Too much, too lit­tle

Coun­try splurges on un­needed care while oth­ers lack ac­cess

Modern Healthcare - - Opinions Editorials - NEIL MCLAUGH­LIN Man­ag­ing Edi­tor

Notes on the news:

Crit­ics have blasted the health re­form law’s pro­vi­sions to de­ter­mine which treat­ments work and which don’t. They com­plain that bu­reau­crats armed with such in­for­ma­tion will co­erce providers and pa­tients into ac­cept­ing chintzy med­i­cal care.

They needn’t worry. The forces aligned in health­care to thwart rapid adop­tion of more efficient care are too strong. The lat­est ex­am­ple comes via a study in the May 11 Jour

nal of the Amer­i­can Med­i­cal As­so­ci­a­tion. This study looked at 2007 re­search that made head­lines when pub­lished. That re­search showed that in­ten­sive drug treat­ment in non­emer­gency pa­tients with chest pain worked just as well as an­gio­plasty in pre­vent­ing heart at­tacks. It im­proved sur­vival and re­lieved dis­com­fort in the long run.

Last week’s ar­ti­cle re­ported that two years af­ter the ini­tial study, there was only a tiny in­crease in pa­tients given drug treat­ment first. Not only is the drug reg­i­men more ben­e­fi­cial to the pa­tient, it also saves money. Ex­perts es­ti­mate that more than $2 bil­lion could be saved if drug treat­ment were tried be­fore re­sort­ing to an­gio­plas­ties.

The au­thor of the 2007 study was quoted in an Associated Press story as say­ing physi­cians and pa­tients re­sist drug treat­ment for a va­ri­ety of rea­sons. Pa­tients may see drug ther­apy as too time-con­sum­ing and just want a quick fix, for ex­am­ple. Doc­tors may fear law­suits if they don’t pull out the high-tech guns and the pa­tient later suffers a heart at­tack. He might have added the lure of higher re­im­burse­ment. The Amer­i­can health­care cul­ture pro­motes es­ca­lat­ing use of re­sources—at least for those who can af­ford it—even when the treat­ments may be in­ef­fi­cient and harm­ful. It’s hard to see any­thing on the hori­zon— and cer­tainly not the Pa­tient Pro­tec­tion and Affordable Care Act—that will

quickly change the more-(and more ex­pen­sive)-is-al­ways-bet­ter cul­ture.

The high price tag for care in this coun­try nat­u­rally hurts those least able to pay for it. An HHS re­port re­leased last week showed that unin­sured pa­tients can af­ford to pay about 5% of the amount hos­pi­tals bill for care.

The anal­y­sis re­viewed house­hold as­sets and in­come among the unin­sured in 2006-07 as well as hos­pi­tal bills and the cost of hos­pi­tal care in 2008. As­sets were de­fined as bank ac­counts and other pos­ses­sions that could be eas­ily con­verted to cash. Re­searchers found that the me­dian unin­sured house­holds with in­come be­low 200% of the fed­eral poverty level es­sen­tially had no as­sets to pay hos­pi­tal bills. Me­dian unin­sured house­holds with in­come above 200% of the poverty thresh­old but be­low 400% of the line had $300. This study used old fig­ures. Con­sider the job­less­ness cre­ated by the Great Re­ces­sion and the pre­vi­ously men­tioned high prices, and you can see why it’s tough to be poor and sick in this coun­try.

States are tak­ing dif­fer­ent—some­times wildly dif­fer­ent— ap­proaches to the prob­lem of ac­cess to care. Ear­lier in this is­sue, we noted how Ver­mont is seek­ing to es­tab­lish a uni­ver­sal, gov­ern­ment-run health­care sys­tem. Florida, on the other hand, has passed a bill that will place Med­i­caid re­cip­i­ents in pri­vate man­aged-care plans. Repub­li­can lawmakers and GOP Gov. Rick Scott (for­merly chief of Columbia/HCA) backed the mea­sure. This fun­nel­ing of pub­lic money into pri­vate plans is un­likely to con­trol costs (think Medi­care Ad­van­tage) and prob­a­bly will re­sult in fewer ser­vices to Med­i­caid re­cip­i­ents since the plans will get a cut of the sav­ings. Other ben­e­fi­cia­ries could in­clude ur­gent-care clin­ics cater­ing to Med­i­caid pa­tients, such as the one Scott founded.

But you can be sure that while some gain, those with the fewest re­sources will suf­fer.

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