Health Beat: Glass Half-Empty, Glass Half-Full, part 3--Older Americans at Risk

December 20, 2009

Glass Half-Empty, Glass Half-Full, part 3--Older Americans at Risk

Few observers have commented on how older Americans will fare under the amended Senate health reform legislation, but as things stand, many could be priced out of the health care market. The Senate bill lets insurers in the Exchange charge an elderly person up to three times as much as they would charge a younger customer. Thus many middle-class and upper-middle class Americans in their late 50s or early 60s who don’t have employer-based insurance could find themselves locked out of health care reform.

Under the bill that passed the House, insurers could only double premiums for the elderly. In the past, I had assumed that the House bill would prevail on this point. I also thought that the public plan might be more generous. After all, it would be hard to argue that a government plan that made insurance unaffordable for middle-class, unemployed and self-employed Americans in their late 50s and early 60s was serving the public good. Surely some in Congress would protest, and the public plan would find a way to keep a lid on premiums, probably by incorporating Medicare reforms that lower costs. If private insurers wanted to complete for customers in that 55-64-year old market, they would have to follow suit.

Now, however, it seems unlikely that any major provisions from the House bill will be added to the final legislation. This was part of the deal that the Senate struck with Ben Nelson in order to secure his vote. Meanwhile, the public option is no longer part of the reform bill. As a result, it is quite possible that the comprehensive insurance that older Americans need will be too expensive for many, just as it is in Massachusetts.

Meanwhile commentators such as Ruth Marcus argue that charging elderly customers more makes sense: “older people cost more money to insure than younger Americans -- and more than three times as much. Is it fair to require younger people to shoulder all the extra cost?”

But what Marcus doesn’t do is take a hard look at the numbers. Whether or not you think younger Americans should help foot the bill for their elders, the fact is that if this provision stands, the majority of customers in this older cohort simply won’t be able to afford good coverage.

As I noted in an earlier post, households in the 55-64 age group report average joint income of just $55,400. Only 25 percent enjoy joint income over $100,000. In other words, fully one quarter of earn somewhere between $55,400 and $100,000—too much for a couple to qualify for much of a subsidy, too little to able to afford pricey insurance.

Remember, couples earning more than $58,280 will not be eligible for subsidies. A middle-class couple earning $50,000 would receive only a small premium credit. How can they afford to pay three times what a younger person pays? They can’t.

Yet middle-aged Americans need full, comprehensive coverage. A 20-something might feel comfortable with a Bronze plan that covers only 60 percent of the cost of “essential care”—after all, he doesn’t plan to use the insurance very often. But most 60-somethings need to go to doctors regularly to control chronic diseases and address the many problems that come with age. And if they are middle-class, they probably cannot afford to shell out 40% of the charge for each visit to a specialist. Granted, their out-of-pocket payments would be capped at $11,900, but for a household earning just $59,000 before taxes, that’s more than 20 percent of their after-tax income. Even for a couple earning $75,000, $11,900 is a hefty sum. No doubt many would simply put off going to the doctor.

Just how much would a couple have to scrape together to buy a better plan? Judging by prices for Federal Employees’ Plans, a top-of-the line Platinum policy which covers 90% of medical bills is likely to cost a younger couple at least $10,000—probably closer to $12,000 in today’s group market. That means that even if an insurer charged the older couple only twice as much, the premiums would run $20,000-$24,000 annually, rendering insurance unaffordable for both the middle-class and most of the upper-middle-class.
If it seems impossible that a 60-year-old couple earning $59,000 a year would be expected to pay that much, consider this: In Massachusetts, where insurers are allowed to double premiums based on age, a 64-year-old adult living in Boston is asked to shell out between $830 a month and $1,000 a month—or up to $12,000 a year for one person--for a policy with low co-pays and deductibles. For an older couple in Boston, an identical policy runs between $1,740/mo. and $2,000/month.—or $24,000 a year. In the end, everything may turn on what state you live in. States will have an opportunity to protect their older citizens. While the amended version of the legislation sticks with the 3:1 ratio, it adds that if a “qualified health plan is offered in a State with age rating requirements that are lower than 3:1, the State may require that . . . plans comply with the State’s more protective age rating requirements.”

This provision is enormously important, but I am afraid it will only create tension between generations. If insurers are not allowed to triple premiums for older customers, younger customers in that state will wind up paying more. And of course insurers want the younger customers.
Assuming that a state does not shield its older citizens, the legislation offers one alternative: if the cheapest insurance available costs more than 8% of a person’s income, he or she can be exempted from the mandate.
As I have suggested in the past, “universal coverage” that exempts those who cannot afford it takes us back to square one: rationing care based on ability to pay.

The Only Solution: Cut the Cost of Care

The only way insurance will be affordable for many families at the upper end of the middle-class—or for older American--is if the cost of health care itself falls. This means squeezing out the waste; refusing to be gouged by drug-makers; trimming fees for some specialists’ services; and refusing to pay hospitals extra for inefficiencies and errors that lengthen hospital stays and threaten patient safety.
Otherwise, the amount that private insurers pay out in reimbursements to hospitals, doctors and patients will continue to climb by 8% a year, just as they have for the past ten years. And premiums will rise in tandem.
But do you really think private insurers will suddenly get tough when negotiating with drug-makers, device-makers, hospitals and specialists?

