two myths perpetuated about healthcare economics

[Surfer]

I got into it the other day with a few liberals about health care costs. They posted an article on facebook from the NYLies that started off with this quote, "IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality."

So I posted some non-partisan quotes from the CBO who stated, "For example, very premature births are more likely to be included in birth and mortality statistics in the United States than in several other industrialized countries that have lower infant mortality rates.... Low birthweight is the primary risk factor for infant mortality and most of the decline in neonatal mortality (deaths of infants less than 28 days old) in the United States since 1970 can be attributed to increased rates of survival among low-birthweight newborns. Indeed, comparisons with countries for which data are available suggest that low birthweight newborns have better chances of survival in the United States than elsewhere."

Then today I got into an argument with somebody from that crowd who had read my comments, and accused me of being "on the fringe" and "pretty radical." He was saying that "its obvious we could cut medical costs if we spent more on preventative care."

This "preventative care" idea is another myth. Its just not true, and numbers have borne that out. If you spend more on preventative care, you spend MORE on total care. Its really simple to understand, but liberals refuse to accept it and continue to perpetuate this crazy idea that you can spend more up front, prevent disease, and save money in the long run. Sounds great, except, its not true... People will still get heart disease, HTN, diabetes, and strokes, and still ultimately die from those diseases... it will just be later in their lives, when they have already exhausted more health care dollars.

Anyways... I love schooling liberals in medical economics, any thoughts on these two myths??

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[Surfer]

oh, and while i don't have the article in front of me right now, the myth of america having a low life-expectancy being somehow related to health care is also a lie. If you take traumas out of the mix, we have the #1 life expectancy IN THE WORLD. #1. Suicides, murders, and traffic accidents cause a lot of death in america (sadly), but are in no way related to the health care system... so those numbers shouldn't be included in the debate about how effective our system is at preventing, treating, and curing disease.

 

[bdrensch]

You can make a study support any position, if that's your goal. I agree completely.

Political involvement in health care is showing to be extremely dangerous. I believe It's incredibly foolish that anyone believes that increased public policy will improve health in the US, as if politicians know better than physicians or the hospital administration. Public policy is already strangling the incentives of being a physician, which is why careers like PA, NP, even pharmacists are replacing the role of physicians in health care. In reality most of those careers are just political creations to make of the increasing shortage of physicians, and the high risk associated with being one.

 

[bdrensch]

oh, and while i don't have the article in front of me right now, the myth of america having a low life-expectancy being somehow related to health care is also a lie. If you take traumas out of the mix, we have the #1 life expectancy IN THE WORLD. #1. Suicides, murders, and traffic accidents cause a lot of death in america (sadly), but are in no way related to the health care system... so those numbers shouldn't be included in the debate about how effective our system is at preventing, treating, and curing disease.

Great point!

 

[W222]

Then today I got into an argument with somebody from that crowd who had read my comments, and accused me of being "on the fringe" and "pretty radical." He was saying that "its obvious we could cut medical costs if we spent more on preventative care."

This "preventative care" idea is another myth. Its just not true, and numbers have borne that out. If you spend more on preventative care, you spend MORE on total care. Its really simple to understand, but liberals refuse to accept it and continue to perpetuate this crazy idea that you can spend more up front, prevent disease, and save money in the long run. Sounds great, except, its not true... People will still get heart disease, HTN, diabetes, and strokes, and still ultimately die from those diseases... it will just be later in their lives, when they have already exhausted more health care dollars.

Anyways... I love schooling liberals in medical economics, any thoughts on these two myths??

This has to be the stupidest thing I have ever read on here. True prevention is the answer; meaning changing poor habits that have become the norm in this country. No cigs, no fast food, exercise dail. Obviously, starting to treat insulin resistance in a morbidly obese smoker will likely fail. Prevention has to start long before the disease sets in. As shocking as you may find this statement, I have NEVER met a vegitarian marathon runner with heart disease, DM, or PVD. I have met plenty of 45 yo obese smokers with DM, PVD and s/p 3V CABG.

 

[Surfer]

This has to be the stupidest thing I have ever read on here. True prevention is the answer; meaning changing poor habits that have become the norm in this country. No cigs, no fast food, exercise dail. Obviously, starting to treat insulin resistance in a morbidly obese smoker will likely fail. Prevention has to start long before the disease sets in. As shocking as you may find this statement, I have NEVER met a vegitarian marathon runner with heart disease, DM, or PVD. I have met plenty of 45 yo obese smokers with DM, PVD and s/p 3V CABG.

