Money Matters in Health
Tuesday February 7th CNN has a debate between Senators Bernie Sanders and Ted Cruz. The former will advocate for a Single Payer System, and the latter for insurance companies to continue to run the Health Care system. I hope you make the time to watch.
When you watch the debate keep in mind these facts: the USA Health Care system only covers 10% of factors that influence health,[1] a fact that ranks our country dead last in the industrialized world.[2] The top 5 countries in health quality spend one half of what we do per patient per year,[3] mostly because insurance companies’ overhead expenses are so high, even three times higher than government-run Medicare.[4]
Here is a YouTube video that contains the actual debate. Watch it now or sometime later, after you peruse this article.
https://www.youtube.com/watch?v=2ugBYg1zbuY
Lastly, a report showed that ~90% of what our Health Care system does is driven by profits, not evidence.
With these and many other facts in mind I quit the system to do what is best for my patients without insurance companies holding me back. Interestingly, February 2nd, TV Channel 2 had a report in their 10PM news that it is cheaper NOT to use one’s health insurance and pay out of pocket in many cases.[5]
Below you will find a sample of many articles appearing in the medical literature expanding on the idea that the health care system is not serving the public well. There is no need to study them if you get the point this blog makes.
Financial ties of principal investigators and randomized controlled trial outcomes: cross sectional study BMJ 2017;356:i6770 Financial ties between principal investigators and the pharmaceutical industry were present in 132 (67.7%) studies.
Industry-backed studies less likely to link sweet drinks and diabetes
The New York Times (10/31, O’Connor, Subscription Publication) reports researchers from the University of California, San Francisco, performed a meta-analysis of soft drink consumption studies and their “relationship to obesity and diabetes published between 2001 and 2016” and found that “about 60 studies…were fairly rigorous in their methodology.”
The New York Daily News (10/31, Pesce) reports studies backed by the sugar-sweetened beverage industry were less likely to identify a link between sugary drinks and diabetes than those that were funded by other sources, according to a report published in the Annals of Internal Medicine. Mark Hyman, MD, the director of the Cleveland Clinic Center for Functional Medicine, said, “The sugar industry and soda companies are following the same playbook as the tobacco industry did trying to defend tobacco.”
$4B wasted on mammograms and false positives per year, J. Health Affairs April 6 2015
Revolving door between government and industry Future jobs of FDA’s haematology-oncology reviewers BMJ 2016;354:i5055
Evidence Gaps and Ethical Review of Multicenter Studies
- Science 6 November 2015: Vol. 350 no. 6261 pp. 632-633
“Evidence gaps and ethical review of multicenter studies–Large, multicenter clinical studies are the backbone of evidence-based prevention and health care. Ethical review of multicenter research is usually conducted by the institutional review board (IRB) of each participating institution. However, variation in interpretation of regulations by IRBs is common and can have ethical and scientific implications (1, 2). Recent mandates in the United States aim to reduce the administrative burden and to expedite multicenter research by conducting ethical review with a single, central IRB of record (CIRB). Yet the quality of ethical review must not suffer. We characterize current models of ethical review in the United States and identify research gaps that must be addressed before such policies are instituted.”
How 21st century capitalism is failing us, BMJ 2014;349:g7516
“It requires a thoroughgoing democratic transformation. The popularity of Thomas Piketty’s book Capital1 was perhaps the publishing surprise of the year, but it is paradoxical for three reasons. Firstly, its 700 academic pages are hardly an inviting bedside read. Secondly, its appeal was primarily to people already worried by rising inequality, even though its main argument is that increasing inequality is built into capitalism and will be hard to overcome. And, thirdly, for those of us who regard a combination of low inequality and little or no economic growth as a precondition for environmental sustainability, Piketty’s message is doubly unwelcome: it implies that slower economic growth leads to faster rises in inequality.
So could the attraction of this book—its title echoing Marx’s magnum opus—be that it lays the blame for increasing inequality firmly at the feet of capitalism rather than suggesting that minor reforms would solve the problem? The popularity of Naomi Klein’s latest book, This Changes Everything,2 may stem from the same source. Subtitled “Capitalism vs the Climate,” it shows how large corporations, particularly fossil fuel companies, have bought off governments and many environmental groups, watering down policy proposals, legislation, and international environmental agreements. Even the much publicised environmental commitments of several major industrialists have not lived up to their promises. The upshot is that we have frittered away the little time we had to substantially reduce carbon emissions so that environmentalists increasingly believe that we are heading for catastrophic temperature rises.
