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The Best Science Writing Online 2012
Showcasing more than fifty of the most provocative, original, and significant online essays from 2011, The Best Science Writing Online 2012 will change the way...
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Two years ago you could scarcely open a newspaper without reading about health care, and you might be forgiven for thinking (or hoping) that the debate was over. Yet the Patient Protection and Affordable Care Act that was signed into law in March 2010 offers more concrete plans for reforming the health insurance system than for reforming the health care system. It will change how we pay for health care but not how much we pay—and that is a problem. Government actuaries have calculated that total health care spending by the public and private sectors will grow from $2.7 trillion (17.4 percent of GDP) in 2011 to $4.6 trillion (19.6 percent) in 2019. The U.S. needs to get smarter about restraining soaring medical bills while improving the quality of care.
The U.S. is not alone in facing this dilemma, but it is arguably the most deeply encumbered by it. It spends far more per capita than any other industrial nation, yet all that money fails to buy the best care. In terms of people’s level of disability, the care they receive for chronic conditions, and their life expectancy, the U.S. ranks below many other countries that spend much less. Compared with the average American, the average citizen of France or Israel lives three years longer, the average Australian four years, and the average Japanese five years.
Why does health care cost so much more and deliver so much less in the U.S.—and what can be done about it? No single or simple explanation covers all the bases, but three factors loom particularly large. First, the U.S. health care system is highly fragmented, leading to much duplication of effort. A 2007 study, for example, found that older patients see an average of seven different doctors, including five specialists from four different practices, in any given year. Second, clinicians and health organizations are paid on the basis of the services they provide rather than improvements in their patients’ health, creating perverse economic incentives to overuse drugs, procedures and hospital beds. Third, doctors and hospitals are quick to adopt expensive new drugs, procedures and technologies without requiring that they prove significantly more effective than cheaper alternatives.
Politicians have acknowledged the crippling cost of medicine, yet their proposals do little to fix these basic flaws. For instance, replacing Medicare benefits with vouchers that individuals can use to buy their own health insurance, as was recently proposed by House Committee on the Budget Chair Paul Ryan, merely shifts more of the financial burden to private citizens. And most of the cost-saving initiatives found in the Affordable Care Act are demonstration projects—not large-scale reforms. The factors that inflate health costs must be addressed widely and directly. Fortunately, promising solutions are beginning to emerge:
Reducing Fragmentation. The Department of Veterans Affairs, federally certified community health centers, and a few regional care systems are demonstrating that greater coordination of care can keep people healthy and out of the hospital. For example, several Philadelphia hospitals have assigned nurse practitioners to organize the care of elderly patients with chronic illnesses after they were discharged. Readmission rates have dropped by more than a third and net expenditures by nearly 40 percent, despite the extra personnel costs.
Phasing Out Fee-for-Service. So-called accountable care organizations are pairing hospitals with community health teams. These groups will be paid a set amount per patient based on the severity of the individual’s condition, such as diabetes. The organization earns a bonus if the person’s health improves and keeps any savings if it manages to meet its health targets for less than the contracted amount.
Comparing Effectiveness of Procedures. On page 50, in “The Best Medicine,” science writer Sharon Begley describes a powerful analytical tool to help rein in cost. Dubbed comparative effectiveness research, this approach originally involved mining the available data about conditions and treatments to figure out how expensive therapies stacked up against cheaper options. The technique has now been extended to determine whether some ways of organizing the care provided by hospitals and health centers are more effective than others. For example, it can check whether the ratio of general care clinicians to specialists should be increased or whether elderly patients would benefit from support services that allow them to live longer at home.
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27 Comments
Add CommentVery nice, and has nothing to do with science.
Reply | Report Abuse | Link to thiscomment on "physician heal the system"
Reply | Report Abuse | Link to thisThe "system" is broken But ever since I have been a physician(1970)the system has tried to heal/repair itself.