So tell me then, what do all those vegan marathon runners die of?? You call my statement stupid, but it's true! Fact, you can't prevent disease generally speaking, but you can delay its onset.

 

[cchoukal]

Prevention means a lot of different things. If you spent money on social services, garbage collection, vaccinations, and preventing contamination of food and water, surely this prevents illness and is cost-effective. I think what surfer refers to is things like colonoscopies and mammograms, PSA screens, chest CTs for every lung nodule, etc. In medical school, one of our MPH's went through the numbers on these things specifically related to cancer and it always costs more to screen and catch early than NOT to screen and merely treat the cancer.

Of course, part of the cost savings is that more people will die (although we're often surprised to find out that things like screening PSAs and screening mammograms save neither money NOR lives).

Outside of cancer, though, I'd be very surprised if catching and treating things like DM and HTN didn't save money, and counseling on things like car seats, smoking cessation, gun safety, and other things that don't cost much are probably also cost effective.

Of course, for every year of life extended by these measures, that's another year the patient could be out there utilizing healthcare services. On the other hand, that's another year they could, theoretically, be working, contributing to society, and stimulating the economy by buying unnecessary material goods. These incidentals are never part of the calculations.

There was a really interesting editorial in the NYTimes form the authors of a study that showed that, while the US spends more on actual healthcare delivery, if you combined the cost of healthcare with the cost of certain social services thought to benefit health (WIC, welfare-to-work programs, services to get the homeless off the streets, and others), European countries spend more. You could interpret this to mean we're doing it right because we, overall, spend less, but given the equivocal or better outcomes they achieve, I'd rather interpret this to mean that targeted social spending probably prevents more costly illness.

 

[cchoukal]

So tell me then, what do all those vegan marathon runners die of?? You call my statement stupid, but it's true! Fact, you can't prevent disease generally speaking, but you can delay its onset.

I'm not sure I agree with this. While screening colonscopies/mammograms are not cost-effective as applied broadly at age-specified thresholds, surely you agree that polypectomy and lumpectomy, before local invasion, does actually prevent disease.

The trick is targeting these screening methods to those most at risk.

And there's vaccinations and infrastructure things like clean water that surely prevent disease. Perhaps you're referring more to the lifestyle diseases like DM2 (which I actually think is preventable), HTN, and CAD (which perhaps are not).

 

[deleted126335]

I got into it the other day with a few liberals about health care costs. They posted an article on facebook from the NYLies that started off with this quote, "IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality."

So I posted some non-partisan quotes from the CBO who stated, "For example, very premature births are more likely to be included in birth and mortality statistics in the United States than in several other industrialized countries that have lower infant mortality rates.... Low birthweight is the primary risk factor for infant mortality and most of the decline in neonatal mortality (deaths of infants less than 28 days old) in the United States since 1970 can be attributed to increased rates of survival among low-birthweight newborns. Indeed, comparisons with countries for which data are available suggest that low birthweight newborns have better chances of survival in the United States than elsewhere."

Then today I got into an argument with somebody from that crowd who had read my comments, and accused me of being "on the fringe" and "pretty radical." He was saying that "its obvious we could cut medical costs if we spent more on preventative care."

This "preventative care" idea is another myth. Its just not true, and numbers have borne that out. If you spend more on preventative care, you spend MORE on total care. Its really simple to understand, but liberals refuse to accept it and continue to perpetuate this crazy idea that you can spend more up front, prevent disease, and save money in the long run. Sounds great, except, its not true... People will still get heart disease, HTN, diabetes, and strokes, and still ultimately die from those diseases... it will just be later in their lives, when they have already exhausted more health care dollars.

Anyways... I love schooling liberals in medical economics, any thoughts on these two myths??

I have heard this also but haven't seen the data. Specifically that if you exclude trauma, obesity, prematurity, our life expectancy is pretty good. Is it fair to exclude all of the above-I think so as these are failings of American culture more than the health care delivery system.

 

[Orin]

The myth of america having a low life-expectancy being somehow related to health care is also a lie. If you take traumas out of the mix, we have the #1 life expectancy IN THE WORLD. #1. Suicides, murders, and traffic accidents cause a lot of death in america (sadly), but are in no way related to the health care system... so those numbers shouldn't be included in the debate about how effective our system is at preventing, treating, and curing disease.

I apologize, but I have to call shenanigans.