The growing trickle of institutions (including the BMA) disinvesting from fossil fuel companies is a welcome expression of a desire not to be seen to benefit from profits of the companies ultimately responsible for carbon emissions. But exactly who owns their shares and receives their profits makes little difference to the companies themselves. Another recent book that launches a major attack on capitalism, this time on health grounds, is Nicholas Freudenberg’s Lethal but Legal.3 He sets out the evidence that the food, alcohol, tobacco, automobile, pharmaceutical, and gun industries are now the main sources of damage to public health. And of course, in the endless conflicts between public and corporate interests, corporations use their huge advertising wealth, media, and political influence to defend themselves to the hilt. They pack regulatory systems with people who will defend their interests, they buy politicians, and continue to maximise the sales of their products in the face of massive evidence of harm—from obesity, drunkenness, smoking related disease, environmental damage, and so on.
If we wanted evidence that the antisocial behaviour of big corporations is a large political problem, their record on tax evasion provides it. Estimates of the cost just of corporate tax avoidance to the UK government vary between £4bn (€5bn; $6bn) and £12bn depending on whether estimates include things like “legal” profit shifting.4 5 (Loss of tax revenues from all sources is estimated as £34bn upwards.)
In 2008, the US Government Accountability Office reported that 83 of the country’s biggest 100 corporations had subsidiaries in tax havens.6 The Tax Justice Network reported that 99 of Europe’s largest 100 companies also used tax havens,7 and it estimates that over half of all world trade passes—on paper—through tax havens in order to avoid or reduce taxation. The amount of money lost in tax revenue by developing countries far exceeds all international development aid.8 9 As well as tax avoidance and the huge sums of money that Klein shows the fossil fuel industry pours into subverting efforts to reduce carbon emissions, business and its sophisticated marketing and advertising arms is hell bent on maximising sales and consumption—even though consumerism is a big obstacle in the path towards environmental sustainability.
But consumerism is not simply a reflection of the desire of business to sell. It is also an expression of the importance of status competition among consumers. Research shows that status anxiety is intensified by greater income inequality.7 10 As a result, people in more unequal societies give higher priority to buying status goods.11 They also work longer hours, save less, get into debt more.12 13 14 Inequality makes money even more important as it becomes the key to demonstrating our status and worth to each other.
But if our future lies in maximising wellbeing rather than economic activity, we will be aided by what might be called “a convenient truth”15: rather than benefiting from further economic growth, health and happiness in rich countries is now better served by improvements in the quality of social relations and community life.16 17 It looks as if greater equality would reduce consumerism and improve the social environment.
It should not be beyond the wit of modern societies to ensure that production is undertaken in the service of the public good, humanity, and the planet. The obstacle is that large corporations are so powerful that our democratically elected politicians are afraid to touch them—and far too afraid to start thinking about alternatives.
The Bureau of Investigative Journalism estimated that in a single year the British financial services industry spends more than £92m on lobbying politicians and regulators “in an ‘economic war of attrition’ that has secured a string of policy victories.”18 What this figure would be if other sectors—pharmaceuticals, food processing, arms, energy, alcohol—were added in is anyone’s guess, but it certainly compromises the democratic political process.
Could an extension of democracy into economic life be part of the solution? More democratic business models include companies owned and controlled directly or indirectly by some or all of their employees, companies with varying degrees of employee representation on boards, consumer cooperatives, mutuals, and credit unions. They include organisations as different as the London Symphony Orchestra, the Mondragon Cooperatives, Oxbridge Colleges, John Lewis Partnership and Waitrose, Suma Wholefoods, Divine Chocolate, Cafe Direct, and, perhaps more informally, Gore-Tex. Around half the member states of the EU have at least some legal provision for employee representatives on company boards or remuneration committees.19
Those like Germany, with stronger legislation, have had smaller rises in inequality. Evaluations suggest that more democratic companies not only have smaller income differences within them but also enjoy higher productivity.20 21 As well as reducing income inequality, wholly employee owned companies are also part of the solution to the increasing concentration of capital ownership which is Piketty’s focus. More democratic business models would help to disperse capital ownership as well as income from profits. There is even evidence that more democratic businesses are more ethical.22 23 Perhaps then our salvation lies in a thoroughgoing democratic transformation of capitalism.