It has only gotten worse. On the one hand the amount that a physician has to know is too great for even the specialized to carry all the info...thus sub-specialization. Even here it is too much info. LIKE IT OR NOT ...this fact is here to stay.
comment on "physician heal the system"
Reply | Report Abuse | Link to thisThe "system" is broken.But ever since I have been a physician(1970)the system has tried to heal/repair itself.
It has only gotten worse. On the one hand the amount that a physician has to know is too great for even the specialized to carry all the info...thus sub-specialization. Even here it is too much info. LIKE IT OR NOT ...this fact is here to stay. The selection process for MD's and esp. for specialists is so biased toward accomplishments, intelligence, physical attributes, etc.
that finding ANYONE that can carry and USE all the info out there is not going to happen. Yet I hear a subliminal cry for the good old days where A patient went to A doctor and was treated for ANY disease/problem. This scenario is not compatible with the level of care demanded today and thank goodness for that. Yes, if this was possible one of your problem complaints...2007 study...patient had to see 7 different doctors including 5 specialists etc. would be solved. Well it can happen with the Family Practice MD IF one accepts the lower level of expertise offered and the lower level of care. If his diagnosis/treatment was incorrect THEN WHAT...sue the MD....OR....go see the requisite number of MD's to get the job done correctly????? I say you can't have it both ways.
PROBLEM number 2.....why does care is the USA cost more than in ?? ..... Costs are the same wherever found...please read The World IS FLAT.
PROBLEM number 3 We MD's have forgotten Ben Franklin's "Never be the first the new to try or the last to set the old aside" Personally, I have been confused by this myself.I am an Orthopedic surgeon with a subspeciality in Hand and see the elderly on so many different meds I wonder if the patient's med list is ever critically analysed for necessity/duplication. This is multifactorial in etiology.....TV, Internet, new MD syndrome, etc.
As much the fault of the patient as the MD.
PERSONAL:
With all this improvement I lost the ability to treat my patients equally unless I work for a hospital system...so I worked for a hospital system.
Even here in the hospital setting admonitions by people like yourself writing articles like this one calling for "the good ole days of simple medicine delivered by ole doc so and so but with all the new bells an whistles" are just about to drive the small hospitals out of business. I am told when my patient is to be discharged and how to utilize ever diminishing resources.
I am hopefully going to be able to give the best care possible in spite of you geniuses.
L Benoist MD
A major source of the cost-benefit problem is that the average patient doesn't takes responsibility for behaviors that lead to the aggravation of expensive chronic diseases such as alcoholism, obesity, smoking related conditions, and non-compliance; just a selected short list. Why do people drink and drive? It is disturbing to leave the hospital and see a group of overweight nurses in a selected area outside, even in midwinter, smoking cigarettes, then going back in to take care of a heart patient in the cardiac unit. Educated and exposed directly to the consequences of unhealthy behaviors, they especially, should know better.
Reply | Report Abuse | Link to thisPossibly if patients are to some extent directly responsible for the cost of a medical service instead of a third party, motivation to behave in a manner that improves the condition for which care is sought would reduce our national medical bill, and we would be more healthy.
Charles F. Eberle MD
Albuquerque NM
This is one of the best commentaries I've seen written on the ills of the health care system. Yet it falls short. Here are some additional points in brief:
Reply | Report Abuse | Link to this- The cost of end-of-life care
- The cost passed-on malpractice insurance in a litigious society
- The cost of inefficiency in medical record keeping
- The cost of inefficiency in the payment process that providers must go through to be paid by insurance companies.
- The expectation by most that someone else should pay for their health costs and that they should have unlimited access to expensive tests and treatments without having to pay much.
- The overprescribing of tests, drugs, and treatments as a result of patient expectations, fear of being sued, the need to cover mortgage costs for MRI and other costly equipment, and the notion that "Someone else is paying" so why not?
