This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Health Care and Profits, a Poor Mix
By Eduardo Porter
The New York Times, January 8, 2013
Our reliance on private enterprise to provide the most essential services stems, in part, from a more narrow understanding of our collective responsibility to provide social goods. Private American health care has stood out for decades among industrial nations, where public universal coverage has long been considered a right of citizenship. But our faith in private solutions also draws on an ingrained belief that big government serves too many disparate objectives and must cater to too many conflicting interests to deliver services fairly and effectively.
Our trust appears undeserved, however. Our track record suggests that handing over responsibility for social goals to private enterprise is providing us with social goods of lower quality, distributed more inequitably and at a higher cost than if government delivered or paid for them directly.
From the high administrative costs incurred by health insurers to screen out sick patients to the array of expensive treatments prescribed by doctors who earn more money for every treatment they provide, our private health care industry provides perhaps the clearest illustration of how the profit motive can send incentives astray.
By many objective measures, the mostly private American system delivers worse value for money than every other in the developed world. We spend nearly 18 percent of the nation’s economic output on health care and still manage to leave tens of millions of Americans without adequate access to care.
Today, again, entitlements are at the center of the national debate. Our elected officials are consumed by slashing a budget deficit that is expected to balloon over coming decades. With both Democrats and Republicans unwilling to raise taxes on the middle class, the discussion is quickly boiling down to how deeply entitlements must be cut.
We may want to broaden the debate. The relevant question is how best we can serve our social needs at the lowest possible cost. One answer is that we have a lot of room to do better. Improving the delivery of social services like health care and pensions may be possible without increasing the burden on American families, simply by removing the profit motive from the equation.
Eduardo Porter’s NYT article on the poor mix of health care and profits resonated with PNHP members, and appropriately so. It reminds us that our mission is not only to provide an efficient health care financing system that would cover everyone equitably, but also to ensure that health care be provided as “a public service rather than bought and sold as a commodity” (from PNHP Mission Statement). Including passive investors in health care has moved the bottom line up as the top priority while relegating patient service to a footnote.
Growth In Medicare Spending Per Beneficiary Continues To Hit Historic Lows
By Richard Kronick and Rosa Po
U.S. Department of Health and Human Services, January 7, 2013
Medicare spending per beneficiary grew just 0.4% per capita in fiscal year 2012, continuing a pattern of very low growth in 2010 and 2011. Together with historically low projections of per capita growth from both the Congressional Budget Office and the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary, these statistics show that the Affordable Care Act has helped to set Medicare on a more sustainable path to keep its commitment to seniors and persons with disabilities today and well into the future. The success in reducing the rate of spending growth has been achieved without any reduction in benefits for beneficiaries. To the contrary, Medicare beneficiaries have gained access to additional benefits, such as increased coverage of preventive services and lower cost-sharing for prescription drugs.
At a time when politicians are ready to attack Medicare spending, this report on the projected slow growth in Medicare spending per beneficiary might seem to be useful in helping to keep the wolves away. But there are some very serious concerns behind these projections.
There has been some debate about whether the slowing is due to the recession and slow recovery, or if it is due to the implementation of some of the features of the Affordable Care Act, or if it simply due to changes in practice patterns related to evolving efforts of health care professionals to improve the practice of medicine. It is likely that all play some role.
Beyond dispute, however, is the fact that Medicare has been very effective in slowing the growth in spending though various forms of administered pricing, such as DRGs. The S&P Healthcare Economic Indices have shown that Medicare has been far more effective than the private commercial insurers in slowing the rate of growth in health care spending.
As this and other reports have shown, spending controls have not been at the cost of a reduction in benefits to Medicare beneficiaries; in fact benefits have expanded, though only modestly. Spending controls have been limited to slower payment growth for health care professionals and institutions. Although the Affordable Care Act has introduced measures to allegedly improve quality while controlling spending, the current efforts at implementation indicate that the emphasis is on spending restraint, with only token attention to quality measures – measures which are of dubious effectiveness anyway.