Not likely. In order to win market share, insurers need to keep brand-name drugs in their formularies; they want marquee hospitals and popular, brand-name specialists in their networks. This means that they will continue to pay whatever suppliers and providers demand, and hike premiums to cover the costs.
Meanwhile, competition for the well-heeled customers who can afford ever-more expensive insurance will heat up. Insurance companies who cannot attract those customers will drop out of the market, as will middle-class and many upper-middle-class older Americans--unless the government intervenes
As I explained in part 2 of this post, the Senate bill still calls for an Independent Medicare Commission made up of physicians and other medical experts who would oversee Medicare spending—hiking some fees, while reducing others. (Already, Medicare itself has proposed raising reimbursements for primary care by 4% next year, while lowering payments to cardiologists by 6%.)

The Commission would bundle its recommendations in a package, and Congress would have to vote “yea” or “nay” on the entire package within a fairly short period of time. It could not edit the changes. This would protect the Commission from Congressional meddling, and pressure from lobbyists.

Unfortunately, when the Senate’s two health care bills were merged, the Commission lost some of its clout. For example, hospitals were exempted from cost-cutting for ten years. But, as I noted in part 2, Senators Joe Lieberman, Jay Rockefeller and Sheldon Whitehouse have now introduced an amendment that would strengthen the Commission, and let it use financial carrots and sticks to insist that hospitals begin providing better value for Medicare dollars.

Keep an eye on this amendment.

Under the Senate Bill, Medicare Could Pave the Way

There is just one way that private insurers might begin to address the waste in our bloated health care system: if Medicare provides political cover, by cutting costs and simultaneously embarking on a campaign to demonstrate to the public that it is possible to trim spending while lifting the quality of care.

The medical establishment has begun to acknowledge that unnecessary tests can be hazardous to your health. Just this week the Archives of Internal Medicine reported on two new studies estimating that the radiation exposure from the 72 million CT scans ordered in 2007 alone will result in 15,000 additional cancer deaths twenty to thirty years down the road. An editorial in the Archives pointed out that there is an eight-fold difference in CT scan use around the country, with no better outcomes where more scans are done. (For details and some pointed commentary on what needs to be done,see GoozNews)
Around the nation, responsible physicians are conveying this information to patients, medical students, interns and residents. They also are talking about the pros and cons of mammograms. A great many women read past the politically- motivated fear-mongering, and are beginning to ask questions.

This all helps to prepare the public for the upcoming Medicare cuts that will try to wring some of the hazardous waste out of the system. Seniors need to understand that that the goal is to protect patients from unnecessary procedures. No one will be denied needed care. No one will be told that they can’t have a mammogram. No one will be told that Medicare no longer covers CT-scans.

But by lowering the fees that it lays out for CT-scans, Medicare hopes to make the procedure less attractive to physicians who are paid fee-for-service. For example, we know that when doctors lease or buy diagnostic testing equipment and begin using it in their offices, they recommend twice as many tests for their patients. Next year, Medicare plans to reduce reimbursements for these in-office tests.

Mammograms, by contrast, are not terribly expensive. It is unlikely that Medicare—or anyone—would cut fees. But there is “shared-decision-making” legislation under consideration that would pay health care professionals for the time it takes to give patients a full understanding of the risks and benefits of mammograms, as well as other elective tests and treatments. We know that when patients are fully informed, they decide against elective procedures 20 % to 30% of the time.

Meanwhile, doctors like Boston surgeon Atul Gawande are calling attention to the fact that complications following surgery kill more Americans each year than car accidents. Prudent physicians who share decision-making with their patients explain the dangers.

In the film, Money-Driven Medicine, Dr. Jim Weinstein, who spent the first half of his career as an extremely successful orthopedic surgeon, explains that often he just didn’t feel that his patients were “getting a fair shake.”

"When it came to risk," he says, "I knew that many of my patients were thinking, 'I trust my doctor. He is so good that nothing bad will happen to me.' I wanted to say, 'Wait. Stop. This is important. You could die. You could get an infection.'". Ultimately, Weinstein devoted the second half of his career to spear-heading the shared-decision-making movement at Dartmouth.

As care becomes more patient-centered, wise physicians are urging patients to consider their options. Try medication, physical therapy, or change of diet first. Don’t rush into anything. Sometimes back pain disappears. In many cases, outcomes are better for patients diagnosed with early-stage prostate cancer who choose “watchful waiting” rather than radiation. Breast cancer patients who choose lumpectomies over mastectomies are just as likely to survive, though in the worst-case scenarios, they may have to return for additional treatment.

Recently I quoted Dr. Donald Berwick, president of the Institute for Health Care Improvement: “The best health care is the very, very least healthcare that we need. The best hospital bed is empty not full. . . The best CT-scan, the one we don’t need.” This is the lesson that Americans need to learn—as quickly as possible. If they don’t, health care reform will sink under its own weight, wrecked by over-treatment and over-spending.

Posted by Maggie Mahar on December 20, 2009 | Email this post

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Heather & Don

Heather--

But age rating (charging older people higher premiums) is not the norm for most of the nation.

In the employer-based large group market where most Americans now buy their insurance there is no age-rating. All employees pay the same premiums for the same insurance.