The system is badly broken. I don't share the optimism of the article about fixes on the horizon. To really fix the system, the public must be educated about the problem and the public debate must challenge many assumptions about the current system which is unsustainable. Attitudes of the Health Care Providers, the Public, and the Insurance Industry must all change in order to have meaningful reform. Instead, we just hear fear mongering by the Industry and the politicians they pay for. We have created a monster: a health care industry that generates so much revenue and profit that they can afford massive amounts of PR and lobbying that no-one can afford to counter. The Health Care Industry spends 10 times the amount of the Petroleum Industry on Lobbyists. I don't have the figures, but they also spend massive amounts on advertising including lavish treatment of Doctors to get them to prescribe expensive treatments and tests. If someone sees a way out of this cycle, please console us.
This was an interesting article, but none of the suggested remedies seem remotely likely to bring down the cost of health care to be comparable to other industrialized nations.
Reply | Report Abuse | Link to thisThis makes me ask a really dumb question. Is it possible that health care in the US is simply more expensive, at least in part because we are one of the centers of new medical research? I do not mean this at all as chauvinistic, but merely as an open question. Is the US funding basic medical research such that we are innovators for medical advances, that are inherently more expensive than primary care? I did my post-doc in Edinburgh years ago, and was impressed at the high quality of primary medical care in the UK. However, many argue that specialty care is at a higher level in the US than in the UK, albeit at much higher cost, and without a social safety net. However, I wonder if it is a valid question that medical care will always cost more in the US (even assuming we eventually achieve more equitable distribution) simply because we invest more in new medical research and technology? Many of the best ideas come from all around the world of course, but I wonder if they aren't developed here, as in so many other areas of science.
I just don't see how better medical record keeping, reduction of malpractice, etc. could ever reduce our national medical costs overall to those approaching other countries. It seems perhaps there migh be another explanation for the large disparitiy.
Reply | Report Abuse | Link to thisA NATIONAL HEALTH PROGRAM
The time has come for the people of America to understand that the health of its people is key to its ability to “provide for the common defense.” Where we have always taken as a given that a military force is essential for our common defense, we now need to realize that the health of our people is equally important, and that providing for that need is the function of government. How? I suggest the nation assume control of its health industry by nationalizing all medical activity — the training and assigning of doctors, contracting for the construction and running of all hospitals, contracting and selection of all drug suppliers, providing the funds and selecting medical research centers, and providing for the universal care of its citizens.
Elliot
The fundamental problem with government managed health care is that the process is controlled by politicians and politicians are notoriously incompetent when it comes to anything other than getting elected and re-elected. There is also the issue of vested interest. As soon as we allow government to manage health care costs we open the door to government control of the entire process including control of any activity that is deemed to be potentially injurious to health. If government is responsible for costs associated with health care it is legitimate for government to control behavior that may increase the costs to the state. The impact this fact has on personal liberty has not been thought through by the proponents of government managed care.
Reply | Report Abuse | Link to thisA fourth factor in the high price of health care in the US is the cost of medical malpractice insurance.
Reply | Report Abuse | Link to thisOne significant factor in why other countries have overall better outcomes at a more affordable cost is due to access to primary care. The Patient Centered Medical Home Model does address this to some degree (not mentioned in this article).The Patient Protection and Affordable Care Act requires all citizens, the True Payors, to purchase insurance. The crisis is that, due to economic discrepancies, there is an outlandish shortage of primary care physicians in our country. In response to "Health care that is fairer..." it is important to mention the Elephant in the Room - an economic injustice. The income of one health insurance company CEO could be redirected to provide compensation for 200 well-paid primary care physicians. There is no mention of reforming this injustice either in the new law nor in most health care reform discussions. Why is this? I invite anyone to argue the relative value of accounting and managing one company being 200 times more valuable then preventing and managing disease and saving the lives of 2000+ individuals each year.
Reply | Report Abuse | Link to thisThank you for your comments. Through dialog we can develop our priorities, which in turn will effect change. As long as the abstract concept of profit at the cost of humanistic contributions exists in our society there needs to be controls and regulations of behavior. The health care industry, in this sense, is a contradiction to the humanitarian delivery of health care. Lives are not widgets.