Trauma is not the number 1 cause of death or even a major cause. Accidents/Suicide/Homicide are numbers 5/10/15 respectively on the 2009 list. Combined, they make it to number 3, but are still way behind (> 3 fold) the number one and two causes of death, heart disease and cancer .

http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf

Furthermore, suicide/murder correlate with psychological problems, which is a major healthcare problem.

Regarding your infant mortality point, even if we accept the premise that premature births are primarily secondary to low birth weight, that would fall under the umbrella of maternal factor and prenatal healthcare. It highlights the problems with access and OB care. However the premise is no longer correct as the 2009 data suggest the more infant deaths are 2/2 "Congenital malformations, deformations, and chromosomal abnormalities" though it is only by ~10%.

The preventative care argument is interesting because it is so challenging to address costs you don't accrue. How do I sell you that investing $50 now will save you $1000 later? I think most of us would be able to logically deduce that from first principles, but showing you the monetary savings requires more work. More importantly, the preventative interventions actually need to work, like vaccines instead of a lifestyle change that requires compliance.

I feel that the most important aspects of the CBO reports on healthcare, even that one from 1992 you're quoting, is something we can all agree on: we spend a boatload of $$$ and are getting an inadequate return.

"More generally, despite spending more per capita than other countries, the United States lags behind lower-spending countries on several metrics, including life expectancy and infant mortality. Indeed, evidence suggests that a substantial share of spending on health care contributes little if anything to the overall health of the nation, but finding ways to reduce such spending without also affecting services that improve health will be difficult."

http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf

 

[jwk]

I have NEVER met a vegitarian marathon runner with heart disease, DM, or PVD.

I have - he had a quadruple bypass at age 27. Bad genes will get you !

 

[DavesNotHere]

I apologize, but I have to call shenanigans.


Furthermore, suicide/murder correlate with psychological problems, which is a major healthcare problem.

great point

Regarding your infant mortality point, even if we accept the premise that premature births are primarily secondary to low birth weight, that would fall under the umbrella of maternal factor and prenatal healthcare. It highlights the problems with access and OB care. However the premise is no longer correct as the 2009 data suggest the more infant deaths are 2/2 "Congenital malformations, deformations, and chromosomal abnormalities" though it is only by ~10%.

While this is true, the OP (and obviously correct me if i'm wrong) i think was just saying that the statistic given that America has a poor/worst neonatal mortality rate is an unfair statement because other countries are presenting skewed data and not including low-birth weight neonates which is throwing off the numbers

 

[deleted126335]

I apologize, but I have to call shenanigans.

Trauma is not the number 1 cause of death or even a major cause. Accidents/Suicide/Homicide are numbers 5/10/15 respectively on the 2009 list. Combined, they make it to number 3, but are still way behind (> 3 fold) the number one and two causes of death, heart disease and cancer .

http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf

Furthermore, suicide/murder correlate with psychological problems, which is a major healthcare problem.


http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf

Again, Is this an indictment of the US healthcare system or US culture?

 

[jwk]

It highlights the problems with access and OB care.

In a lot of areas, that's simply BS. The care is there - but for whatever reason, some people simply choose not to use it. It's the old " you can lead a horse to water but you can't make him drink" concept. Transportation, OB/pre-natal care, meds, etc. are all available at little or no cost, especially in larger towns and cities with heavier population densities. Sadly, for whatever reason, some just don't care. Yeah, I know I'm cynical - but I've also been in the medical field for more than 35 years.

 

[Surfer]

In a lot of areas, that's simply BS. The care is there - but for whatever reason, some people simply choose not to use it. It's the old " you can lead a horse to water but you can't make him drink" concept. Transportation, OB/pre-natal care, meds, etc. are all available at little or no cost, especially in larger towns and cities with heavier population densities. Sadly, for whatever reason, some just don't care. Yeah, I know I'm cynical - but I've also been in the medical field for more than 35 years.

Exactly. The programs are there. What's not there is the individual responsibility. These moms will simply not show up to prenatal visits, even though they are free to them. They will also continue to smoke crack and shoot up heroin, simply because they want to. Its not an indictment on our health care system, its an indictment on our culture (not my culture, mind you, their culture of no-responsibility/consequences).

 

[Surfer]

I apologize, but I have to call shenanigans.

Trauma is not the number 1 cause of death or even a major cause. Accidents/Suicide/Homicide are numbers 5/10/15 respectively on the 2009 list. Combined, they make it to number 3, but are still way behind (> 3 fold) the number one and two causes of death, heart disease and cancer .

http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf

Furthermore, suicide/murder correlate with psychological problems, which is a major healthcare problem.

