Bradley and Lauren Taylor  in which they argue that the reason Americans spend so much more per capita on health care than any other developed nation—and achieve poorer results—is that we substitute medical benefits for social benefits, to the detriment of well-being. We are a long way from allowing federal money to be used to pay for gardening supplies, say, so that a person with dementia would be happy puttering around at home and not become agitated and restless, perhaps triggering pharmacological treatment or even nursing home care, as has happened in the UK. But it’s a start.
         The telehealth expansion is another one of those strategies, such as electronic medical records, that on the surface is very appealing, but for which the evidence of effectiveness is mixed. It feeds nicely into the conviction that there are technical fixes to the American health care system, rather than major structural problems that must be addressed. Probably not the best use of scarce resources, but not a terrible idea.
         Finally, the Act mandates that the GAO carry out three investigations to assess the consequences of various strategies that have been piloted or proposed. One of these is a special reimbursement code for physicians to formulate a comprehensive care plan for patients with certain serious conditions. Another is whether Medicare Part D should lift its ban on drugs that help patients lose weight. The GAO is usually thorough and unbiased in its evaluations. All sound efforts at systematic evaluation—as opposed to wholesale, uncritical adoption of policies and programs—should be supported.
          Will the House pass the bill? Will it discover the most interesting parts of the legislation, ie the provision that lets Medicare Advantage programs offer benefits that are not “medical” in the conventional sense? We shall see. Tell your representative that if s/he wants to take credit for something, this would be a good place to start.

October 02, 2017

All that Glitters...

          Admissions to American Intensive Care Units (ICUs) from hospital emergency departments are on the rise—they doubled from 2003 to 2009—and admissions among patients aged 85 and older growing the most rapidly of all: they increased 25 percent every two years. What we still don’t know is whether or when the ICU helps them. This past week, French researchers published a study in which they shed some light on the question. What they found is that ICU admission in basically high functioning people over age 75 did not improve their chance of survival—and may have made it worse. The ICU probably didn’t make any difference in their level of function or health-related quality of life six months after discharge (if they were still alive)—but there is some suggestion it caused a deterioration.
         In a nutshell, what the researchers did was to come up with a standardized protocol for determining who should be admitted to the ICU, based on the particular conditions they had and how severe the conditions were. They then randomized hospitals to either use this special protocol or to rely on whatever they normally did to make decisions about ICU admission. To be eligible for the study, you had to be at least 75 years of age and at baseline, ie before you got acutely ill, you had to be independent in almost all your daily activities. When physicians used the special triage system, older patients were far more likely to be admitted to the ICU (61 percent) than when they did not (34 percent). But the death rate in the ICU, and the length of stay in the hospital were the same in the two populations. Overall hospital mortality was higher in the intervention group (30 percent) than in the controls (21 percent). Moreover, decline in independent functioning was greater at six months in the intervention group than in the controls.
         What should we make of all this? I think it’s reasonable to conclude something about what we're not doing. We’re not currently depriving many older patients of care that would be beneficial for them. Maybe all those physicians who don’t admit certain elderly individuals to the ICU aren’t discriminating against them; maybe they’re on to something. What we don’t know is whether the doctors who provide “routine care,” those who use criteria other than the officially sanctioned ones for determining who gets in to the ICU, are still over-utilizing the ICU. What we don’t know, although it’s a bit implausible, is whether there are older patients who are excluded both by the seat-of-the-pants criteria and the rigorously-determined criteria, who would nonetheless benefit from a trip to the ICU.
         Behind all the methodological considerations and the statistical conclusions, we have two inescapable realities: first, there are many older people who are so sick and so close to the end of life that no technology, no medication, no amount of monitoring or nursing care will keep them alive—and that’s true even for the population addressed in this study, which excluded anyone who was frail. Second, the ICU is a medical intervention, much like a drug or a procedure, and it comes with side effects. For older individuals, those side effects may outweigh any potential benefits of the intervention. So when the physician recommends the ICU for you or your older relative, think twice before agreeing.


September 24, 2017

A Day to Shout

        This past week was Rosh Hashanah, the Jewish New Year. I discussed the origins and evolution of the holiday at my synagogue, observing that the original name of the holiday, as indicated in the Torah, the Jewish bible, is “The Day of Shouting.” And what was it that people were supposed to shout about? Originally, they were supposed to shout out their praise of God. Some of the admirable qualities that have been attributed to God are “caring for widows and orphans,” which is biblical shorthand for “caring for the vulnerable,” and “welcoming the stranger, for you were strangers in the land of Egypt,” which is synonymous with accepting outsiders, newcomers into the community. But already early on in Jewish history, and particularly over the last several hundred years, the tradition is that these “attributes of God” are seen as aspirational—as qualities that people should strive to emulate in their own lives. So, translating into contemporary language, on Rosh Hashanah, we are supposed to strive to care for the poor and the sick and to open our doors to refugees.