Thus there are two major fronts of attack over which we should be acutely concerned:
1) The government, under the banner of the Affordable Care Act, will continue to selectively ratchet down growth in Medicare spending while largely leaving the private sector plans alone. The expanding differential between lower public payment through the Medicare and Medicaid programs and higher private payments through the private insurance plans will cause more health care providers to abandon the public programs, with a consequent threat of impaired access for the beneficiaries of the public programs. As long as private insurers are there to provide a relief valve, there is a very real risk that the public programs will be underfunded. If private plans were eliminated, as a single payer the government would be obligated to ensure the solvency of the health care delivery system.
2) The current political push for austerity measures has made these public programs vulnerable to the “we-have-a-spending-problem-not-revenue-problem” cranks that populate our nation’s capitol. There is a genuine fear that some of the critical thinkers negotiating with the cranks will plea pragmatism as they trade away important features of our social programs.
We need the opposite approach. We need to reinforce Medicare and then expand it to cover everyone. Complacency with the current politically-expedient implementation of Affordable Care Act will lead us further down the path of no return, that is unless we’re ready for a revolution.
U.S. Health in International Perspective: Shorter Lives, Poorer Health
Institute of Medicine, January 2013
The United States is among the wealthiest nations in the world, but it is far from the healthiest. Although Americans’ life expectancy and health have improved over the past century, these gains have lagged behind those of other high-income countries. This health disadvantage prevails even though the United states spends far more per person on health care than any other nation.
To gain a better understanding of this problem, the National Institutes of Health (NIH) asked the National Research Council and the Institute of Medicine to convene a panel of experts to investigate potential reasons for the U.S. health disadvantage and to assess larger implications. The panel’s findings are detailed in its report, U.S. Health in International Perspective: Shorter Lives, Poorer Health.
The panel was struck by the gravity of its findings. For many years, Americans have been dying at younger ages than people in almost all other high-income countries. This disadvantage has been getting worse for three decades, especially among women.
When compared with the average of peer countries, Americans as a group fare worse in at least nine health areas:
* infant mortality and low birth weight
* injuries and homicides
* adolescent pregnancy and sexually transmitted infections
* HIV and AIDS
* drug-related deaths
* obesity and diabetes
* heart disease
* chronic lung disease
Many of these conditions have a particularly profound effect on young people, reducing the odds that Americans will live to age 50. And for those who reach age 50, these conditions contribute to poorer health and greater illness later in life.
The United States does enjoy a few health advantages when compared with peer countries, including lower cancer death rates and greater control of blood pressure and cholesterol levels. Americans who reach age 75 can expect to live longer than people in the peer countries. With these exceptions, however, other high-income countries outrank the United States on most measures.
Why are Americans so unhealthy?
The panel’s inquiry found multiple likely explanations for the U.S. health disadvantage:
* Health systems. Unlike its peer countries, the United States has a relatively large uninsured population and more limited access to primary care. Americans are more likely to find their health care inaccessible or unaffordable and to report lapses in the quality and safety of care outside of hospitals.
* Health behaviors. Although Americans are currently less likely to smoke and may drink alcohol less heavily than people in peer countries, they consume the most calories per person, have higher rates of drug abuse, are less likely to use seat belts, are involved in more traffic accidents that involve alcohol, and are more likely to use firearms in acts of violence.
* Social and economic conditions. Although the income of Americans is higher on average than in other countries, the United States also has higher levels of poverty (especially child poverty) and income inequality and lower rates of social mobility. Other countries are outpacing the United States in the education of young people, which also affects health. And Americans benefit less from safety net programs that can buffer the negative health effects of poverty and other social disadvantages.
* Physical environments. U.S. communities and the built environment are more likely than those in peer countries to be designed around automobiles, and this may discourage physical activity and contribute to obesity.
The tragedy is not that the United States is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary. Superior health outcomes in other nations show that Americans can also enjoy better health.
