Liver transplant outcomes better in UK

Maggie Mahar, author of one of the best books on our health care mess, Money-Driven Medicine: The Real Reason Health Care Costs So Much, has a good article at her blog on cherry picking numbers to "prove" that the U.S. has best health care in the world.

Mahar researched the numbers behind the Wall Street Journal column on Nataline Sarkisyan, the 17-year-old California girl who died last month after her insurance company refused to pay for a transplant. That column's author referred to an unnamed British medical journal study on survival rates for transplants for people suffering from chronic liver disease and acute liver disease.

Mahar begins her rebuttal by asking whether fact that we perform a greater number of transplants on seriously ill patients is reason to claim that U.S. health care is better — "or does it simply mean that we are more inclined to experiment on our sickest patients?"

It all depends on how well the average patient who is plucked out of the ICU to undergo a liver transplant fares. If he or she goes on to enjoy several years of high quality life, one would be inclined to say “yes”—our more aggressive care equals better care. But if too many patients suffer complications and then die in great pain twelve or 15 months later, it would be much harder to argue that “doing more” makes U.S. healthcare “better”—especially when both the money and the liver could have been spent on another patient who had a better chance of surviving.

She found the study used by the WSJ writer. She writes that indeed it found that patients' five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Ireland than the U.S. The WSJ author also cherry picked this statistic: "in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.”

Meaning that by the end of the first year, the differences canceled each other out. Mahar writes:

Begin with how the patients were faring during the first 90 days... during this time, mortality rates in the U.S. were lower (regardless of whether patients had originally suffered from acute or chronic liver diseases.) This is, in large part, the article suggests, due to lower nurse/patient ratios in the U.S. and more intensive care during the first weeks following surgery.

But what Gottlieb omits is the crucial fact that, when the researchers went back and looked at “patients who survived the first post-transplant year,” they discovered that “patients who had suffered from chronic liver disease in the U.K. and Ireland had a lower overall risk-adjusted mortality” than patients in the U.S. In other words, survival rates for patients who had a chronic disease before the transplant were better in the U.K. and Ireland. As for patients suffering from acute liver disease, longer-term survival rates past one year were just as good in the U.K. and Ireland as in the U.S. Moreover, if you checked patients in the interval between 90 days and one year, outcomes were similar in the two health care systems.

So in fact, "Outcomes in the U.K./Ireland were just as good for one group and decidedly better for the second... "

TPMCafe with more single-payer

Maggie Mahar's post at TPMCafe kept me up until 1 in the morning last night, reading it and all its links.

I decided to buy her book on the spot — Money-Driven Medicine is a great deal for $8 at Amazon. Here's how she begins the TPM piece:

I understand why some believe that radical reform is politically impossible. But they remind me of those who said that we could never pass Medicare. Eventually, the pain became too great. Too many seniors could not afford care, and popular support trumped the then-powerful AMA. In 1962, Gallup polls showed public support at 69% and President Kennedy called for Medicare in front of crowd of 20,000 in Madison Square Garden.

Still, it wasn’t easy.

After Kennedy’s speech, the Medicare bill was defeated 52-48. This did not stop the Democrats—they understood what was at stake. They knew that the opposition would be fierce, but they also understood that this was like civil rights. It was not a time for caution. It was a time for politicians who cared about issues....

Great stuff.

Mahar seems to say, however, that even if we did institute a single-payer system that costs could still be out of control unless we fixed provider reimbursement: "The most honest physicians admit that in our system, over-treatment is driving healthcare inflation."

This sounds like the conservative argument that overuse is the problem, but in fact overtreatment and overuse are different creatures — although they're both created by the perverse incentives of our current system's for-profit market structure. Both would be most easily rectified via a single-payer system.

She criticizes fee-for-service — which seems to be a sacrosanct part of the single-payer deal for many physicians who support reform.

To support her position, Mahar links to a wonderful piece she did for Dartmouth Medicine Online about their research on costs.

In study after study, the Dartmouth team has shown that Medicare spends twice as much, per patient, in some regions of the country than in others--for reasons that have absolutely nothing to do with medical science, the severity of the patient’s illness, or even his or her preferences.

What’s driving the higher costs? Supply.

“Build the beds and they will come.”

Based on their research, the Dartmouth team estimates that one out of three of our health care dollars are squandered on redundant tests, unnecessary hospitalizations, unproven bleeding-edge procedures and over-priced new drugs and devices that are no better than the products that they have replaced.

Some hospitals spend two-and-a-half times what others do, without better outcomes. In fact, outcomes are worse.

Both pieces are thought-provoking. Single-payer will only be part of reining in costs. If we have single-payer and continue pharmaceutical advertising, or single-payer Plan D, shackling government's ability to negotiate for better costs, or single-payer with physicians still over-utilizing questionable pharmaceuticals, lab tests, technology, etc. — we'll still have problems. Other countries are so far ahead of us on all of this.