And, under reform, everyone will be able to be in a large group-- small employers can get group rates in the Exchanges, as well individuals buying their own insurance.

In the past, it made sense that insurers would charge a small company with a large number of older employees more because the company just wasn't big enough for the differences in how much the insuer will wind up spending on the employees to average out.

In a large company, you have such a mix of older, younger, healthier, sicker employees that insurers don't worry about precisely how many older employees there are working at the corporation.

In addition, in New York State, insurers are prohibited from taking age into account when setting premiums.

And New York isn't alone in protecting its older citizens: states greatly limit how much more insurers can charge older people. In Vermonth, they can charge them only 20% more--not 200% or 300% or 400%.

So the reform legislation is not moving in the right direction.

Originally, the legislatin was supposed to move toward guaranteed issue and pure community rating--everyone is charged the same premium for the same coverage in a given communitiy.

Everyone in the pool, no one out.

I suspect we'll move in that direction, and that individual states will follow Vermont and New York's model, passing laws to protect older citizens.

Of course, this is likely to happen first in states with more citizens over the age of 50.

Finally, it's worth noting that age-rating discriminates against women because more women live longer.

Age-rating is much like gender rating-- yes, women require more helath care just as older people require more health care.

But just as no one should be penalized for being a women, no one should be penalized for being over 55.

Don--

Bluhm's moral stance is interesting, and I think appropriate.

Insurance is all about spreading risk so that we help each other in the case of catastrophe.

As you get older, medical catastrophe becomes more likely, which is why traditionally, younger people have helped care for older people, knowing that, when they age, a younger generation will look out for them.

We need that kind of solidarity, across generations, acorss gender lines, across class lines, if we are going to be a humane and stable society.

Posted by: Maggie Mahar | January 09, 2010 at 05:01 PM

Heather:
Thanks for posting that information from Blue Cross.
When we are looking at compression of rating bands, what the goal seems to be is affordable coverage as we age.
This is laudable, if the young do not face too stringent a premium in the early years.
This is a problem that was considered back in 1993 by William Bluhm In an article entitled "Duration-Based Policy Reserves."
He wrote on page 12 "The select and ultimate pricing sets premiums each year to fund only the claims expected in that year. There is no built-in premium to the expected increase in claims by policy duration. Because of this, the increase in yearly premiums substantially exceeds the increase that would result only from claim trend and aging of the insured."
Rate compression attempts to provide a built-in extra premium (reserve) to alleviate some of the premium increase due to the duration of the policy (aging of the insured).
This increase in premiums has a name, for it is a method used by insurers - called "durational rating."
Bluhm took somewhat of a moral stance on durational rating, which is unusual for actuaries to publicize. He wrote on page 13 "Membership in the original pool was part of the guarantee being bought by the insured. To the extent this pricing method involves the healthier part of the pool to lapse, those healthy members are no longer subsidizing the unhealthy insureds. This is an abrogation of the original insurance guarantee, especially to those whose health has worsened."
Page 49 "Personally, I find it immoral to knowingly entice unknowing insureds into a risk pool in which, should they become uninsurable, they will inevitably be trapped in an antiselection spiral that was knowingly built into the premium structure by their insurer."
Go to:
Google "Duration-Based Policy Reserves"
Don Levit

Posted by: Don Levit | January 08, 2010 at 11:07 AM

http://www.bcbs.com/issues/uninsured/background/impact-of-changing-age-rating.html

Here's a link with some further information - note that it is from the Blue Cross Blue Shield Association, and therefore written from a vested interest perspective.

Posted by: Heather | January 06, 2010 at 05:08 PM

The author indicates that some older Americans won't be able to afford health insurance if their premiums are 2 or 3 times more than the rates for young adults - however, she fails to note that "age rating" is the norm today for individual & family plan insurance.

Currently, age rating means older people may pay up to 11 times more than the young. 42 states have legislation allowing the age rating differential to be 5:1 or more. The House and Senate bills are both trying to implement a much lower cap on this age rating multiple.

So, whether or not you agree that age rating should exist at all, or just be lowered... both the House and Senate bills are "directionally correct" in that they would tighten the age rating bands.

Posted by: Heather | January 06, 2010 at 05:08 PM

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Posted by: kiramatalishah | January 04, 2010 at 06:29 AM

The suggestion that its not necessary to do a clinical trial is supportable. The problem is that there is no clinical trial and they allow that.

Posted by: Gregory D. Pawelski | December 31, 2009 at 01:05 AM

Maggie,
My main point was that a CT study such that Greg wants will not meet IRB approval for the reasons stated. As far as putting people down, all I am stating is the truth. There is an awful lot of Monday Morning Quarterbacking that goes on around here and the simple fact is you or Greg don't have to make the decisions that Legacy, FP and I make every day. It is very easy to pontificate on high about the overuse of CT scans when you have never ordered one. It is not putting people down it is just stating the facts. We know they are accurate and can be a lifesaver. They have changed how we practice medicine and in most of us in some instances WILL NOT operate without one, which is why there will never be Level 1 evidence for some of the things we do.