Regarding your infant mortality point, even if we accept the premise that premature births are primarily secondary to low birth weight, that would fall under the umbrella of maternal factor and prenatal healthcare. It highlights the problems with access and OB care. However the premise is no longer correct as the 2009 data suggest the more infant deaths are 2/2 "Congenital malformations, deformations, and chromosomal abnormalities" though it is only by ~10%.

The preventative care argument is interesting because it is so challenging to address costs you don't accrue. How do I sell you that investing $50 now will save you $1000 later? I think most of us would be able to logically deduce that from first principles, but showing you the monetary savings requires more work. More importantly, the preventative interventions actually need to work, like vaccines instead of a lifestyle change that requires compliance.

I feel that the most important aspects of the CBO reports on healthcare, even that one from 1992 you're quoting, is something we can all agree on: we spend a boatload of $$$ and are getting an inadequate return.

"More generally, despite spending more per capita than other countries, the United States lags behind lower-spending countries on several metrics, including life expectancy and infant mortality. Indeed, evidence suggests that a substantial share of spending on health care contributes little if anything to the overall health of the nation, but finding ways to reduce such spending without also affecting services that improve health will be difficult."

http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf

Ummm, where did i say trauma was the #1 cause of death? The point is, by excluding deaths from trauma from all life-expectancy statistics, the USA comes out #1 in terms of overall life expectancy.

Also, you should know that for young people (teens and young adults), trauma is the #1 cause of death in this age group. Killing a bunch of teens in car accidents, gang shootings, or suicides, very definitely skews the life-expectancy downward. And you can't tell me gang-shootings and car accidents have ANYTHING to do with our health care system, because they don't. They are simply cultural factors. You think if you could get the gang-bangers into a family practice clinic for a checkup they'd stop shooting each other?? Why do liberals insist on refusing to acknowledge when their ideas are simply incorrect?

 

[Orin]

The point is, by excluding deaths from trauma from all life-expectancy statistics, the USA comes out #1 in terms of overall life expectancy.

Even if I accept your point, there is no way we are doing that much better to justify spending that much more money.

More importantly to me though, I think the math is incorrect.

This argument has been raised for a long time and is based on poorly presented information by Ohsfeldt and Schneider. My point is that removing a small number of outliers isn't going to suddenly raise the life expectancy 5 or 10 years. Again, while trauma /suicide is the leading cause of mortality in certain populations, overall it is still relatively small.

http://theincidentaleconomist.com/wordpress/how-flawed-is-life-expectancy/

Even if you look just at life expectancy at age of 65, we still are not getting an adequate return for our spending.

The culture debate is another problem, and I don't know enough to discuss the role of healthcare in shaping the culture.

 

[DHT]

we still are not getting an adequate return for our spending.

This is our biggest problem as I see it.

I completely agree with the OP's comments (but I don't know if I would go as far to say we are #1).

Screening is not cost effective at all. The cheapest way to die is to die instantly from a disease you didn't even know you had. Screening not only allows you to catch diseases early and treat them with increased success, but then the patient goes on living, utilizing healthcare dollars, and then being diagnosed with another disease down the line that we also pay to treat. That does NOT mean I don't think screening is good, but I will not pretend to think that improved screening will save money.

I also agree with the life expectancy issue with points already mentioned. I wouldn't expect us to get to #1 by controlling for trauma/suicide/infant mortality, but I would certainly expect us to be closer to the other top performers.

USA also has a few unique issues that they have to deal with:
We have by FAR the most aggressive malpractice environment in the world. This results in defensive medicine, through increased utilization of expensive imaging and tests with low likelihood to benefit the patient or change their care. Hospitals and doctors have to spend a small fortune to protect themselves from lawsuits. There are incredible settlements/verdicts for pain and suffering in states without caps on non-economic damages. In the USA you can sue for just about anything and frivolous lawsuits are RAMPANT. All of the costs of our litigious environment are passed on to the consumer, all of which would have no positive impact on outcomes.

Another problem we face is that we have one of the fattest laziest populations in the world. Our prevalence of diabetes is much higher than any of the other countries we are commonly compared to for healthcare outcomes. There is only so much that modern medicine can do. A lifetime of abusing your body can not be outdone by all the high-tech healthcare in the world.

We also have trouble in this country rationing care when it is futile. I think one thing other countries do better than America is have frank end-of-life conversations with families. I think a huge amount of savings could be accomplished in this area in America, but as it is now, we pull out all the stops for far more than we should. Perfect example is dialysis utilization in America compared to other developed countries.