         But there’s more. Over the centuries, not only have these qualities attributed to God become qualities that people should strive to adopt themselves, but it has also become our responsibility to act. The shouting that we are supposed to do on Rosh Hashanah is not so much singing God’s praises as it is calling out to our fellow man to act. And the actions in question, not surprisingly, include caring for the poor and the sick and embracing refugees.

         The health care bill that is expected to come to the Senate floor this week is the very epitome of how to avoid caring for the poor and the sick. If you cannot afford medications, hospital care, or insurance premiums—that’s your fault. Next time, work harder, go to better schools or, better yet, choose parents who are themselves smart, educated, and affluent so they can assure that you, too, will be smart, educated, affluent—and able to afford to pay whatever it costs to get good care. In fact, if you have cancer or diabetes or some other chronic, serious condition, that’s your fault, too, so why should someone else have to subsidize your treatment? This bill, which pretends to include benefits comparable to those currently available under the Affordable Care Act, is not a means of providing health insurance to all those left out by the three other programs for obtaining coverage: Medicaid, Medicare, and employer-supported insurance. Rather, it is a strategy to gut Medicaid, one of the three pillars of the current system. The ACA was designed to take a three-legged stool and enhance its stability by adding a fourth leg; the latest travesty proposed by Senate Republicans would instead amputate one of the three legs. So, here’s my shout out to my fellow Americans: say “no” to the Senate proposal. Shout out to your senators—especially if you’re from one of those states such as Maine and Alaska whose senators have previously expressed concern about the poor and the sick in their states, or if you’re from one of the states that stands to lose the most from the new bill, such as Florida and Nevada. Shout to those people you know who live in those states that they should shout out to their senators. Make this Rosh Hashanah truly the “Day of Shouting.”

September 17, 2017

Taking the Heat

When a record heat wave swept across Europe in the summer of 2003, elderly Parisians were particularly hard hit. “French heat toll almost 15,000,” screamed one BBC headline in September. The cause of death: dehydration and hyperthermia. The diagnosis of the problem: not enough air conditioning, made worse by too many physicians on vacation in August. Across Europe, over 70,000 people died of heat-related causes. We thought we were immune: our nursing homes are air conditioned and we have plenty of nurses, doctors, and regulations. But now we have the disturbing reports of 8 deaths among nursing home residents of a facility in Florida in the aftermath of Hurricane Irma. The nursing home lost power and its back-up generator was useless when a critical component, the transformer, failed. Despite access to an acute care hospital across the street, no one thought to transfer the frail, elderly long term care residents until they were already suffering from severe dehydration and/or hyperthermia. What can we learn from this very sad story?

First, we should drill down and look at the specific facility where the problem occurred. All of the west coast of Florida was affected by the hurricane, after all, but only one nursing home lost patients. The Rehabilitation Center of Hollywood Hills is a Medicare and Medicaid licensed 152 bed facility. It is a for-profit nursing home. And if we consult Nursing Home Compare, the site operated by the Centers for Medicare and Medicaid Services to allow consumers to compare the quality of different nursing homes, we find that the home currently has an overall rating of two stars, or below average. Even more revealing is the further breakdown: in the area of health inspections, it received only one star, or much below average, though in quality it got three stars (average) and in terms of the staff: patient ratio it actually got four stars (above average). So what exactly does this mean?

The problem at Hollywood Hills was not a failure to follow the rules—the facility had a back up generator and supplies for seven days (though their ice collection was presumably not terribly useful if they had no refrigeration). The problem was judgment. Nobody in charge determined that conditions were too dangerous and residents needed to be evacuated. They only figured that out after people began dying, although it takes a couple of days for a lethal degree of dehydration to set in. What our current evaluation system for nursing home lacks is the capacity to measure the ability to respond to novel challenges, to be creative. Perhaps we need to set objective standards, not merely relative standards. If we set the bar high enough, then the lowest performing facilities would still be adequate. That said, it’s striking that the overall rating of the facility was poor. Nursing Home Compare is on to something—we need to have a better way of insuring that the poorer facilities improve. 

The other take home lesson from the tragedy is that Hollywood Hills was the canary in the coal mine. Yes, only one nursing home in Florida seems to have behaved with such monumental lack of understanding of what happens to frail old people in sustained 100 degree heat. But the truth is that we will see more hundred degree weather—and more Hollywood Hills behavior—in the future. A recent government report—issued before President Trump and EPA Director Pruitt banned references to “climate change” from official documents, “The Impact of Climate Change on Human Health in the United States: a Scientific Assessment,” makes clear that there will be profound, widespread consequences of rising temperatures. The vulnerable elderly will be among the hardest hit, but they are merely harbingers of what is to come unless we take major steps now.