“U.S. Health in International Perspective: Shorter Lives, Poorer Health” – Full 405 page report can be downloaded for free at this link:
The United States is sick, literally and figuratively. We have the most expensive health care system, yet the worst health outcomes of the wealthier nations. The failures are not only with our health system but with much broader sociopolitical institutions.
In response to these glaring deficiencies, this NRC/IOM report places an emphasis on further research to better define the problem and identify interventions that would help. Research is fine, but we do not need to wait any longer when so many of the deficiencies our already in our face.
The brief paragraph above on health systems confirms the pressing need for an effective universal insurance system, along with an expansion of our primary care infrastructure. Enacting the PNHP single payer model would finally set us in the right direction toward a high-performance health care system.
The social and economic conditions, physical environments, and health behaviors demonstrate a crying need for much more effective sociopolitical public policies. Not only do we need a reinforcement of our public health system, we also need greater public action in education, community planning, and especially responsible government policies to correct the gut-wrenching social and economic injustices that permeate our society.
From the opponents of reform we continue to hear that we have the greatest health care system in the world and that we have the very best health outcomes. Download this highly credible report so that you will have it readily available to expose these liars for what they are. Also use it to educate politicians on the broad spectrum of urgent public policies that we so desperately need.
And while we’re at it, we need to fire the politicians who are promulgating these cruel lies.
Retention of Rural Family Physicians After 20–25 Years: Outcomes of a Comprehensive Medical School Rural Program
By Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham, MD and Abbie J. Santana, MSPH
Journal of the American Board of Family Medicine, January-February 2013 vol. 26 no. 124-27
“The shortage of primary care physicians in rural areas, especially family physicians, has been a serious problem for decades, with major implications in access to health care for a substantial proportion of the US population….Retention is a key component of the rural physician supply, in part because it has a multifold impact on the rural workforce; for example, one physician practicing in the same rural area during a 35-year career has a similar impact as 5 physicians who practice for an average duration of 7 years…”.
The authors describe the impact of the Physician Shortage Area Program (PSAP), a special program at the Jefferson Medical College of Pennsylvania that “…recruits and selects medical school applicants that have grown up or lived in a rural area or small town for a substantial portion of their life after college and who were committed to practicing family medicine in a similar area” and provides them with other experiences during medical school. “Of the 37 PSAP graduates [from 1978-86] who originally entered rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 (including 5 in adjacent counties). Comparable data for non-PSAP graduates showed that 24 of 52 (46.2%; P = .02) were in the same rural area (including 5 in adjacent counties).”
These are really good results, demonstrating that the PSAP at Jefferson is effective in training students who not only enter rural practice but remain in it over time. And, they indicate, “PSAP outcomes are similar to those of the 5 other RPs with published outcomes.”
The Redistribution Of Graduate Medical Education Positions In 2005 Failed To Boost Primary Care Or Rural Training
By Candice Chen, Imam Xierali, Katie Piwnica-Worms, and Robert Phillips
Health Affairs, January 2013, 32(1):102-110
ABSTRACT Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation’s hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs…
Note: Today’s message on the shortage of rural family physicians was prepared by Joshua Freeman, MD, Professor and Chair of the Department of Family Medicine at the University of Kansas Medical Center. He also writes a highly commendable weekly blog on Medicine and Social Justice, accessible at: http://www.medicinesocialjustice.blogspot.com/
What is wrong with this picture? Taken together, these studies show us that despite the fact that we know what strategies work to increase the number of rural family physicians, they are not being truly embraced by policymakers at either the medical student or resident level. The PSAP and similar programs are effective, but are far too small. Twenty percent of Americans live in rural areas, but over the 9 year period studied in which 37 PSAP graduates entered rural practice, Jefferson Medical College, which has an enrollment of over 250 students a year, thus graduated over 2200 students. This is at a school with one of the nation’s most successful programs; at many schools it is much worse. At the graduate training (residency) level, only 3% of redistributed positions went to rural training, despite that being a primary intent of the policy.