Swimming against the Current — What Might Work to Reduce Low-Value Care?
N Engl J Med 2014; 371:1280.
“Given the evidence that as much as one third of U.S. health care spending is wasteful, however, health care organizations are now embracing explicit consideration of value and turning their attention to overuse. Reducing overuse could theoretically improve quality while slowing spending growth. American Board of Internal Medicine Foundation’s Choosing Wisely program, the U.S. Preventive Services Task Force, and the National Quality Forum have advanced the dialogue about low-value care by identifying services that deserve that label.
Demand-side interventions — targeting patients — principally include financial incentives and education. Increasing patient cost sharing
Supply side: caregivers incentivised is best—risk sharing, in which providers accept financial responsibility for total costs of care. In a national survey, 92% of physicians said they felt responsible for ensuring that patients avoid unnecessary tests and procedures, and 58% believed that physicians were best positioned to do so.
Evidence-based guidelines, i.e. Canada gives up on PSA CMAJ Epub October 27 2014
Transitioning to a population-health focus
To address overuse, we now need to work against the current of culture and payment models that still largely reward volume over value
Price, cost, and competition in health care, JAMA October 22/29 2014 Cover issue: Editorial page 1639: Who benefits from health system change?” Not the patients.
The Oregon experiment re-examined: the need to bolster primary care
BMJ 2014;349:g5976
Drug Companies’ Patient-Assistance Programs — Helping Patients or Profits?
N Engl J Med 2014; 371:97
Too much medicine BMJ 2013;346:f1328
Pinching the poor? Medicaid cost‐sharing under the ACA.
New Engl J Med. 2014 Mar 27;370(13):1177‐80.
“If this sort of flexibility encourages more states to expand Medicaid, most low-income adults will be better off for the effort — since some cost sharing is almost certainly preferable to being left without any coverage at all.”
The US Health Disadvantage Relative to Other High-Income Countries, JAMA 2013;309:771. Institute of Medicine Report
“The US spends more on HC than does any other country, but its health outcomes are generally worse than those of other wealthy nations… Although this disadvantage has been increasing for decades, its scale is only now becoming more apparent.”
“Shorter life expectancy than 16 wealthy nations (including newborns)… The USA ranks near the bottom on both prevalence and mortality for multiple diseases, risk factors and injuries.”
“Why? A lack of Universal health Care, weaker primary care, greater barriers to access and care coordination is also a problem.”
“People in the US consume more calories… pronounce income inequality… high rates of poverty… The US ranks below other countries in social mobility.”
“The US health disadvantage may only worsen with time… committee urged prompt action of proven strategies such as those outlined in Health People 2020 and the recommendations of the National Prevention Council which target the conditions responsible for the US health disadvantage-from infant mortality to injuries, obesity and chronic diseases.”
What Business Are We In? The Emergence of Health as the Business of Health Care, New England Journal of Medicine 2012;367:888.
“Although doctors and hospitals focus on producing health care, what people really want is health. Health care is just an expensive means to that end. What lessons can we learn from companies that failed because they didn’t recognize the larger business they were in?”
From Sick Care to Health Care — Reengineering Prevention into the U.S. System, New England Journal of Medicine 2012;367:888.
“Flexner’s acute care model remains securely embedded in the U.S. health care system. But given our chronic-disease epidemics, unsustainable costs, poor outcomes, frequent medical errors, and worsening health disparities, we must replace it with a prevention model.”
[1] “Bridging the divide between health and health care,” JAMA 2013;309:1121
[2] http://www.ajmc.com/contributor/julie-potyraj/2016/02/the-quality-of-us-healthcare-compared-with-the-world/
[3] “Health system report ranks UK first, US last,” BMJ 2014;348:g408. US last of 11 industrialized nations. They spend $3,406 on average. US $8,508, Commonwealth Fund report June 17 2014. “The state of USA health,” JAMA 2013;310:591.
[4] https://www.bloomberg.com/news/articles/2013-04-10/the-reason-health-care-is-so-expensive-insurance-companies
[5] Video available on request.
FOR MORE INFORMATION, GO TO: http://hugorodier.com/
