Geography & healthcare

Consumer Reports has published an article on the Dartmouth Atlas of Health Care - a wonderful thing. Consumer Reports is really on a tear about healthcare, and this article provides our friends and neighbors information about a big part of what's wrong with U.S. healthcare.

Because physicians are paid on a fee-for-procedure, cost-plus basis, the incentives are to do more procedures, rather than just the right procedures. Physicians and nurses are generally ethical people, but they're just human. Add the need to pay for that MRI machine to the old lady's son insisting on "Do whatever's necessary, doc," and you end up with unnecessarily aggressive treatments - something proven out by the crazy regional differences on how many procedures patients are getting some places - without better outcomes.

Geography and health care
The amount of medical care that people get for serious illnesses varies enormously from place to place. In the last two years of life, the average patient spent 11 days in the hospital in Bend, Ore., and 35 days in Manhattan. In those same two years, patients visited the doctor an average of 34 times in Ogden, Utah, and 109 times in Los Angeles.

The Dartmouth Atlas based those findings on the Medicare claims records of millions of patients who died from (in order of prevalence) congestive heart failure, chronic pulmonary (lung) disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular (circulatory) disease, diabetes with organ damage, and severe chronic liver disease. Together those ailments account for about 90 percent of deaths of people older than 65.

Over the years, Dartmouth research has yielded some startling insights:

• The local supply of doctors and hospitals has more influence on the amount and type of care that patients receive than their actual medical conditions have. The more medical resources a region has, the more aggressive the treatments are.
• In the regions that deliver the most care, patients have a slightly higher death rate than patients with the same conditions treated in areas that treat less aggressively.
• Patients treated most aggressively are no more satisfied with their care.
• The cost differences are vast. Average Medicare spending over the last two years of life for all hospitals ranged from a high of $81,143 in Manhattan to a low of $29,116 in Dubuque, Iowa.

So the Dartmouth folks are big on best practices, as are other medical systems that keep down healthcare costs - and simultaneously maintain good access. (Note in the Consumer Reports' articles that "Patients in the high-spending, aggressive-care regions waited longer in emergency rooms and doctors' offices than patients in lower-spending regions did.")

Linda Gorman, from the libertarian Independence Institute and a commissioner on Colorado's Blue Ribbon Commission for Health Care Reform, was always vehemently against "best practices." She argued that the science was too soft, that it was subjective, that by God if a patient wants bad care then it's their right to get it - or something along those lines.

These are folks who also consider the science behind global warming to be a bunch of hooey. I don't know whether they also think the moon landing was a hoax.

Part of progress - and survival - comes from measuring cause and effects and paying attention to the answers. Dartmouth has come up with some pretty good answers here - information that's important whether we get a healthcare system or remain stuck with laissez-faire, for-profit healthcare. If we had a healthcare system, we could move more quickly and surely with this information towards more efficient and humane standards. Until that day, we'll muddle through and probably get partway there. Or not.

Low U.S. medical literacy

It's definitely not Lake Wobegon, "where all the children are above average."

In fact, by definition, half the population is below average -- in anything. Which just goes to show how ridiculously complicated and user-deadly the U.S. healthcare market is. Only about one in ten of us has the skills necessary to successfully negotiate the system and get appropriate care. The only reason we don't know it is because, for the most part, most of us are healthy.

A Medical News Today article cites a study that indicates that just 12 percent of 228 million adult Americans have those skills. The assessment is from the Agency for Healthcare Research and Quality. These skills include weighing the risks and benefits of treatments, being able to calculate health insurance costs, and understanding how to deal with complicated medical forms.

Moyers covers the Cal Nurses

Take a look at this great segment from Bill Moyers' Journal, at PBS.

It brings back my favorite observation from T.R. Reid's "Sick Around the World" special: the fact that we in the U.S. don't have a health care system, we have a market. In the same way that sprawl isn't city planning. It's what happens when there isn't city planning.

Uninsurance Hurts the Insured Too

When I saw this editorial in the New York Times, I had mixed feelings. It's on the Harvard study on emergency room delays. (The article in the Boston Globe on that is here.)Their lede:

The nation’s failure to provide health insurance for all Americans seems to be harming even many of those who do have good health coverage. That is one very plausible interpretation of a disturbing increase in waiting times at emergency rooms that are often clogged with uninsured patients seeking routine charity care.

gives me the sense that one plausible solution is to bar giving medical care to the uninsured via emergency rooms. Although, according to Bush and libertarians, care in emergency rooms is why we already do have "universal health care" in America. The libertarians don't think it's right. It would be a shame if more people came to fear for their own care and instead of doing the right thing, chose to punish instead.

The NYT edit reads, "Uninsured patients — and those who have no primary care doctor — flock to emergency rooms for routine coverage, clogging the system."