The problem is that there are powerful forces whose interests conflict with these goals. Medical schools and their faculties are often more interested in replicating themselves by recruiting students with high grades who will enter medical subspecialties or research than they are in recruiting students who will meet the most urgent healthcare needs of our nation. The same motivation affects graduate medical education, where most training positions are not in primary care, and the vast majority are in urban centers. In addition, hospitals, which are the main sponsors of residency training, tend to be more focused on their own interests than the community’s. They therefore prefer residents and fellows in specialties that can make them more money or lower their costs rather than those training to be rural primary care providers.
At the medical student level, programs like PSAP need to be dramatically increased, even if taking more students committed to rural practice decreases the number admitted who have more “traditional” strengths. At the residency level, loopholes must be closed so that new residency positions intended to create more rural primary care doctors are not instead used for other, more popular or more financially desirable, specialties. To the extent that medical schools and hospitals can “game” the system, they will, so policymakers must recognize these tendencies and explicitly block them.
Idaho governor: Eliminate personal property tax
By The Associated Press
The Examiner, January 7, 2013
(Idaho Gov. C.L. “Butch”) Otter is… not immediately endorsing the expansion of Idaho’s Medicaid coverage to include more than 100,000 additional low-income residents whose bills would largely be paid for with funding from Washington.
Instead, Otter now plans to spend the next year studying how Idaho’s federal-state funded health care system for the poor can be revamped to make it less focused on paying fees for services and more on requiring Medicaid beneficiaries to take more responsibility for their health.
Wow! What a great idea! Instead of paying for essential health care services for Medicaid patients, let’s make those people “take more responsibility for their health.” We could expand the same concept to everyone, including Gov. Otter, and then our health care spending problem would be solved.
Please excuse the abject frivolity of this comment, but what I really want to know is, what has happened to compassion in America?
National Health Spending In 2011: Overall Growth Remains Low, But Some Payers And Services Show Signs Of Acceleration
By Micah Hartman, Anne B. Martin, Joseph Benson, Aaron Catlin, the National Health Expenditure Accounts Team
Health Affairs, January 2013
In 2011 US health care spending grew 3.9 percent to reach $2.7 trillion, marking the third consecutive year of relatively slow growth. Growth in national health spending closely tracked growth in nominal gross domestic product (GDP) in 2010 and 2011, and health spending as a share of GDP remained stable from 2009 through 2011, at 17.9 percent. Even as growth in spending at the national level has remained stable, personal health care spending growth accelerated in 2011 (from 3.7 percent to 4.1 percent), in part because of faster growth in spending for prescription drugs and physician and clinical services. There were also divergent trends in spending growth in 2011 depending on the payment source: Medicaid spending growth slowed, while growth in Medicare, private health insurance, and out-of-pocket spending accelerated. Overall, there was relatively slow growth in incomes, jobs, and GDP in 2011, which raises questions about whether US health care spending will rebound over the next few years as it typically has after past economic downturns.
Faster growth in 2011 reflects higher cost sharing for group health insurance plans and increased enrollment in consumer-directed health plans that have higher deductibles, copayments, or both. Additionally, increases in the number of uninsured people over the past few years had resulted in more direct out-of-pocket spending than might otherwise have been the case.
Slower growth in Medicaid spending reflected states’ efforts to control expenditure growth as the enhanced federal matching rates expired and state revenues continued to increase at a slow rate. With fewer federal matching dollars and continued pressure on their budgets, some states implemented cost-control measures that included provider reimbursement reductions, eligibility restrictions, benefit reductions, and increased cost sharing.
Medicare spending for physicians’ services also accelerated in 2011, increasing 7.6 percent compared to 3.2 percent growth in 2010, even as the increase in physicians’ fees was lower in 2011. Faster fee-for-service spending growth for physician services, therefore, is attributable to a rebound in the volume and intensity of services after unusually slow growth in 2009 and 2010.
In 2011 national health spending increased 3.9 percent—the same rate of growth experienced in 2009 and 2010. The recent recession had an immediate and noticeable effect on the health sector because of high unemployment, loss of private health insurance coverage, and a reduction in the resources available to pay for health care. All of these factors contributed to historically low growth in aggregate health spending during 2009–11.