New technology: America enjoys high-tech healthcare. New and high-tech interventions are MUCH more expensive for marginal improvement. I would not expect this to be cost-effective, but if it were me, I would probably want it for myself.

Cancer Survival: The US has the highest breast and prostate cancer survival rates in the world (despite the very large underserved inner city population we have). People people who survive cancer go on to utilize healthcare resources throughout the remainder of their lives. Although a positive statistic, it is one that carries with it downstream costs which add to our healthcare expenditures.

Basically, I am just trying to say that comparing the healthcare system of two countries is just as useless as comparing the healthcare in 2 states (ex: Utah vs Mississippi). The populations are too different and have very different needs. There are too many confounding variables that go into the many statistics that people try to use for comparisons, that any attempt to do so will not be valid. Statistics never tell the whole story and this is especially true in healthcare. I think focusing our efforts on sources of waste is a much more valuable use of time and energy than trying to compare the US to other countries. I do think there are plenty of ways to improve our healthcare system, but I definitely do not think we are as bad as the media tries to portray.

 

[W222]

Then today I got into an argument with somebody from that crowd who had read my comments, and accused me of being "on the fringe" and "pretty radical." He was saying that "its obvious we could cut medical costs if we spent more on preventative care."

This "preventative care" idea is another myth. Its just not true, and numbers have borne that out. If you spend more on preventative care, you spend MORE on total care. Its really simple to understand, but liberals refuse to accept it and continue to perpetuate this crazy idea that you can spend more up front, prevent disease, and save money in the long run. Sounds great, except, its not true... People will still get heart disease, HTN, diabetes, and strokes, and still ultimately die from those diseases... it will just be later in their lives, when they have already exhausted more health care dollars.

Anyways... I love schooling liberals in medical economics, any thoughts on these two myths??

Again, I will go on to say this is the stupidest thing I have ever read. Essentially, you are saying that by preventing someone's death from say colon cancer at 50 through screening then you are damning the system because that person will then live longer and use more resources. Thats a F@CKING obvious statement. Your argument takes on the essence of complete BS when you take certain diseases and certain examples; take DM or HTN for instance. Screening people for HTN or DM allows for early diagnosis and prevention of longterm sequelae that will cost the system far more in the long run; unless of course you are proposing just giving them the old KCl injection right after diagnosis.

And this has nothing to do with liberals vs conservatives. There are plenty of fat conservatives that are sucking the system dry because they can't step away from the table or put the cigs down. I have heard it said that " hey, they have great private insurance that they pay for," but that argument fails because my premiums go up to pay for their poor lifesytle choices.

 

[DHT]

Again, I will go on to say this is the stupidest thing I have ever read. Essentially, you are saying that by preventing someone's death from say colon cancer at 50 through screening then you are damning the system because that person will then live longer and use more resources. Thats a F@CKING obvious statement. Your argument takes on the essence of complete BS when you take certain diseases and certain examples; take DM or HTN for instance. Screening people for HTN or DM allows for early diagnosis and prevention of longterm sequelae that will cost the system far more in the long run; unless of course you are proposing just giving them the old KCl injection right after diagnosis.

And this has nothing to do with liberals vs conservatives. There are plenty of fat conservatives that are sucking the system dry because they can't step away from the table or put the cigs down. I have heard it said that " hey, they have great private insurance that they pays for," but that argument fails because my premiums go up to pay for their poor lifesytle choices.

Well you started of strong by suggesting that the answer is primary prevention (ie. lifestyle changes before the disease sets in).

Unfortunately, now you sound like a pre-med. Anyone in medicine knows that treating chronic diseases like DM or HTN only delays the sequelae. It does not prevent them all together. No one denies that screening is worth doing to improve the quality of life of the population, but it certainly does not save healthcare dollars (anyone with a basic understanding of epidemiology knows this - it is often touched on in medical school). Orin and cchoukal have the only argument that supports screening MAY be cost effect: if you delay the sequelae, you keep people in the workforce longer which adds to the economy and delays disability. I don't know the exact numbers on this, but I would still be surprised if screening resulted in a net savings (either way, increased productivity and less disability would not be reflected in the healthcare spending metric). Cancer screening is most definitely not cost effective* - but certainly something I would want done for my population.