It's important to note that it's not just routine coverage that the uninsured seek care for. It's also life-threatening conditions -- which might have been "routine coverage" had it been treated months earlier, in a physician's office.

What's more, part of the problem is that hospitals, needing to compete in a brutal for-profit environment, are closing emergency rooms, and physicians are declining to be part of care for emergency room patients. From the edit: "The Institute of Medicine, a unit of the National Academy of Sciences, warned two years ago that the nation’s emergency rooms were at a breaking point."

In response -- emergency room closures or near misses:

• in St. Louis
• in Philidelphia
• in Brooklyn and
• in Buffalo

That's just a round-up of today's closure news.

Here in Denver, they're closing city hospitals and relocating to the suburbs. Not a problem, say the PR people -- but if you talk with docs and nurses at Denver Health downtown, they're deeply concerned about what the urban healthcare future holds.

Headed In The Right Direction?

My mother was dirt poor growing up growing up in North Florida. She got out as fast as she could. Like many other poor Southerners in the 1940s, she headed to Chicago, where she graduated from Mount Sinai Hospital's nursing program.

Not too long ago she mused aloud how her life might have been different if her family hadn't been so poor when she was growing up. The casual observer might think that she'd done OK, poor childhood or not. Indeed, all the Joiner kids were part of the karmic reward of the American dream lifting all boats after World War II. All five siblings made it to the middle class, all but one, in fact, to the upper middle class. My mother and her younger sister married doctors; her older sister became a nurse and married a teacher, and the youngest sister married a city planner. My uncle became an engineer. My own mother never worked outside the home after her first child was born. She lived in a sprawling suburb of big houses on oversize lots and took a nap every afternoon.

But the naps, rather than giving insight into some innate laziness on her part (and there is some of that — in a never-ending rebuke to her own, driven mother), are more a legacy of the malignant effects of poverty. Debilitating, health sapping poverty. The Southern variety. My mother's health was never good, her stamina nonexistent.

The Public Library of Science's journal of Neglected Tropical Diseases has a piece on current U.S. health disparities. It's a reminder of how close the connection is between health and success.

During the early 20th century hookworm was a highly endemic soil-transmitted helminth infection in the American South, and a major cause of severe anemia and malnutrition in the region. Together with malaria, niacin deficiency (pellagra), typhoid fever, ascariasis, trichuriasis, and other conditions common to areas of tropical and subtropical poverty, hookworm helped to foster the concept of the “sick man of the South” or the “lazy Southerner.” The poverty-promoting aspects of these diseases are powerfully illustrated by the recent work of the economist Hoyt Bleakley, who has estimated that because of its impact on child growth and development, school performance, and school attendance, chronic hookworm infection in the American South was responsible for a 43% reduction in future wage-earning.

The writer's conclusion? "There are no excuses for allowing such glaring health disparities to persist in one of the world's wealthiest countries."

Except that, of course, there are plenty of excuses. A couple trillion dollars worth of excuses. Ask a progressive. They'll explain why real health care reform — that is, the proven reform that universal, single-payer health care brings, just isn't feasible.

And as long as that's the progressives' line, it's true. And as long as that's true, our nation will continue heading in the wrong direction, towards a developing world status in health care, education, and the chasm of disparity between rich and poor.

Sicko's even at Business Week

Sicko's even at Business Week — and with a positive review. Which is as it should be. Our healthcare system is bad for business.

"Anything—including a film—that can bring this issue into the public eye is good for the debate," says heart surgeon Dr. William Plested, president of the American Medical Assn. "So, I'm cheering on Michael Moore, even though I haven't seen the film."

Business Week has a nice trailer for the film there.

Can we reform the system? Or are the cynics right, and it's "unfeasible"? If that's the case, we're in the decline and fall of our democracy. Here's a comment from a recent Washington Post back and forth with Steven Pearlstein:

If you look at wealth inequality from an historical point of view, you will see that countries with a vast difference in the percent of wealth held by the upper 1 percent (say) as compared with the lower 90 percent (say) soon go down the tubes. The reason is that wealth translates into political power, and soon the country is making decisions that benefit the top 1 percent and not the country as a whole. This is discussed in detail in Kevin Phillips' "Wealth and Democracy." Since this is a feedback situation, it tends to happen and has at least started to happen several times in our history. The strength of America has been that just when the trend starts to enter the strong feedback stage, something has happened that redistributes the wealth. The rise of unions and FDR are two such examples. What we have to worry about is that the trend of wealth piling up in the top 1 percent or 0.1 percent is increasing and we see the country taking positions that benefit only the Rich. Two examples are taxing dividends and capital gains at a lower rate and the attempt to abolish the estate tax. I am sure you can come up with many more such examples.

Time to redistribute, wouldn't you say? Or are we too "free market" to save the country?