In 2011, however, there were some signs of change, evident in faster growth in nonprice factors such as the use and intensity of health care goods and services. Additionally, insurance coverage expanded in 2011 for dependents under age twenty-six, and overall private health insurance coverage did not decline as had been experienced in the prior three years.
Nonetheless, economic, income, and job growth in 2011 was modest and less than might normally be expected during an economic recovery. This fact raises questions about whether the near future will hold the type of rebound in health care spending typically seen a few years after a downturn. Data for the years 2012 and 2013 will provide important indications of the state of the US health system as the major insurance expansions associated with the Affordable Care Act grow nearer on the horizon.
National Health Expenditures (NHE), 2011
$2,700.7 – NHE, billions
17.9 – NHE as percent of GDP
$8,680 – NHE per capita
In 2011, health care costs grew at the same rate as the growth in the gross domestic product (GDP). Thus the recent severe recession and slow recovery, plus the initial phase of implementation of the Affordable Care Act, have not had a major impact on the growth of health care spending.
At a time when Medicare spending is under close scrutiny, especially for potential opportunities to reduce the federal deficit, the fact that the volume and intensity of services have increased disproportionately warrants scrutiny. Physician behavior may drive reforms that could have other consequences, favorable, or more likely unfavorable.
Shifts in Medicaid spending should raise red flags. More of the costs are being shifted to states at a time that they are facing budget crises. States are responding with measures such as provider reimbursement reductions, eligibility restrictions, benefit reductions, and increased cost sharing. These changes can result in greater impairment of access just at a time when massive enrollment increases are anticipated. This can have very serious consequences for a welfare program that is already critically underfunded.
Out-of-pocket spending is increasing, especially due to an increase in enrollment in consumer-directed health plans with high deductibles – a market strategy to reduce health care spending by erecting financial barriers to care.
Although reducing the increase in health expenditures down to the rate of increase in the GDP sounds like good news, the trends behind the numbers should have us all deeply concerned.
Need I say, a single payer…
The Complexities of Comparing Medicare Choices
By Uwe E. Reinhardt
The New York Times, January 4, 2013
The roughly 50 million Americans covered by the federal Medicare program have a choice of receiving their benefits under the traditional, free-choice, fee-for-service Medicare program or from a private, managed-care Medicare Advantage plan. The private plans have a steadily increasing number of enrollees — currently 13 million, or 27 percent of beneficiaries.
A fundamental question that has engaged health-policy researchers and commentators for some time is whether coverage of Medicare’s standard benefit package under Medicare Advantage plans is cheaper or more expensive than it is under traditional fee-for-service Medicare.
The answer is yes.
At the risk of going over ground already covered in Economix and in the scholarly literature on the subject, this answer may warrant some explanation.
(At this point, Professor Reinhardt provides an excellent explanation, with numerous helpful links, of the complexities in pricing of the Medicare Advantage plans. If you wish to understand this topic better, and understand why his answer is “yes,” the full article is well worth reading. DMc)
The only correct “yes” is that Medicare Advantage plans are more expensive. The extra cost is invisible to beneficiaries because it is borne by taxpayers. The plans can be considered less expensive only if you believe that it is fair for taxpayers to provide the private plans with extra funds for their ability to cheat through well documented favorable selection (HSR DOI: 10.1111/1475-6773.12006) and the gaming of risk adjustment (GAO 12-51, Jan 12, 2012 and NBER Working Paper No. 16977).
While we’re at it, we should also mention the profound administrative waste of not only the Medicare Advantage plans but also the private Medigap plans (the latter paid by excessive premiums), and the administrative burden that they place on the health care delivery system.
Congress should stop wasting our public funds in these efforts to push us into private plans. If they took the same public and private funds already being spent and used those to improve the benefits of the traditional Medicare program (especially reducing cost sharing and capping out-of-pocket spending), then we would have an even better Medicare program. In fact, it could become the basis of the Improved Medicare for All that many of us long for but has remained elusive to a large extent because of the elevated stature that the private insurance industry holds in the Halls of Congress.