*Just to clarify, cancer screening is cost effective for the single disease that was detected early. However, throughout the survivors life, they continue accumulate healthcare costs, may get cancer again, and ultimately die from another disease process, all costs that would have been avoided if they had not survived the first cancer (I have to emphasize I think cancer screening is great, it just isn't cheap).

 

[vector2]

No one denies that screening is worth doing to improve the quality of life of the population, but it certainly does not save healthcare dollars (anyone with a basic understanding of epidemiology knows this - it is often touched on in medical school). Orin and cchoukal have the only argument that supports screening MAY be cost effect: if you delay the sequelae, you keep people in the workforce longer which adds to the economy and delays disability. I don't know the exact numbers on this, but I would still be surprised if screening resulted in a net savings (either way, increased productivity and less disability would not be reflected in the healthcare spending metric).

http://care.diabetesjournals.org/content/25/4/684.full.pdf

Diabetes Care. 2002 Apr;25(4):684-9.

Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria.

Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R.
Source
Care Coordination Program, Geisinger Health Plan, Danville, Pennsylvania 17822-3020, USA. [email protected]
Abstract

OBJECTIVE:
Little is known about the impact of disease management programs on medical costs for patients with diabetes. This study compared health care costs for patients who fulfilled health employer data and information set (HEDIS) criteria for diabetes and were in a health maintenance organization (HMO)-sponsored disease management program with costs for those not in disease management.

RESEARCH DESIGN AND METHODS:
We retrospectively examined paid health care claims and other measures of health care use over 2 years among 6,799 continuously enrolled Geisinger Health Plan patients who fulfilled HEDIS criteria for diabetes. Two groups were compared: those who were enrolled in an opt-in disease management program and those who were not enrolled. We also compared HEDIS data on HbA(1c) testing, percent not in control, lipid testing, diabetic eye screening, and kidney disease screening. All HEDIS measures were based on a hybrid method of claims and chart audits, except for percent not in control, which was based on chart audits only.

RESULTS:
Of 6,799 patients fulfilling HEDIS criteria for the diagnosis of diabetes, 3,118 (45.9%) patients were enrolled in a disease management program (program), and 3,681 (54.1%) were not enrolled (nonprogram). Both groups had similar male-to-female ratios, and the program patients were 1.4 years younger than the nonprogram patients. Per member per month paid claims averaged 394.62 dollars for program patients compared with 502.48 dollars for nonprogram patients (P < 0.05). This difference was accompanied by lower inpatient health care use in program patients (mean of 0.12 admissions per patient per year and 0.56 inpatient days per patient per year) than in nonprogram patients (0.16 and 0.98, P < 0.05 for both measures). Program patients experienced fewer emergency room visits (0.49 per member per year) than nonprogram patients (0.56) but had a higher number of primary care visits (8.36 vs. 7.78, P < 0.05 for both measures). Except for emergency room visits, these differences remained statistically significant after controlling for age, sex, HMO enrollment duration, presence of a pharmacy benefit, and insurance type. Program patients also achieved higher HEDIS scores for HbA(1c) testing as well as for lipid, eye, and kidney screenings (96.6, 91.1, 79.1, and 68.5% among program patients versus 83.8, 77.6, 64.9, and 39.3% among nonprogram patients, P < 0.05 for all measures). Among 1,074 patients with HbA(1c) levels measured in a HEDIS chart audit, 35 of 526 (6.7%) program patients had a level >9.5%, as compared with 79 of 548 (14.4%) nonprogram patients.

CONCLUSIONS:
In this HMO, an opt-in disease management program appeared to be associated with a significant reduction in health care costs and other measures of health care use. There was also a simultaneous improvement in HEDIS measures of quality care. These data suggest that disease management may result in savings for sponsored managed care organizations and that improvements in HEDIS measures are not necessarily associated with increased medical costs.

 

[DHT]

http://care.diabetesjournals.org/content/25/4/684.full.pdf

Diabetes Care. 2002 Apr;25(4):684-9.

Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria.

Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R.
Source
Care Coordination Program, Geisinger Health Plan, Danville, Pennsylvania 17822-3020, USA. [email protected]
Abstract

OBJECTIVE:
Little is known about the impact of disease management programs on medical costs for patients with diabetes. This study compared health care costs for patients who fulfilled health employer data and information set (HEDIS) criteria for diabetes and were in a health maintenance organization (HMO)-sponsored disease management program with costs for those not in disease management.

