I’ve said repeatedly that in the long run I am optimistic about health care reform and health care finance reform in this country for a very simple reason; we do so much stupid and counterproductive things at present that significant improvements can be achieved by not being stupid. We don’t have to be brilliant, we don’t have to push the knowledge frontier, we just had to stop being stupid.
The Incidental Economist recently looked at a case of system stupidity on how a certain set of breast cancers are treated:
There are RCTs looking at using shorter, more intense radiation treatments for many early-stage and other types of breast cancer. It works just as well, has similar side effects, but it takes less time and it costs less. In 2011, the American Society for Radiation Oncology endorsed it. In 2013, Choosing Wisely encouraged it.
And, hooray, the use of hypofractionated WBI increased from 11% to 35% in 2013 in the “endorsed” cohort. It went from 8% to 21% in the “permitted cohort”. Hypofractionated WBI cost, on average, about $2900 less in the “endorsed” cohort and about $8600 less in the “permitted” cohort.
The preferred treatment schema costs less, and hassles the patients’ lives less while producing the same results. Cheaper, faster and the same outcome is a massive system engineering win.
in Canada, 6% of patients who received WBI without regional lymph node irradiation got the longer therapy. In the US, 72% did. In Canada, 53% of patients under age 50 without regional lymph node involvement received hypofractionated WBI; in the US, 13.0% did….
if you have a fee-for-service system, then it’s going to be hard to change provider behavior….
The incentives are lined up in the United States for providers to be systemically stupid by engaging in costlier and longer term treatments because that determines their paychecks. People seldom willfully give up several thousand dollars worth of income at once on a repeated basis. So we as a society and an insurance finace system has to change the incentives and pay structures so this case of system stupidity can be minimized.
And UnitedHealthcare is experimenting with an incentive shifting system:
UnitedHealthcare (UNH), the biggest U.S. health insurer, is taking aim at controlling costs of treatment with a new pilot program that will provide a set sum for a patient’s coverage. The plan is being developed with the University of Texas MD Anderson Cancer Center and will enroll about 150 patients at first…what happens if the cost of treatment exceeds the bundled payment? The annual payment won’t increase if complications increase treatment costs. Eight bundles are available for patients, depending on what services they need, the insurer said.
“The bundled payments (there is a total of 8) cover all services and care provided by MD Anderson for treatment, including complications,” UnitedHealthcare said. “Each bundle has a fixed, specific price depending on the type of services and care included in a treatment regimen. For example, some patients may just need radiation and chemotherapy, while others may need those services plus surgery.”
The bundles are not covering breast cancer in this pilot trial but the logic is expandable in forcing the providers to choose the most efficient treatments in order to make significant money instead of ordering more treatments to make more money. Bundled payments are one of the big health financing reforms that does not require policy brilliance; it requires patience, dogged determination to work with the data as it is, and an ability to retweak as needed.
In a similar vein, Europe (especially Germany) has been testing herbs against expensive drugs; and a lot of the time, the herbs do better, or as well, for far less cost.
The annoying thing to me is the fact that shorter courses were equal to longer courses was presented as some big news. The American Society for Radiation Oncology (ASTRO – our professional society) has hypofractionated radiation in the guidelines as an equivalent option since 2010. Data was presented at the ASTRO meeting in 2008. The National Surgical Adjuvant Breast Project (NSABP – the leading breast cancer research organization) has had hypofractionated radiation as an option for a long time. The Radiation Therapy Oncology Group (RTOG) had a randomized trial which recently met its accrual goal where the experimental arm was including a “boost” dose with the whole breast radiation treatment with everything being completed in 15 treatments (the standard arm was the treating physicians choice between 30 or 22 fractions.)
I realize nothing will change until doctors no longer get paid more for the longer courses.
Why do you want to deprive doctors and other medical professionals of their livelihood? The free market has spoken and the free market likes stupid, because stupid makes money for the right people.
I’d feel better about this, if we’d regulate our herbal remedy providers at all, because with all the stuff in the stores we’re approaching the “good old days” of “snake oil” sales man.
Even stuff that’s proven to work may not work for you between different producers, because who the fuck knows what the hell a producer is using.
@gene108: I’m coming from a place where few doctors even conceived of my health issue, and only one has been able to help.
Herbs have been absolutely vital for me. We should do more… only I suspect the pharmaceutical companies would like to make them illegal… as is the case with one famous herb :)
It’s pretty interesting looking for vitamins in the UK. Even something as simple as Vitamin C is mostly only sold packaged with other things and in much lower doses than in the UK. Mostly chewable. I’m guessing it must be the governmental regulation that keeps it from being on the shelves.
My nephrologist recommended Red Yeast Rice to keep my LDL cholesterol down. Used a brand sold at Whole Foods, than the Whole Foods generic as they carried no other brands after a while.