Sen. Kirk returns to Senate after year-long recovery from stroke
By Emily Goodin
The Hill, January 3, 2013
Sen. Mark Kirk (R-Ill.) returned to the Senate on Thursday after nearly a year’s absence.
Kirk, who had a stroke in January 2012, walked up the Capitol steps holding a cane and with the help of Vice President Biden and Sen. Joe Manchin (D-W.Va.).
Cheers rang out as Kirk began his climb. He walked into the Capitol shortly before noon, when the 113th Congress was gaveled into session.
Sen. Mark Kirk’s message to stroke victims: ‘Don’t give up’
By Natahsa Korecki
Chicago Sun-Times, January 2, 2013
(Sen. Mark Kirk) spoke with the Sun-Times in a sit-down interview in the U.S. Capitol one day before he plans his dramatic climb up the Capitol steps. He offered a new perspective on the Illinois Medicaid program and what it offers to those with low incomes.
He does plan to take a closer look at funding of the Illinois Medicaid program for those with no income who suffer a stroke, he said. In general, a person on Medicaid in Illinois would be allowed 11 rehab visits, he said.
“Had I been limited to that, I would have had no chance to recover like I did,” Kirk said. “So unlike before suffering the stroke, I’m much more focused on Medicaid and what my fellow citizens face.”
Kirk has the same federal health-care coverage available to other federal employees. He has incurred major out-of-pocket expenses, which have affected his savings and retirement, sources familiar with Kirk’s situation said.
It was quite moving watching the live C-SPAN broadcast of Sen. Mark Kirk today, climbing the Capitol steps to the resounding ovation given to him by his colleagues in the Senate. After his severely debilitating stroke, his message to other stroke victims is, “Don’t give up,” and he didn’t.
He has had a year to think about stroke victims on Medicaid in Illinois and what the limit of a total of eleven rehabilitation visits must mean to them. This is clearly an inhumane public policy that must be changed.
But what about all of the other patients with major medical problems who do not get the care that they need because they are uninsured, or Medicaid doesn’t provide adequate access, or private insurance…
What about private insurance? Sen. Kirk has coverage through the Federal Employees Health Benefits Program (FEHBP) – a menu of private health plans. That is about as good coverage as you can get today, yet with the major out-of-pocket expenses, it has not protected his savings and retirement.
We have a much bigger problem in health care other than simply trying to figure out how we can get Medicaid patients adequate rehabilitative services after a stroke.
If only Sen. Kirk’s colleagues in the Senate and House could learn from his travails. They might begin to consider that we really do need a comprehensive health care system that takes care of all of us – an Improved Medicare for All.
In the battle for reform, remember Sen. Kirk’s words, “Don’t give up.”
Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories
By Katherine M. Flegal, PhD; Brian K. Kit, MD; Heather Orpana, PhD; Barry I. Graubard, PhD
JAMA, January 2, 2013
In this study, we used the National Heart, Lung, and Blood Institute’s terminology with categories of underweight (BMI of <18.5), normal weight (BMI of 18.5-<25), overweight (BMI of 25-<30), and obesity (BMI of ≥30). Grade 1 obesity was defined as a BMI of 30 to less than 35; grade 2 obesity, a BMI of 35 to less than 40; and grade 3 obesity, a BMI of 40 or greater.
The most recent data from the United States show that almost 40% of adult men and almost 30% of adult women fall into the overweight category with a BMI of 25 to less than 30.
In the United States and Canada, more than half of those who are obese fall into the grade 1 category (BMI of 30-<35).
According to the results presented herein, overweight (defined as a BMI of 25-<30) is associated with significantly lower mortality overall relative to the normal weight category with an overall summary HR (hazard ratio) of 0.94.
The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity.