RESEARCH DESIGN AND METHODS:
We retrospectively examined paid health care claims and other measures of health care use over 2 years among 6,799 continuously enrolled Geisinger Health Plan patients who fulfilled HEDIS criteria for diabetes. Two groups were compared: those who were enrolled in an opt-in disease management program and those who were not enrolled. We also compared HEDIS data on HbA(1c) testing, percent not in control, lipid testing, diabetic eye screening, and kidney disease screening. All HEDIS measures were based on a hybrid method of claims and chart audits, except for percent not in control, which was based on chart audits only.

RESULTS:
Of 6,799 patients fulfilling HEDIS criteria for the diagnosis of diabetes, 3,118 (45.9%) patients were enrolled in a disease management program (program), and 3,681 (54.1%) were not enrolled (nonprogram). Both groups had similar male-to-female ratios, and the program patients were 1.4 years younger than the nonprogram patients. Per member per month paid claims averaged 394.62 dollars for program patients compared with 502.48 dollars for nonprogram patients (P < 0.05). This difference was accompanied by lower inpatient health care use in program patients (mean of 0.12 admissions per patient per year and 0.56 inpatient days per patient per year) than in nonprogram patients (0.16 and 0.98, P < 0.05 for both measures). Program patients experienced fewer emergency room visits (0.49 per member per year) than nonprogram patients (0.56) but had a higher number of primary care visits (8.36 vs. 7.78, P < 0.05 for both measures). Except for emergency room visits, these differences remained statistically significant after controlling for age, sex, HMO enrollment duration, presence of a pharmacy benefit, and insurance type. Program patients also achieved higher HEDIS scores for HbA(1c) testing as well as for lipid, eye, and kidney screenings (96.6, 91.1, 79.1, and 68.5% among program patients versus 83.8, 77.6, 64.9, and 39.3% among nonprogram patients, P < 0.05 for all measures). Among 1,074 patients with HbA(1c) levels measured in a HEDIS chart audit, 35 of 526 (6.7%) program patients had a level >9.5%, as compared with 79 of 548 (14.4%) nonprogram patients.

CONCLUSIONS:
In this HMO, an opt-in disease management program appeared to be associated with a significant reduction in health care costs and other measures of health care use. There was also a simultaneous improvement in HEDIS measures of quality care. These data suggest that disease management may result in savings for sponsored managed care organizations and that improvements in HEDIS measures are not necessarily associated with increased medical costs.

Of course you see short term savings! The point of treating diabetes is to delay the sequelae. I don't dispute the conclusions of this study (I would dispute their methodology though).

I would like to point out a few things. There is a highly statistically significant difference in patient age and insurance status between the groups in the study (in favor of the intervention group). Insurance may be an indirect indicator of socioeconomic status of the patient which is commonly associated to poorer health outcomes and higher ER utilization. Also, probably the biggest problem with their study is that they don't break up charges and inpatient stays into elective and non-elective sources. Plenty of people are having elective surgery at this time (ex. hip and knee replacements) which are not separated from non-elective admissions. So I am not sure how much you can reliably get from this study, but as I said, I do not dispute their conclusion. The main thing I gather from this article is that their intervention plan has a significant improvement in HbA1c.

And a final issue (and probably the most important) is that both groups were screened, diagnosed, and being treated for their diabetes, but 1 group had a more intensive educational component. So really this study is not really applicable to what we are talking about and is more of a testament to their educational program over what the standard of care is.

 

[epidural man]

This has to be the stupidest thing I have ever read on here. True prevention is the answer; meaning changing poor habits that have become the norm in this country. No cigs, no fast food, exercise dail. Obviously, starting to treat insulin resistance in a morbidly obese smoker will likely fail. Prevention has to start long before the disease sets in. As shocking as you may find this statement, I have NEVER met a vegitarian marathon runner with heart disease, DM, or PVD. I have met plenty of 45 yo obese smokers with DM, PVD and s/p 3V CABG.

I bet if you search, you can find lots of stupider things. I'm sure I have said way stupider things.

Are you just being dramatic?.......ahhhh, silly you!

I do have a question though - since insurance companies don't care about you, or me, or the people that work for them, or whoever, the only thing they care about is money - how come they don't pay for smoking cessation? If prevention saves sooooo much money, that would seem a no brainer, correct?

 

[epidural man]

Even if I accept your point, there is no way we are doing that much better to justify spending that much more money.

More importantly to me though, I think the math is incorrect.