Bought a different brand of the same product at Wegman’s, and did not work.
Really feel like I should be able to buy the same product – like say aspirin – from different companies and expect a minimum level efficacy.
I’ve become very suspicious of OTC herbal supplements and such ever since.
Villago Delenda Est
The fact that there is so much stupid in the health care delivery system is a function of greed.
On edit: I see gene108 has already covered the reason for the stupid.
Is this the same as capitation? Where doctors basically get paid more when they provide the least treatment? I believe that this has been tried, and I find it personally terrifying. The minute I get expensive, I’m expendable. The minute I get really sick, I am ‘stealing’ my doctor’s take-home pay. If I am mis-construing the point, please let me know.
Unfortunately, manufacturing anything to FDA drug standards is expensive. Even if you’re starting with an herbal, all the QA/QC/cGMP stuff adds immensely to the cost. The main benefit will be that you won’t have to pay monopoly rents to a patent holder.
Ted and Hellen
What a freaking, bizarro mess/joke the ACA has turned out to be.
Single payer is the only rational answer.
Therefore, Republicans and Democrats will never adopt it.
Link to test results?
Thanks for an informative, encouraging yet in other ways depressing column.
Villago Delenda Est
@Ted and Hellen: The “rational answer” isn’t “rational” to greedheads.
@Emily68: Test results to what?
@weavrmom: slightly different — I’ll have a post on the difference this weekend as you raise a great question.
While Richard Mayhew pontificates about the importance of the American health care system “not being stupid,” he himself engages in the most grotesquely stupid kind of behavior imaginable…
…Namely, claiming that “incentive shifting” systems will bend the cost curve.
This is stupid because it assumes doctors and hospitals and imaging clinics and overpriced labs and insanely overpriced medical devicemakers are so dumb they won’t quickly figure out how to game the system created by the incentive-shifting.
Let’s take a practical example to see how stupid Mayhew’s scheme really is:
Here’s whats really going to happen:
At first the bundling will reduce costs. Then, after a few months or a year or so, the doctors and hospitals involved in this bundling will figure out how to charge “extra” fees directly to the patient not covered by the insurance. So what this kind of “bunding” horseshit actually does is not cost reduction, but cost-shifting from the insurance company to the individual patient. Net costs will go up for the patient, and down for the insurer. Of course liars like Richard Mayhew will point to lots of phony graphs and charts to “prove” that the cost curve is bending, when in fact it’s just shifting so that the insane overpricing slides downhill (the way all shit slides downhill) from the insurer to the individual patient.
The only way to really bend the cost curve for good is the one method Mayhew won’t discuss. Single-payer national health care. You need to take the profit out of the health care system. Otherwise, smart doctors and nurses and radiologists and lab techs and hospitals and medical device makers and big pharma monopolists will simply game the system and find endlessly inventive ways to jack up costs that wind up pissing away trillions of dollars more on nothing worth a damn.
Mayhew and his ilk simply will not admit the reality — those vacation homes in Maui are going to have go away for all those doctors. Those “prescribe 10 regimens of our big pharma drug and get a new car” deals are going to have to go away for those insanely overpriced drugs. Those sweetheart contracts with rigid non-disclosure agreements preventing the hospital from publicizing the costs are going to have to go away for all those $15,000 automated insulin pumps with their $8,000-per-year “mandated firmware upgrades” from all those medical devicemakers.
@Ted and Hellen:
You will be pleased to know that the ACA is the reason Vermont’s getting a single-payer system in 2017. Woo!
@VFX Lurker: actually, Vermont probably won’t go single payer in 2017 as they can’t figure out how to finance the system in a politically plausible manner. Remember, health insurance and health care for the non-elderly, non-poor, is primarily provided through either employer sponsored coverage or now the Exchanges. The people with employer sponsored coverage, as a class don’t want to give that up. And getting them to pay the same level of taxes that they currently pay in premiums or salary increases deferred into premiums is political suicide (this is a good reminder as to why single payer was not on the table in 2009, the Democrats’ critical votes did not want to vote for something that the CBO would score as an 8 trillion dollar program in the first decade.
@mclaren: Good to see you and hope you are well as it has been a while since I’ve heard your one note.
Again, I will ask you two simple questions about me.
a) How much budgetary authority do I control — an order of magnitiude should be sufficient…
b) How many people report to me either directly or indirectly.
I have a feeling that you massively overinflate my position.
And a slightly more complex question — how do you propose to fix the system in a manner that can get 218-51-1-5 that does not involve a threat to nationalize the entire US healthcare system?
As always, thank you for posting good and important information here. I knew that Vermont had signed legislation to go single-payer in 2017 (aka “Green Mountain Care”), but I did not know that Vermont’s citizens were resisting the change to single-payer.