Posted by: jenga | December 28, 2009 at 12:58 PM

There's a movement to radically change California government, by getting rid of career politicians and chopping their salaries in half. A group known as Citizens for California Reform wants to make the California legislature a part time time job, just like it was until 1966.

latest trend

Posted by: henrylow | December 28, 2009 at 01:12 AM

Legacy--

My comments about putting people down were directed to Gregory along with everyone else. I thought that was clear.

(And I'm sure that, from time to time, I just lose it, and let the conversation become personal. My apologies to all when I lapse. )

Gregory--

The personal feud just isn't useful in advancing our conversation.

Let's just let it go.

Posted by: Maggie Mahar | December 27, 2009 at 11:40 PM

Cute Flyer! My "indiscriminately writing words" was a direct retort to your "ludicrous" comments.

And trying to say "treatments resulting from them do" is YOUR statement, not mine.

Posted by: Gregory D. Pawelski | December 27, 2009 at 09:11 PM

Maggie,

"The treatment following a test may save a life -- the test itself doesn't save a life, though it may provide the information that leads to a correct diagnosis which in turn leads to life-saving treatment."

Wrong again. CT replaced tests that have a higher morbidity and mortality rate like angiography and exploratory laparotomy. So by not doing a test with a higher rate of mortality, you did in fact save a life.

And Gregory went farther than merely saying that CT themselves don't save lives, but the treatments resulting from them do. He said: "There is no evidence of better outcomes for patients. This is not what it does. The test accurately measures what it purports to measure. There is a total lack of information regarding test efficacy." I gave just one example showing better outcomes for patients because of the use of CT.

You chided Concerned FP and Jenga for "putting down" Gregory: "And, on this blog, we don't put people down because they are not physicians ....", but apparently ad hominem comments from Gregory: "It seems like indiscriminately writing words without substance as an alternative to constructive insight is something you may know how to do very well flyer. People who try to win arguments not by debating the issue, but by trying to attack the person making the arguments, I'm not sure exactly what your point is? Do you feel more manly? Something missing in your psychic (sic)?" are OK.

Posted by: Legacy Flyer | December 27, 2009 at 07:41 PM

John Freeland, Gregory, Gregory & Legacy, FP & Jenga, Don, Jim,

Gregory-- Thanks for the link to Len Lichtenfield. He is, of course, right.

Gregory & Legacy--

Gregory put it better than I did-- "tests provide information." The treatment following a test may save a life-- the test itself doesn't save a life, though it may provide the information that leads to a correct diagnosis which in turn leads to life-saving treatment.

This may seem merely a semantic distinction, but it's important.

The phrase "life saving tests" is used too often to sell tests that people don't need-- especially when it comes to cancer.
If you Google "life savings tests" you'll find a great many entries like this one: "Ten Life SAving Tests That Every Man Should Have."

These ads are pitched at healthy, asymptomatic individuals.

The phrase "life savings tests" also calls up many articles protesting what the PSTF said about mammograms, risks as well as benefits.

So that's why I would prefer to draw the distinction: tests lead to diagnosis which leads to treatment. The treatment may save a life. And, sometimes, the "life-saving test" leads to misdiagnosis.

See also my comment below, quoting Gawande on tests, misdiagnosis and autopsies.

Concerned PF & Jenga,

Gregory is not naive. He is an extremely knowledgable patient advocate who knows a great deal about cancer and cancer treatment.

And, on this blog, we don't put people down because they are not physicians, or because they are "only" nurses or are family practioners not medical reserachers.

As far as I can see, the disagreement between Gregory and Legacy comes down to semantics (see my comment above to them), but it is an important one insofar as we put too much faith in so-called "life-saving tests."

Sometimes tests get in the way of a good diagnosis.

In Money-Driven Medicine I quote Dr. Atul Gawande talking about how autopsies show that a great many patients are misdiagnosed--and die of X instead of Y.

It's not just that the death certificate is wrong-- the treatment they received for Y hastened their death from X.

Gawande and some other physicians at Harvard did a study to check just how often this is the case--and discovered that the rate of misdiagnosis is just as high as it was before we had all of these diagnostic tests.

As Gawande says, this is hard to believe--until you realize that diagnostic tests don't help make the diagnosis unless you order the right test.

Often, that means listening to and talking to the patient --something that, in our hectic hospitals, often doesn't happen.

In any case, there is no need for readers to attack each other personally.

Don--

On inurance regulation:
In the senate bill insurers in the large group market must pay out 85% of the premiums they take in , keeping no more than 15% to cover administrative costs.
Insurers in the small group market must pay out 80% of premiums, keeping 20% to cover administrative costs.

So the WSJ piece is exaggerating how much insurers will pay out. (My guess is that it that this a WSJ editorial rather than a news article.)

In addition, if insurers keep on paying doctors and hospitals more, they will jack up premiums, and the 15% or 20% they keep becomes more in absolute dollars.

As for state regulators excluding insurers if their premiums are too high -- the history of states regulating private insurers suggests that most states will let insurers continue set their own prices.

We would be much beter off with federal regulation of insurance, but the insurance industry doesn't want that, for obvious reasons.
. . .

Posted by: Maggie Mahar | December 27, 2009 at 02:33 PM

Legacy Flyer is right.