Reply | Report Abuse | Link to thisThis post reflects the difference between idealism and realism. The process described here would require a law that was impossible for politicians to corrupt and no politician would ever write such a law.
Reply | Report Abuse | Link to thisIs there any way to craft a law that would provide the "justice" you describe?
This post reflects the difference between idealism and realism. The process described here would require a law that was impossible for politicians to corrupt and no politician would ever write such a law.
Reply | Report Abuse | Link to thisIs there any way to craft a law that would provide the "justice" you describe?
This article describes the same government run system that will ration care and radically increase the already obscene administrative costs of health care. Statutory Limitation of admin costs of health care is the key... and directing more "health care" dollars to the direct care of the patient...is the solution.
Reply | Report Abuse | Link to thisScience?
Reply | Report Abuse | Link to thisWhy not an article on Peruvian senior services?
Please....back to science.
While I do not completely agree with danielrch, I think he has a good point: there is not enough science in this article. While the first two paragraphs gave good scientific evidence that a problem exists in the US and the paragraph on Comparing Effectiveness of Procedures also had underlying science, the rest were essentially guesses, or unsubstantiated hypotheses. While these hypotheses as well as many of those presented in other comments sound plausible, presenting them without any scientific backing is no different than what I read in other publications every day. Unfortunately, this sort of guess-at-the-answer-and-claim-it-is-correct is all too common in dealing with social problems. The unique thing that S.A. has to offer is to give us information as to which ideas actually have some good science behind them and which do not. I would like to see much more of that presented here. After all, it is these sort of social problems which are going to change the face of the world in the near future rather than the physical sciences.
Reply | Report Abuse | Link to thisThe underlying problem with health care is that it has become a political football with too many pigs at the trough that have nothing to do with the care of patients.
Reply | Report Abuse | Link to this
Reply | Report Abuse | Link to thisThe fundamental problem with business managed health care is that the process is controlled by businessmen and businessmen are notoriously incompetent when it comes to anything other than creating artificially inflated profits and dividend checks. There is also the issue of vested interest. As soon as we allow businesses to manage health care costs we open the door to business control of the entire process including control of any activity that is deemed to be potentially injurious to health. If business is responsible for costs associated with health care it is legitimate for business to control behavior that may increase the costs to the shareholders. The impact this fact has on personal liberty has not been thought through by the proponents of business-managed care.
There, I fixed it for you. Your statement is now closer to the reality we face now than the fantasy you're trying to sell. The reality is, businesses are NOT more efficient than government, at least once they get to the size necessary to provide health care. The fact is this: if business-managed health care could've provided the "solution" to health care in the US, it would've by now. Instead, it stands as the problem.
But, to address the concept of efficiency, there IS a simple solution: amend the Constitution to eradicate the states. Across the board, the states represent an inefficient layer of middle-management that just absorb efficiency like a black hole. In point: a friend spent much of her career in a health care sales office. Her position was to maintain the certification records for the 12 salespeople in the office in all 50 states. Some states simply require a phone call to be registered, some require an application, some require a certification test, some require education, some require constant continuing education, some require nothing, some require this, some require that....51 different sets of rules does not make for efficiency. Create a Federal health care system, it becomes more efficient by default as it collapses the rules down to one set that's universal across the country.
I take it you have not experienced federal health care as provided by the military, VA or public health. That worked so well I ejected into private practice so could actually take care of patients. When our public health types began screaming for "erecting barriers to care" I had enough. Of course the barriers they already had in place resulted in two children dying in waiting rooms of febrile seizures.
