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Health Care Thoughts: Physicians "Rationing" Health Care

by Tom aka Rusty Rustbelt

Health Care Thoughts: Physicians “Rationing” Health Care  
Nine physician panels have recommended less testing of patients presenting with various conditions and diseases and less treatment for some diagnosis.  

For Details: New York Times

Much of this is low hanging fruit, such as using less antibiotics for sinusitis. Some of this is old news, my physician altered his cardiac and prostate screening years ago

Other recommendations may be more controversial. In 2009 evidenced based recommendations to do less breast cancer screening were met with a firestorm of criticism. Current recommendations to do less cancer screening may meet a similar fate.
   
There will be another controversy, whether or not these guidelines would protect a physician using conservative treatment protocols from malpractice suits. In my experience, probably not.
    
Eventually payment bundling and new payment schemes may accomplish the “rationing” via a different route.
   
Stay tuned.

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Comparative Effectiveness Research

by Tom aka Rusty Rustbelt

Comparative Effectiveness Research (CER) may have inadvertently lost credibility even before health care reform is actually launched.

CER is the darling of the government-dominated health reform movement (not a government take-over, to be clear). The use of evidence-based medicine when combined with cost-benefit analysis has the potential to save a great deal of money while better serving the patients. Many see downsides though; too rigid protocols and interference with physician judgment, or the dirty “R” word, rationing.

The U.S. Preventive Services Task Force recently released a study on various breast cancer screening modalities, recommending more limited screening protocols, particularly delaying routine mammography until age 50 (except in women with unusual risk factors).

Kah – boom!

USPSTF points out film mammography does cut mortality, with the greatest reductions in women over 50, with the best results in the age 60 – 69 cohort. Film mammography does carry a risk of false positives and the pain and inconvenience of unnecessary biopsies.

USPSTF also recommends ceasing mammography on women over 74, citing a lack of reliable evidence of reduced mortality.

There was a huge backlash from women, physicians, cancer activists and some health care associations.

USPSTF also recommends against teaching women to perform ”breast self-exam” (BSE) which has been a standard tool for decades. More backlash.

USPSTF does point out that digital and MRI mammography do not show, at this time, significant improvement over film mammography, but do have greater costs.

None of the conclusion appear to have been made on strong and startling statistics, but on think pros and cons, as one might expect from quants and scientists.

Women apparently want a little less quantitative analysis and a lot more consideration.

USPSTF report

cross-posted at Health care think tank

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Five Myths about health care

rdan

5 myths about health care round the world by By T.R. Reid, Commentary, Washington Post (hat tip Mark Thoma)

…I’ve traveled the world … to see how other developed democracies provide health care. Instead of dismissing these models as “socialist,” we could adapt their solutions to fix our problems. To do that, we first have to dispel a few myths about health care abroad:

1. It’s all socialized medicine out there. Not so. … In some ways, health care is less “socialized” overseas than in the United States. Almost all Americans sign up for government insurance (Medicare) at age 65. In Germany, Switzerland and the Netherlands, seniors stick with private insurance plans for life. Meanwhile, the U.S. Department of Veterans Affairs is one of the planet’s purest examples of government-run health care….
(the rest of the article is below the fold)

2. Overseas, care is rationed through limited choices or long lines. Generally, no. Germans can sign up for any of the nation’s 200 private health insurance plans — a broader choice than any American has. … The Swiss, too, can choose any insurance plan in the country.

In France and Japan, you … can go to any doctor, any hospital, any traditional healer. There are no U.S.-style limits such as “in-network” lists of doctors or “pre-authorization” for surgery. You pick any doctor, you get treatment — and insurance has to pay. …

As for those notorious waiting lists, some countries are indeed plagued by them. Canada makes patients wait weeks or months for nonemergency care, as a way to keep costs down. But … many nations — Germany, Britain, Austria — outperform the United States on measures such as waiting times for appointments and for elective surgeries. In Japan, waiting times are so short that most patients don’t bother to make an appointment. …

3. Foreign health-care systems are inefficient, bloated bureaucracies. Much less so than here. …

4. Cost controls stifle innovation. False. The United States is home to groundbreaking medical research, but so are other countries… Any American who’s had a hip or knee replacement is standing on French innovation. … Many of the wonder drugs promoted endlessly on American television, including Viagra, come from British, Swiss or Japanese labs. Overseas, strict cost controls actually drive innovation. …

5. Health insurance has to be cruel. Not really. American health insurance companies routinely reject applicants with a “preexisting condition”… They employ armies of adjusters to deny claims. If a customer … faces big medical bills, the insurer’s “rescission department” digs through the records looking for grounds to cancel the policy… Foreign health insurance companies, in contrast, must accept all applicants, and they can’t cancel as long as you pay your premiums. …

In many ways, foreign health-care models are not really “foreign” to America, because our … system uses elements of all of them. For Native Americans or veterans, we’re Britain: The government provides health care, funding it through general taxes, and patients get no bills. For people who get insurance through their jobs, we’re Germany: Premiums are split between workers and employers, and private insurance plans pay private doctors and hospitals. For people over 65, we’re Canada: Everyone pays premiums for an insurance plan run by the government, and the public plan pays private doctors and hospitals according to a set fee schedule. And for the tens of millions without insurance coverage, we’re Burundi or Burma: In the world’s poor nations, sick people pay out of pocket for medical care…

This fragmentation is another reason that we spend more than anybody else and still leave millions without coverage. All the other developed countries have settled on one model for health-care delivery and finance; we’ve blended them all into a costly, confusing bureaucratic mess.

Which, in turn, punctures the most persistent myth of all: that America has “the finest health care” in the world. We don’t. In terms of results, almost all advanced countries have better national health statistics than the United States… In terms of finance, we force 700,000 Americans into bankruptcy each year because of medical bills. In France, the number of medical bankruptcies is zero. Britain: zero. Japan: zero. Germany: zero.

Given our remarkable medical assets — the best-educated doctors and nurses, the most advanced hospitals, world-class research — the United States … should be the best in the world. To get there, though, we have to be willing to learn some lessons about health-care … from the other industrialized democracies.

There are, of course, groups that have a strong interest in perpetuating these myths as part of their attempt to block health care reform.

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