There seems to be a pattern of folks picking and choosing "facts" to support an ideological bent. And when their ideological position is undercut or shown to be lacking, the dialogue closes down and debate tactics ensue. There seems to be too much vested in "winning" an argument by any means necessary, rather than sharing a compelling point of view supported by a body of pertinent evidence.

Legacy Flyer, I agree with your assessment of CT scan use and share your frustration with non-medical folks who make sweeping and unsupportable claims in a sophisticated manner that unfortunately gives their position(s) the appearance of more credibility than they deserve. My concern is that well-intentioned, but relatively naive folks who either lack professional experience or don't have a well-informed staff to beak things down for them, will actually believe the claims and pass them along as fact, thereby making real productive change that much harder to achieve. Thanks for taking the time to debunk some of these claims.

Posted by: Concerned.FP | December 26, 2009 at 06:04 PM

Gregory,

You said:

“But as Dr. Lichtenfeld states, too many CT scans are not medically necessary and won't impact the course of treatment for the patient. Too often doctors don't know their patients enough and don't have time for a conversation about the benefits, indications and risks of a particular CT scan.”

I agree with the above statement and have said the same or similar things many times.

What I objected to was the statement: “Of course CT scans do not save lives.” – this statement is wrong. It is “throwing out the baby with the bath water” – the unwarranted conclusion that because some CT scans are not indicated and don’t produce any benefit, all CT scans have no benefit. In fact there are probably quite a few studies done in the 70’s and 80’s showing a higher diagnostic accuracy and LOWER MORBIDITY AND MORTALITY using CT compared to the diagnostic alternatives. I just don’t feel like looking through the old literature to find these studies.

I will refer to one study that demonstrates the advantages of CT over prior diagnostic methods. The study is “Acute Appendicitis: Effect of Increased Use of CT on Selecting Patients Earlier”, Raptopoulos V et al: Radiology 2003; 226:521-526. This study demonstrated decreased hospital stays and fewer “negative appendectomies” (operations done because of the clinical suspicion of appendicitis in which a normal appendix was found). If your child had been discharged earlier from the hospital or had avoided a “negative appendectomy” you might have a different view of the usefulness of CT.

You said: “People who try to win arguments not by debating the issue, but by trying to attack the person making the arguments, I'm not sure exactly what your point is? Do you feel more manly? Something missing in your psychic (sic)?”

Hmm… you are accusing me of using ad hominem arguments??? Well anyway, thanks for asking about my manliness and the state of my psyche – both are doing well.

Posted by: Legacy Flyer | December 26, 2009 at 01:14 PM

Anecdotal observation can be compelling sometimes. However, frequentist scientists feel anecdotal evidence isn't enough. They are from Missouri, show me a randomized study with a large enough population that clearly shows the survival advantage of CT scans and they'll eat their words.

The validation standard insurance companies is accepting from diagnostic tests is accuracy and not efficacy. It is not essential to prove that the use of a diagnostic test improves clinical outcomes, all they have to do for these tests is prove that the test has a useful degree of accuracy.

In the same vein as the parachute clinical trial, there have never been randomized trials to show that giving electrical shocks to a heart that has stopped beating saves more lives than doing nothing.

I just interpret it as illustrating that in life or death situations, one makes judgements based upon the preponderance of available evidence as opposed to proof beyond reasonable doubt.

But as Dr. Lichtenfeld states, too many CT scans are not medically necessary and won't impact the course of treatment for the patient. Too often doctors don't know their patients enough and don't have time for a conversation about the benefits, indications and risks of a particular CT scan.

It seems like indiscriminately writing words without substance as an alternative to constructive insight is something you may know how to do very well flyer. People who try to win arguments not by debating the issue, but by trying to attack the person making the arguments, I'm not sure exactly what your point is? Do you feel more manly? Something missing in your psychic?

Posted by: Gregory D. Pawelski | December 25, 2009 at 10:41 PM

Great post legacy,
What some people that don't practice medicine don't get is in medicine that we can't expect randomized prospective studies on every question and treatment. Some fields will never be amendable to that. In regards to CT usage, I don't know a single surgeon that would operate on an aneurysm or acetabulum without one. There are no surgeons that will sign up for a prospective randomized trial in those instances on CT scan usage and surgical decision making. It certainly wouldn't meet IRB approval. CT scans are a lifesafer. If people posting here truly believe they add nothing. Make a pledge that you and nobody in your family will ever get one. In the craze for comparitive effectiveness those of us in medicine already know, there will never be Level 1 evidence for everything physicians do and to expect anything close to it is naive.

Maggie
I totally agree about unemployment. The housing bubble was a false economy. Those Jobs and all of their interconnections are not coming back.

Posted by: jenga | December 25, 2009 at 01:52 AM

Gregory,

“There is no evidence of better outcomes for patients. This is not what it does. The test accurately measures what it purports to measure. There is a total lack of information regarding test efficacy (randomized trials with outcome measurements for diagnostic tests).”

We don’t have any randomized controlled trials proving that sticking a fork in your eye is bad for you. We don’t have any randomized controlled trials showing that jumping out of a plane at 10,000 ft. without a parachute is bad for you. However the other evidence is overwhelming.