Reply | Report Abuse | Link to thisThe lollipops and unicorns world of health care you advocate is not achievable. Every country that has tried it is in a state of denial even as they try to extricate themselves from the mess. The physicians who have commented above have identified many of the issues that need to be addressed. The overarching issue is that the current system forces healthcare to service the primary payers at the expense of the patient. In such a system, rather than being the purpose for the activity the patient is reduced to a commodity to be bartered. The key player in this is the FED who you propose will salvage the system: they created it in the first place! Track the current problems into history and you will see they took root in 1968 with the enactment of Medicare and Medicaid. These programs were instituted on a corrupt foundation consequently the resultant 40+ years of patching the system has met with continuing failure.
The other side of the coin is the expectation of the typical US patient. As pointed out in the article the many cultural issues are far more important to the health of a nation before access to hospitals and physicians. It is in this venue we stand to make the greatest improvements.
The reason we are the center of new medical research is that our patent system is broken. All capitalists like monopolies, by definition, it means that you are able to charge whatever you like. A significant amount of the research is simply to find new drugs that are best marginally better than the drugs they replace. In general, modern medicine has been a failure for adults. Although life expectancy has improved tremendously for the population, if you examine the data more carefully, you will find that most of the increases have been in infant mortality. For an adult who managed to reach the age of 25, life expectancy has increased by 6 years over the last century. But even amongst that data, the upper class tends to live about 3 years longer than the lower class, so 3 of those years could be attributed to reduction in the stresses brought on by manual labor and better nutrition today. And that trend is now starting to reverse as more people suffer from obesity-related diseases. Is this a success or a failure?
Reply | Report Abuse | Link to thisHospitals have the same problems as today's schools, top heavy administration taking a majority of the available funding. The dregs filter down to the real workers, teachers, doctors, nurses with instructions to do the job and keep the costs down. That way all the front office people can keep their bonuses coming.
Reply | Report Abuse | Link to thisThe subject of starting using new drugs and procedures is a relapsing-remitting one, in some places linked to the falacy that just with the WHO essential drugs you can treat everything, and the rest are candies sold at gold prices by the pharmaceutical industry. In the times of pharmacogenomics we are not only showing that one size doesn't fit all, but finding the way to patient tailored medicine, that in the end will reduce costs and side effects to patients. This is true in the field of medical specialities, but the surgery Dr. Smith performs is different from the surgery Dr. Johnson does. Also a question can be raised, as people willing to adopt in a fast way new things tend to be more close to a borderline personality, but if everybody adopted the conservative approach, novelties would never be implemented. Health Regulatory Authorities are in command of the process of approval of new drugs and procedures, and they deserve to be trusted, as they passed a thight selection process. HRA are the rulers, and should remain to be so.
Reply | Report Abuse | Link to thisMany good comments on this important issue.Just want to add something fundamental.
Reply | Report Abuse | Link to this1. Proper education and radical understanding on aging and disease causative factors.
2. Determine ethology of modern state diseases. Enforce preventative agenda towards early birth education of young generations in parallel massive programs in adult education onto causality of cardio vascular disease, diabetes, cancer etc. Enforce clean air act, clean water act, healthy food act wrapped in healthy behavior act. Liberty is freedom of pain caused by negative impact over long term.
3. Face reality - our current paradigms in medical school span from Fleming to the fear of cancer developing society. 25% of population will be sick by 2020 of some form of cancer. Note, all modern disease have common origin - the way our systems compensate may be different. So combine cardio vascular disease , cancer , diabetes and you get about 50 % of population in a hospital by age of 50, or simply have degenerative society. It i snot about health care- it is about proper education from young age and constant aim towards understanding what life is about.
The transition from managing diseases to eradicating diseases takes a scientific revolution within medical world. After all it is not all about money - it is about the pursuit of happiness converging into mentally progressive society- free of depression, free of drug abuse, free of violence.
I wish one day I meet people that never went to hospital, like my grandmother, with perfect cholesterol and heart conditions at age of 90 passing away while a sleep in her dreams. If one knows how to keep bones healthy at that age, one easily can work until 100 years, or may be never retire only and only if we keep our brain healthy along with all other systems. How that can be done what is the benefit economically wise? Well, think about it!