Obesity Update 2012
16.9% – All OECD nations
33.8% – United States
NIH Body Mass Index (BMI) calculator:
If you are amongst the 30 to 40 percent of Americans who are overweight, you likely are resolving at the beginning of this year to finally do something about your weight. The good news is that you don’t have to. Being overweight (BMI 25->30) is associated with a mortality rate that is 6 percent lower than that for normal weight. Happy New Year.
In fact, even you fall into the category of grade 1 obesity (BMI 30->35), you still have no increase in mortality due to your weight alone. (You can use the BMI calculator at the NIH link above to determine where you fall.)
This, of course, does not mean that you are free to abandon healthy habits. Good nutrition and regular exercise are still important. To increase compliance, just be sure that the exercise program that you select is enjoyable and that it is easily integrated into your daily regimen. Same for selecting nutritious food.
Nevertheless, grade 2 and 3 obesity (BMI 35 or greater) are associated with increased mortality, so prevention and intervention are important. But is that primarily a responsibility of providers in the health care delivery system? Telling people to exercise and eat well is great advice, but it is not very effective, especially since everyone already knows that.
Prevention of obesity is more a function of society at large. Health education, school nutrition programs, responsible food product design by the industry, planning of communities to promote physical activity such as walking, biking or hiking, and including breaks for physical activity for those in sedentary occupations are types of measures that would take place out in the community rather than within the health care delivery system.
However, Grade 2 and 3 obesity do place a burden on the health care delivery system because of their association with chronic diseases. The policy community correctly emphasizes that the delivery system must provide chronic disease services. But that isn’t new. That is what primary care professionals have been doing all along.
What is a problem is that there has been a misplaced emphasis on chronic disease management as if that were a new solution to health care cost and quality issues. This has led to ineffectual tinkering by promoting nebulous models such as accountable care organizations. The efforts would be better directed toward reinforcing the primary care infrastructure.
If we really do want to improve the management of health care spending while improving quality we need to implement fundamental structural reform of our health care financing system by enacting a single payer, improved Medicare for all. It’s a system that would work great for all of us, even for those of us who are overweight.
In today’s qotd message, “Overweight,” I wrote, “Being overweight (BMI 25->30) is associated with a mortality rate that is 6 percent lower than that for normal weight.”
The study demonstrated that the summary hazard ratio (HR) for overweight compared to normal weight was 0.94. Thus, “The researchers found that the summary HRs indicated a 6 percent lower risk of death for overweight.” (The JAMA Network, January 1, 2013).
Videotaped Patient Stories: Impact on Medical Students’ Attitudes Regarding Healthcare for the Uninsured and Underinsured
By Richard Bruno, Allen Andrews, Brian Garvey, Kristin Huntoon, Rajarshi Mazumder, Jaleh Olson, David Sanders, Ilana Weinbaum, Paul Gorman
PLOS ONE, December 12, 2012
The attitudes of medical students toward the current United States healthcare system are not well described in the literature. A graded survey was developed to assess awareness and motivation toward the care of the uninsured and underinsured as well as the impact of a video intervention on these attitudes.
Medical students from nine medical schools were invited to participate and 895 completed the survey. Based on student coordinators’ estimates of their class size, reconciled with AAMC data, the response rate was 22.7%.
Our key findings were: (1) An overwhelming majority of medical students responding agree or strongly agree that everyone should have access to healthcare (96%) and that care should be provided regardless of ability to pay (85%); (2) two thirds of medical students responding agree or strongly agree that they have the personal responsibility to volunteer time for underserved patients (67.4%) and expressed a willingness to forgo a portion of income to provide healthcare to the underserved (66.1%); (3) 72% of respondents agree or strongly agree that publicly funded healthcare should be available to all citizens; (4) these values were strongly correlated with older age and intention to pursue primary care; (5) following a video montage of patient stories, respondents were more likely to indicate a personal desire to be involved in providing care to the underserved.
Ideas for Reform
Many students articulated a need for systemic healthcare reform. Most of those responding were in agreement that there were a number of issues within healthcare that need to be transformed, but they did not agree on any single plan for change. Respondents proposed ideas for reform ranging from changing payment structures, reducing cost of care, incentivizing healthy behaviors, reforming health insurance, to shifting toward a socialized or single payer approach to healthcare.