The evidence for the safety and efficacy of CT (compared to what it replaced) is so compelling in most cases that no randomized control can ethically be done. Just a few examples:
CT scanning in the diagnosis of subdural and epidural hematoma is the standard of care. It replaced cerebral angiography. I have done both and can tell you that CT is faster, more accurate and has much less morbidity than angiography.
CT scanning in the diagnosis of aortic dissection is also the standard of care. Again it is faster, more accurate and has less morbidity than aortic angiography which it replaced.
CT scanning has largely replaced exploratory laparotomy. An exploratory laparotomy is a bad outcome compared to a CT and guided biopsy.
CT scanning has made the negative appendectomy much less common. A negative appendectomy is a bad outcome.
CT scanning in the diagnosis of patients with severe trauma is the standard of care for a whole long list of problems.
I recently attended a conference in Las Vegas on Radiology of Emergency Medicine – for at least 75% of problems, CT was the diagnostic imaging test of choice.
Etc., etc., etc.

You may be talking just about the use of CT in Oncology. I suspect that you are wrong in this area, but there is no reasonable person with any knowledge of medicine who would say that: "In regards to CT scans and there being no evidence of better outcomes for patients."
To even debate this topic with you is ludicrous, you clearly have no idea what you are talking about.

Posted by: Legacy Flyer | December 24, 2009 at 11:58 PM

John Freeland, Gregory, Don,

John-- You wrote: "The surpeme court ruled that money is speech. Too bad speech isn't money."

Well-put!

Yes that ruling stand in the way of campaign finance reform.

And the way our ecampaigns are financed explains wtih lobbyists (and the corporate interests they represent) have such an extraordinary influence in Congress.

I think this can be changed, but I suspect it will be a very long, bloody battle.

Gregoy-- Thanks for the link to Len Lichtenfield. He is, of course, right.

Don--

On inurance regulation:
In the senate bill insurers in the large group market must pay out 85% of the premiums they take in , keeping no moreo than 15% to cover administrative costs.
Insurers in the small group market must pay out 80% of premiums, keeping 20% to cover administrative costs.

So the WSJ piece is exaggerating how much insurers will pay out. (My guess is that it that this a WSJ editorial rather than a news article.)

In addition, if insurers keep on paying doctors and hospitals more, they will jack up premiums, and the 15% or 20% they keep becomes more in absolute dollars.

We would be much beter off with federal regulation of insurance, but the insurance industry doesn't want that, for obvious reasons.

Jim-- on whether there wil be lower unemployement, looking ahead a quarter of a century ---

In a quarter century, many of us will be dead.

For the foreseeable future, we can expect high unemployment. Given the cost of living in the U.S we can't manufacture many goods at a price that is competitive with other countires.

And, increasingly, Asian countries are producing products of high quality at lower prices. For the Ameirican consumer, this is good. For the American worker, however . . .

The governmetn could, and I think will, begin to create more jobs that deliver social services (teacher's aides, chld-care, people cleaning up cities, etc. But these jobs will be supported by taxes. They won't be created by the market.

You're right that many boomers who can will keep on working -- most dont' have sufficient retirement savings to retire.

But incraesingly, 50-something white collar workers are being laid off.

I know a large number of experienced, taleneted, intelligent people who cannot get a job--any job.

Jouranlism, publishing, luxury retail . .
High-end stores in Manhattan have been empty this week.

The GAP was crowded, but people were buying Socks and $11 shirts. . .

Journalism and publishing jobs are not coming back.
In many areas of academia, jobs have dried up

I'm afraid that we are looking at is not cyclical unemployment, this is a secular change in the U.S. economy.

Posted by: Maggie Mahar | December 24, 2009 at 06:04 PM

Legacy Flyer

At least in cancer medicine, no test in oncology has ever been shown in prospective randomized clinical trials to improve patient outcomes. Their performance characteristics are reproducible, favorable and provide information to treating physicians.

There is no evidence of better outcomes for patients. This is not what it does. The test accurately measures what it purports to measure. There is a total lack of information regarding test efficacy (randomized trials with outcome measurements for diagnostic tests).

Posted by: Gregory D. Pawelski | December 24, 2009 at 02:37 PM

Maggie said:
“The 88% of British physicians follow the guidelines comes from the head of NICE (the UK gov’t agency that lays out guidelines). There have been many, many articles written about how US docs don't follow guidelines. Search NEJM, JAMA, Health Affairs.”
“Or, you can just take my word for it that I don't make these things up. For this sort of thing, I take my evidence from primary sources reported in medical journals. Legacy, you've been reading this blog for a while. We agree on some things, disagree on others, but I think you know you can trust me on facts.”
I do trust you on facts, however things aren’t that simple. There are a mass of “facts” out there that need to be interpreted. People have been known to selectively cite certain studies but not others and to draw conclusions that meet their preconceived notions from ambiguous data.
So I did a little further research and Googled “physician”, “guideline use” and “UK” to see how things were going on the “other side of the pond”. I found 4 articles about use of guidelines in Medical Journals from other countries; 2 in Canada, 1 in England and 1 in Australia. Here is what these articles said:

Canada – “Most (69%) respondents were unaware of the guidelines. Of those who were aware, 46% agreed with the guidelines and 39% claimed to follow the guidelines.”
Australia – “Adherence to COPD-CPG recommendations was highly variable.”
Canada – “Family physicians were minimally aware of the existence and the detailed contents of the CCCD guidelines.”
UK – “Only 20% of physicians followed adherence protocols or formal guidelines.”

