Sam Uretsky

Health Reform: Back to Basics

There are three ways to deal with the health care crisis, other than saying we have the best health care system in the world, leaving things alone and putting cents-off coupons in Wednesday’s newspaper to show how affordable things are.

One way to bring health care costs into line would be to nationalize everything. There would be details to work out, but basically every health care provider, which means anybody who has a license to practice any health care profession, becomes a government employee. Every hospital is taken over.

The Federal government has plenty of experience managing health systems—there are military hospitals and Veteran’s Administration hospitals. Most states and large cities also have their own hospitals, so there’s no reason to think the government can’t manage the job. Everybody would be covered, which would reduce administrative costs dramatically, since there wouldn’t be a need to deal with coordination of benefits or claims refusal based on pre-existing conditions. There wouldn’t be the need to demonstrate coverage, or assign claims to collection agencies. There wouldn’t be any more multi-million dollar CEOs or physicians paid to disallow claims.

There would be one formulary, and that would save money through bulk purchases, and save time since there wouldn’t be the constant hassles about drugs that the insurer doesn’t cover. And, if the plan included enrolling every professional into the commissioned corps of the Public Health Service, they would all get to wear their uniforms once a week. The uniforms are similar to Navy uniforms, and look really good. For lots of people, the luxury of not having to decide what to wear tomorrow might be reason enough to support the plan.

That’s not going to happen.

Another approach, less ambitious but potentially worth a few billion dollars each year, would be general adoption of evidence-based medicine. The idea here is to perform some well-designed studies, determine the best treatment for a given condition with allowances for subgroups based on age, gender, and other factors as needed, and develop guidelines based on the study results.

That doesn’t seem likely either. The medical-industrial complex has its own set of rules and myths. For example, each year, about 500,000 people undergo knee surgery for osteoarthritis, at an estimated cost of $3 billion. First, there were studies showing that the surgery was no more effective than less costly (and less risky) physical therapy. Then, a report in the June 2009 issue of the journal Knee, asserted that for young, well motivated patients, unsupervised home exercise programs worked about as well as a session with a physical therapist. So far, no knee surgeons have taken the hint and gone into real estate sales as a second career.

In 2004, the American Academy of Pediatrics advised that in cases of ear infection, many children should be observed, rather than given immediate antibiotic therapy. The benefits would include some reduction in development of drug resistant bacteria, lower drug costs, fewer adverse reactions to antibiotics, and fewer parents getting a gunky pink liquid spit in their face. But in a 2007 report in the journal Pediatrics, only 15% of physicians followed the guidelines. Admittedly the most common reason for failure to follow the guidelines was that parents wanted to see their children actively treated but, one way or another, it means that lots of kids are getting inferior treatment at higher cost.

When the branded combination cholesterol-lowering agent ezetimibe/simvastatin turned out to have no more benefit than simvastatin alone, its use dropped dramatically, so that, according to the trade magazine Drug Topics, in 2008, the combination was merely the 12th most commonly prescribed brand name drug in the US with a total of 14,559,000 prescriptions written. Drug Topics reports that sales of the combination came to about $1.5 billion in 2007, about $100 million more than the sales of generic simvastatin, even though the generic had about 4 times the number of prescriptions written. Based on the study results, that’s a few hundred million wasted, and more adverse drug reactions.

True, sometimes studies disagree, but there are enough examples of routine practice that conflicts with the body of scientific evidence to show that improvements can be made right away, with dramatic cost savings.

So trying to achieve a more scientific basis for care seems like a good idea, but that’s not going to happen.

Then you could gather the leaders of the health industry, hospital and insurance administrators, CEOs of drug and device manufacturers, physicians and union leaders, and ask them all to work together, unselfishly, in a spirit of cooperation, to reform America’s increasingly dysfunctional non-system of providing health care, to offer coverage for everyone and keep the costs within reason.

Maybe we should reconsider plan A.

Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.

From The Progressive Populist, June 15, 2009

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