'Health Care system'- what a misnomer - It's really an elephantine 'Disease Care' system', and the biggest growth industry in developed countries is, we should have guessed: The 'Disease' Industry'.
Reply | Report Abuse | Link to thisThe real growth factor is inherently provided by another growth industry: the SAD (Standard American Diet) Food Industry, which derives its huge profits mainly from addictive, denatured food combinations. It's so sad that, for public health departments, any disease- prevention incentives are worth only about 2 percent of all health investment costs.
Big Pharma' s waiting in the wings, calling the shots, and reaping most research revenues for developing evermore patentable and profitable drugs, all in the name of the growth national product of democracy-or should it read:democrazy?
For some comic relief from this conundrum, visit Youthevity.com
The fundamental reason why health care is so expensive and inefficient is it is driven by fear. We are dealing with a very litigious public fueled by a glut of lawyers. Turn on the tv and all there is on during the day are ads encouraging lawsuits against doctors and pharmaceutical companies. Insurance companies are geared toward profit not promoting wellness. The high cost of insurance creates a sense of entitlement by the consumer. Couple this with a generous dose of fear of litigation and watch the tests and consultations flow. The public will not assume responsibility for their own well-being anymore than they will assume it for anything. The current legal system ensures there is plenty of blame out there just waiting to be plucked. We blame Mc Donalds for making us fat and Philip Morris for making us smoke so why not doctors for making us sick? Then of course there is the most contentious issue,the end game. The average American incurs something like two thirds of their lifetime medical expenses in the the last six months of their life. We have got to get real about terminal disease or it will wipe the system out even faster than the malpractice lawyers. You want to see better health then start making patients accountable for it. Bad drivers pay a fortune for insurance. Patients who choose to ignore advice that will improve their health such as weight reduction or smoking cessation should be held accountable in the form of higher rates for insurance. Stop blaming doctors for problems we have no control over.
Reply | Report Abuse | Link to thisThis editorial is pure political opinion, and has nothing to do with science. I subscribe to SA for science reporting only. Stick to science and stop wasting my money.
Reply | Report Abuse | Link to thisThere were several interesting and potentially useful suggestions for reducing America’s outrageously high health care costs in the July 2011 editorial “Physician, Heal the System.” However, the idea put forth in the “Phasing Out Fee-For-Service” section that organizations be given a bonus when a person’s health improves and the cost for their care comes in under budget can lead to a plethora of abuses. Under this system there will undoubtedly be great pressures to identify an “improvement” before the “cure” is complete in order to receive the bonus. There is a great danger of bonuses being provided for insufficient and incomplete treatment, rather than for less expensive health care success.
Reply | Report Abuse | Link to thisAn example of this is the current Medicare practice of offering bonuses to doctors and hospitals for releasing a patent to a skilled health care facility prior to 72 hours from being admitted to the hospital. If the patent’s hospital stay is over 72 hours, then Medicare will pay for up to 150 days in a skilled nursing facility for follow-on care and rehabilitation. If the stay is less than 72 hours subsequent care is paid for out-of-pocket by the patient.
The bonus approach to lowering Medicare costs is quite popular with the doctors and hospital because they get paid for providing no service. It is also popular with the subsequent heath care providers because they get paid the full retail rates, but it puts a huge drain on the personal resources of the patient.
I think the idea of paying bonuses for under-budget care is a very dangerous and potentially life-threatening practice. I don’t understand why we would want to pay doctors and hospitals more money for less treatment. Extra bonuses for providing fewer services are not required.
Maybe the sentence in the article was just poorly stated. Maybe the phrase, “The organization earns a bonus if the person’s health improves and” (emphasis added) wasn’t intended. Maybe what was intended was the phrase, “The organization keeps any savings if it manages to meet its health targets for less than the contracted amount.” These savings would undoubtedly be offset by other cases where it costs more than the contracted amount to meet the health care targets.