This argument has been raised for a long time and is based on poorly presented information by Ohsfeldt and Schneider. My point is that removing a small number of outliers isn't going to suddenly raise the life expectancy 5 or 10 years. Again, while trauma /suicide is the leading cause of mortality in certain populations, overall it is still relatively small.

http://theincidentaleconomist.com/wordpress/how-flawed-is-life-expectancy/

Even if you look just at life expectancy at age of 65, we still are not getting an adequate return for our spending.

The culture debate is another problem, and I don't know enough to discuss the role of healthcare in shaping the culture.

Come Orin...the OP's point is simple (yet I would guess he refusses to accept that the contrary is true) - and that is - the dems LIE and use statistics to prove their point.

 

[jwk]

Well you started of strong by suggesting that the answer is primary prevention (ie. lifestyle changes before the disease sets in).

Unfortunately, now you sound like a pre-med. Anyone in medicine knows that treating chronic diseases like DM or HTN only delays the sequelae. It does not prevent them all together. No one denies that screening is worth doing to improve the quality of life of the population, but it certainly does not save healthcare dollars (anyone with a basic understanding of epidemiology knows this - it is often touched on in medical school). Orin and cchoukal have the only argument that supports screening MAY be cost effect: if you delay the sequelae, you keep people in the workforce longer which adds to the economy and delays disability. I don't know the exact numbers on this, but I would still be surprised if screening resulted in a net savings (either way, increased productivity and less disability would not be reflected in the healthcare spending metric). Cancer screening is most definitely not cost effective* - but certainly something I would want done for my population.

*Just to clarify, cancer screening is cost effective for the single disease that was detected early. However, throughout the survivors life, they continue accumulate healthcare costs, may get cancer again, and ultimately die from another disease process, all costs that would have been avoided if they had not survived the first cancer (I have to emphasize I think cancer screening is great, it just isn't cheap).

Talk about mental masturbation. So why bother with medical care at all? It just costs too damn much money. If you catch a disease or develop a problem, I guess the cheapest option, and therefor the best by many people's definitions, is to simply curl up and die, preferably sooner rather than later.

 

[DHT]

No you are paying for improved quality of life. Health care was never meant to save a nation money. It is here to improve the health and well being and reduce suffering at a cost to society.

 

[epidural man]

This has to be the stupidest thing I have ever read on here. True prevention is the answer; meaning changing poor habits that have become the norm in this country. No cigs, no fast food, exercise dail. Obviously, starting to treat insulin resistance in a morbidly obese smoker will likely fail. Prevention has to start long before the disease sets in. As shocking as you may find this statement, I have NEVER met a vegitarian marathon runner with heart disease, DM, or PVD. I have met plenty of 45 yo obese smokers with DM, PVD and s/p 3V CABG.

I"m serious W222 - Why don't insurance companies pay for smoking cessation? If prevention saves them money, what's the hold up?

 

[loveoforganic]

I"m serious W222 - Why don't insurance companies pay for smoking cessation? If prevention saves them money, what's the hold up?

1) Some do
2) The cost of the smoking is covered through increased premiums for smokers
3) How often are OTC meds covered by insurance? Most NRT is OTC
4) To my knowledge, there are no serious sequelae due to nicotine withdrawal requiring medical attention. Not the case for some other substances of abuse (which more frequently are covered by insurance)

 

[yappy]

I would like to add another myth to the list: "Doctors are paid too much".

I would like to go into medicine and someone informed me today, that does quite well in a sales position, that they felt doctors made too much money for what they do. They seemed upset at the amount of their co-pay. So making six figures peddling wares you had no role developing or bringing to market is a sqaure deal but doctors are over paid?

I would think that if physicians were able to market them selves the way plumbers or other fee for service professionals do they would see a rise in income and a decease in BS.

 

[W222]

1) Some do
2) The cost of the smoking is covered through increased premiums for smokers
3) How often are OTC meds covered by insurance? Most NRT is OTC
4) To my knowledge, there are no serious sequelae due to nicotine withdrawal requiring medical attention. Not the case for some other substances of abuse (which more frequently are covered by insurance)

This is exactly true. I would add that I am sure the actuarial numbers have been crunched and the insurance companies realize that they can make more by charging smokers a higher premium for the many years they continue to smoke, rather than simply pay the small cost for smoking cessation and lose the increased premiums. If they can make a hundred dollars per year more from the average smoker, what incentive do they have to actually promote a healthy lifestyle change?

 

[cchoukal]

I"m serious W222 - Why don't insurance companies pay for smoking cessation? If prevention saves them money, what's the hold up?

I think they do. UnitedHealth certainly does (phone counseling and support) and my bluecross covers Chantix.