Physician vs. Government Responsibility
While several respondents stated that physicians across all specialties have a responsibility to care for the underserved, a large number of respondents felt strongly that physicians should choose whether or not to volunteer their time serving the uninsured and should not be obligated to do so. Others took this idea further, stating that physicians already sacrifice a lot and should always be compensated for their services. There seemed to be consensus that although physicians must play a role in caring for the underserved, they should not bear the entire responsibility of doing so. Respondents were split over whether this should be the responsibility of the government or not.
Healthcare as a Right
While a significant group of respondents felt that healthcare should be a right for all people, others felt that certain groups should be excluded or that individuals should have to take responsibility for their own health and payment for their own care. Several people stated specifically that healthcare is a right and that all people should have access regardless of their ability to pay, while others stated that healthcare should not be free for anyone and that everyone should be required to pay something. Other respondents specified that while everyone should have access to a basic level of care, those who can pay more should be able to purchase more or higher quality services. Some students clarified that specific groups, such as those who are not citizens or whose health problems are the result of unhealthy behaviors, should not receive care funded by taxpayer dollars. Several respondents also expressed concern that publicly funded care takes away personal responsibility and that people would likely take advantage of the system.
As the nation implements the provisions of the Affordable Care Act we can look forward to a future wherein, regardless of the structure of financing and the delivery system in health care, the altruistic students of today will demonstrate that we’ll be in good hands. They will make the system, regardless of how flawed, work for the benefit of everyone. Or can we be so assured?
This study does have some limitations. Less than one-fourth of students invited to participate actually responded. Because of the nature of the survey, there may have been a self-selection bias toward more altruistic students. A major feature of the study was to assess views before and after viewing a two minute video montage of patients telling their stories. Intuitively it seems unlikely that such a video could change moral and ethical perceptions developed over a lifetime, though 83 percent who viewed the video, as opposed to 77 percent who did not, expressed that they personally wanted to be involved in providing care to those without access (a “statistically significant” insignificant finding).
The key findings listed in the excerpts above superficially seem to be reassuring in that fairly large percentages of these self-selected students hold certain altruistic views. But what about the others? Do 4 percent of medical students really believe that not everyone should have access to health care? Do 15 percent believe that care should not be provided when there is no ability to pay? Do 33 percent believe that they have no personal responsibility to volunteer time for underserved patients? Are 34 percent unwilling to forgo a portion of income to provide health care to the underserved? Do 28 percent believe that publicly funded health care should not be available to all citizens?
You may be troubled as I was on reading the paragraph above titled “Healthcare is a Right.” It demonstrates that the opponents of solidarity and egalitarianism have been very effective in delivering their message that we are not all in this together, that we are each on our own. Particularly prominent are the observations expressing the view that everyone should be required to pay something, otherwise individuals would abandon personal responsibility and take advantage of the system. This, of course, represents the rhetoric of the advocates of consumer-directed health care (CDHC).
So what is wrong with CDHC? Steffie Woolhandler and David Himmelstein summarized it well in the following paragraph from their article, “Consumer Directed Healthcare: Except for the Healthy and Wealthy It’s Unwise.”
“Behind the rhetoric of consumer responsiveness and personal responsibility, CDHC sets in motion huge resource transfers. The sick and middle-aged pay more, whereas the young and healthy pay less. Women spend more, whereas men spend less. Workers bear more of the burden, whereas employers bear less. The poor skip vital care while the rich enjoy tax-free tummy tucks. And, as in every health reform in memory, bureaucrats and insurance firms walk off with an ever larger share of health dollars.”
The question then, are these particular medical students merely passively, naively and uncritically accepting the framing as presented by the CDHC advocates, or do they really believe in a social order that is defined by our individual efforts and rejects moral precepts of social justice? Or is that even a valid dichotomy? The rhetoric of this sector of the nation’s medical students is not very reassuring.
Happy New Year anyway.
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