Executive Summary – physicians in Canada, Australia and the UK don’t follow guidelines either.

I am not claiming that these 4 Articles represent an exhaustive and definitive compilation of all articles on the subject. On the other hand, just because the head of NICE claims that 88% of physicians follow guidelines doesn’t make it so. I don’t think you are lying or have made up your sources, neither am I.

Posted by: Legacy Flyer | December 24, 2009 at 01:43 PM

Maggie and Gregory agree: "Of course CT scans do not 'save lives.'" and ARE WRONG.

They are "throwing out the baby with the bathwater". A properly indicated CT can be a lifesaver. I could easily give you hundreds of examples where a CT has detected a serious abnormality that needed immediate treatment or detected a serious abnormality that otherwise would have gone unrecognized until much later. I would invite you to return to the 1970s with its exploratory laparotomies, open biopsies and diagnostic angiography if you have any doubt.

The problem is not with CTs, which are valuable tests when used properly, but with the indiscriminate over use of CTs.

And as I have said before much (but not all) of this overuse is due to fear of malpractice.

Posted by: Legacy Flyer | December 24, 2009 at 12:14 PM

Maggie

Dr. Len Lichtenfeld, American Cancer Society's deputy cheif medical officer, said recently on his blog that too many CT scans are not medically necessary and won't impact the course of treatment for the patient.

Too many CT scans replace the history and physical and talking with the patient. Too often doctors don't know their patients and don't have time for a conversation about the benefits, indications and risks of a particular CT scan.

They don't have the time or the inclination to have a conversation that might outline an alternative path consistent with reasonable medical judgment.

It's a lot simpler to just go ahead and order the CT. And, if they happen to own the machine and can be paid by the insurance company, the decision gets even easier.

http://www.cancer.org/aspx/blog/Comments.aspx?id=336

Posted by: Gregory D. Pawelski | December 24, 2009 at 12:29 AM

Dr. Rick: your diagnosis regarding the sickness of our political system can't be ruled out. The problem is that the Supreme Court ruled that money is speech. Too bad speech isn't money.

The case was Randall v. Sorrell, 04-1528, 04-1530 and 04-1697. The Court, in 2006, ruled Vermont's campaign finance limits violated or skated too close to violating the First Amendment.

The serious implications of that ruling are what's infecting the process, in my view.

Posted by: John Freeland | December 23, 2009 at 05:50 PM

Ginger G is right on retirement age, which appears to be rising anyway. unemployment is weather, temporarily painful but changing. retirement age is climate. as retirement age rises, you not only help resolve projected medicare and social security imbalances, but also meet projected labor shortage-- believe it or don't-- labor economists see in next quarter century.

Posted by: jim jaffe | December 23, 2009 at 03:30 PM

Gregory & Ginger G

Gregory-- Of course CT scans do not "save lives."

But as Dr. Gawande and others have pointed out, when you step back, see that the volume of CT scans has doubled over 7 years-- and that the volume of many other diagnostic tests has been soaring--and that over the same period of time, there has been no improvment in the general health of the population, it is far to say that we are doing way too many diagnostic tests.

On the harm-- see the Op-ed in the NYT by Welch, Woloshin and Schwarts about an "Epidemic of Diagnosis."

Ginger G-- With 10% unemployment, it's not clear that we want to encourage older workers to stay in the workforce.

In any case, these days many "earlier retirees" did not retire early by choice. Employers are often eager to lay off their most expensive (older) employees.

Posted by: Maggie Mahar | December 23, 2009 at 12:17 PM

Sarag:
Thanks for providing the video link.
While the public option is not in the legislation, is it quite possible that private insurers would be regulated as public utilities.
According to an article in the Dec. 22nd Wall Street Journal entitled "Harry Reid Turns Insurance into a Public Utility,"
a recent CBO report focused on the bill's rebate program, which holds that once an insurance company spends more than 10% of its revenues on administrative expenses, its customers are entitled to an indefinite statutory rebate determined by state regulatory authorities subject to oversight by the Secretary of HHS."
"The CBO concluded that this one restriction turned the Reid bill into 'an essentially government program.'
While the Reid bill does not impose any direct price controls insurers can charge "the bill authorizes state regulators to exclude insurers from the exchanges if their prices are too high."
So, if this is accurate, we have the federal government requiring benefits, and authorizing premiums, regardless of whatever profit or loss ensues.
Are these provisions in both the House and Senate bills?
If so, the public option would seem to be mandatory, at some point in the near future.
Don Levit

Posted by: Don Levit | December 23, 2009 at 11:21 AM

Here is a video that sums a lot of things up http://www.youtube.com/watch?v=9BUI2VYC_Gg

Posted by: Sarag | December 23, 2009 at 10:28 AM

Perhaps these high non-group rates will keep people in that older bracket in the job market?

As someone who works in the DC area I know how many people retire at 55. We've got big investments in these people. Maybe encouraging them to continue working is not a bad aim.

Posted by: GingerG | December 23, 2009 at 05:52 AM

Maggie

In regards to CT scans and there being no evidence of better outcomes for patients. Is there evidence that a CT scan saves lives? No. No diagnostic/laboratory test ever has. This is not what it does.

What is the appropriate standard to judge medical tests? 1. Efficacy (use of tests improves clinical outcomes). 2. Accuracy (the test accurately measures what they are purported to measure).

Diagnostic/laboratory tests are judged by accuracy and reproducibility and never by their effect upon treatment outcomes. Most tests used today have comparable "sensitivities" and "specificities."

CT scans were not approved because they saved lives in a controlled clinical trial that compared the outcome of patients who received care with or without the benefit of a CT scan.

They were approved because their performance characteristics (sensitivity/specificity) are reproducible, favorable and provide information to treating physicians.

A cardiac CT scan provides anatomic information regarding the presence or absence of blockages in coronary arteries. Such findings alone do not determine whether or not a patient requires an invasive procedure such as an angiogram or angioplasty/stent.

Such decisions should be based on physiologic indicators such as presence of angina or, more importantly, an abnormal stress test. A cardiac CT scan by itself will never be proven to save lives. However, it is yet another tool in the arsenal that must be used properly.

In cancer medicine, the CT scan is used to follow the size of the patient's tumor while the patient is receiving repeated courses of chemotherapy to determine whether or not the treatment is working and whether or not different drugs should be given, instead.

This is an entirely unproven benefit, and were appropriate studies ever to be performed, there wouldn't be any measurable benefit at all, in terms of improving patient response to chemotherapy or patient survival with chemotherapy.

Posted by: Gregory D. Pawelski | December 22, 2009 at 10:40 PM

Jim J., NG, Ed& Dr. Rick, Pat S., Legacy (dec 22, 11 am comment) , Tim , Alena, Dr. Rick, Legacy (other comment)

Jim- I have to say that your opening made me laugh out loud:

"While I never realized that Soviet Citizens were doe-eyed . . ."

Which I don't do often --or at least not oftenenough. Thank you! A nice holiday present. )

And you are right that, for a long time, Medicare has been making some effort to make sure that "the right patiets are getting the right care at the right time."

Bariatric surgery is dangerous. Many patients never fully recover. This is not a "tummy tuck." It makes sense only in extreme cases--where obesity could lead to the death of the patient ("morbid obesityl")

Some would call this "rationing care"--I would call it protecting patients

NG-- I agree: senators from sparsely populated states have too much power. Representational democracy should come closer to representing the population.

Ed & Dr. Rick--

I agree: senate rules need to be changed. See Paul Krugman's recent column in the NYT.

Pat. S.---

Good to hear from you, and thanks much. I knew you had studied this and hoped you would respond.

Legacy--
Thank you. Yes.

Tim--
I take it that you are saying that leaving it to Congress to design our health care priorities is not such a good idea? If so, I agree.
Legilsators are not medical experts.

Alena-

Welcome to the blog, and thank your.

Dr. Rick--

Yes, I think that's it in a nutshell. . . We just have to keep stroking the keys.

Long process. Changing beliefs that are deeply embedded in our culture.

But well worth doing. No, scratch that. Essential. must be done.

Legacy--

After I wrote about WW II, it cocureed to me that I houdl have given more crecdit to the Russians (and their cruel winters).

At the end of the war, there is no doubt: the Russians mzde the difference. I should have given them full credit.

At the beginning, however, the UK made the difference. The British could have decided that this was "the continent's problem."

They thought about that,but didnt'.

The 88% of British physicians follow the guddelines comes from the head of NICE (the UK govt' agency that lays out gudeliens)

There have been many, many articles written about how US docs don't follow guideliens. Search NEJM, JAMA< Health Affairs.

Also, see www.dartmouthatlas.org on differences in practice patterns at U.S. academic medical centers.

Finally, I'm not talking about medical professionals make these decisions on a case-by-case basis (bedside rationing)

I'm talking about a panel of medical exerets (physicians, medical ethicists, medial resrachers, etc.) NOT congressmen drawing up guidelines.

And this panel needs to be protected from Congress. Otherwise, lobbyists wind up drawing up the guidlines.

Please see my response to FP as to why Congressmen are not well-suited to make wise decisions in this area.

Finally,as I have written in earlier posts, Medicare plans to slash fees for all CT-scans and some other tests as well as self-referred tests.

I can't repeat all fo the deatil in each post, so slid over this fact in the most recent one.

The reasons for slashign fees for all CT scans? Volume of these tests has doubled in 7 years with no evidence of better otucomes for patients.

We greatly over-pay for these tests when compared to other developed countries.

MedPAC rsports draw the logical conclusion that we over-do these tests in part becasue they are so lucative in our fee-for-service system.

Have written about this before, citing the report.

Again, I'm sorry, but I just don't have time to dig back into the reaserach adn find the citation for each individual reader.

If you Google HealthBeat (use Google not the Health Beat search engine)you can find earlier posts where I first cited the reserach and provided links.

Or, you can just take my word for it that I don't make these things up. For this sort of thing, I take my evidence from primary sources reported in medical journals.

Legacy, you've been reading this blog for a while. We agree on some things, disagree on others, but I think you know you can trust me on facts.
Jim J., NG, Ed& Dr. Rick, Legacy (dec 22, 11 am comment) , Tim , Alena, Dr. Rick, Legacy (other comment)