On wasteful medical spending.

On wasteful medical spending.

Given that our bizarre medical spending practices could doom the U.S., it feels strange to write about this topic as a participant-observer.  So let me state upfront: I tried!  I argued with my medical care providers for several minutes, trying to keep them from wasting money.  I used logic.  I cited evidence.  I lost the argument.  They stuck to their position with the unwavering intransigence of bureaucratic rule-followers.

They were probably right to ignore me.  If a bigwig in a suit writes guidelines saying, “Do it this way,” a nurse or doctor might be fired for doing things differently.

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Art by MTS<:U on Flickr.

The background: many people in my hometown recently contracted mumps.  Those who work with young people were instructed to get a “mumps titer” — this means measuring the concentration of mumps antibodies in a person’s blood — and those with low readings would be told to get vaccinated.

Sounds sensible enough.  But the titer is more expensive than the vaccine, and we have the vaccine in abundance, so I went in and asked them to just vaccinate me.  Yes, I was vaccinated already as a child, but it doesn’t hurt to get a booster.

They refused.  It’s a live vaccine, see?  To vaccinate you, they inject the actual virus.  The goal is to produce a “subclinical infection.”  But some adults have an adverse reaction — they get sick.  To minimize risk, our health care provider wanted to vaccinate only those people who seemed to need it.

The problem with this logic is fairly clear — although some people may get sick from the vaccination, the people who get sick are going to be those who were not yet immune.  By screening people with high titers, the total number of patients suffering an adverse reaction won’t go down at all.

The faulty logic would be problematic even if the mumps titer was a good assay.  But it’s not.  It’s fairly well known that it produces many false negative results — people who appear not to be immune to mumps, but are.  According to my health care provider’s policy, many people who are already immune to mumps will be vaccinated again.

This is fine from a health perspective, of course.  A second immunization will not hurt.  These people are very unlikely to get sick from the attenuated virus.  The only problem is that money was wasted on the titer.

Worse, common titer assays have a fairly high false positive rate: that is, people who appear to be immune, but aren’t.  Under my health care provider’s plan, these people won’t be vaccinated.  Now, these are people who might get sick from the vaccine — but they’d get much sicker if exposed to the actual virus.  If they’re not vaccinated, they’ll be left at high risk.

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Compared to simply vaccinating everyone, testing everyone by mumps titer costs somewhere around twice as much.  Add in the number of vaccines that have to be given after the tests and the plan is even more expensive — even if everyone in the population already is immune to mumps and you’re only giving booster shots to those with false negatives, that could easily be twenty percent or more.  If you’re dealing with a mixed population where some people aren’t immune, the outlook is worse.  Then you’re also risking that someone with a false positive result, whom you decline to vaccinate, gets sick.  Mumps can make you very sick, especially adults.  It can cause brain inflammation — my father, who contracted mumps as a child, needed a spinal tap to get through it.  A scary procedure.  Much more expensive than the vaccine.

(Well, a spinal tap now is much more expensive than the vaccine now.  For my father to have been vaccinated, someone would have had to build a time machine and launch the shot into the past.  Time travel takes huge amounts of energy & is rather more expensive than a spinal tap.)

Nobody at my health care clinic was convinced.  They were adamant.  No vaccine without phlebotomy!

At least the universe has a sense of humor.  After all that, of course my titer would be a false negative.  Their money wasted, they called me back and had me get the unnecessary shot.  Just like I’d requested from the beginning.

On medical spending.

On medical spending.

Trepanation_-_feldbuch-der_wundartzneyBack when doctors were curing headaches by drilling holes through people’s skulls, or slapping on a few leeches to drain out the bad blood when sick patients came stumbling through the door, medical spending wasn’t a big deal.  There weren’t any serious political considerations attached.  If you were wealthy, you might visit a doctor and get yourself killed.  If you were poor, you’d probably go without medical care.  You’d live or die according to the virulence of your disease and the quality of your diet.  Maybe you’d buy a small amulet representing one of the healing saints, or pay a witch to bury herbs in an auspicious location near your house.

I haven’t done an extensive review of the historical data, but to the best of my knowledge no ancient kingdoms were bankrupted trying to provide leeches to all their sick citizens.

Now, though, the situation is different.  Medical care is better.  Doctors know enough that patients receiving care fare significantly better than those left untreated.

There are dramatic economic consequences of improved medical care, though.  Leeches and bloodletting and trapanation were ineffectual, but they were cheap.  Modern medical care actually saves people’s lives, but it comes at a huge cost.  In the United States, health care spending is about a fifth of the total economy, and rising.

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Albrecht_Dürer_-_Death_and_the_Lansquenet_(NGA_1943.3.3611)Death is scary.  For people who started learning philosophy with Camus (which is not something I’d recommend — this can result in an excessively bleak world view and is probably appropriate only for incurable depressives), inescapable death seems to be the major quandary in our attempt to ascribe meaning to life.

The fear of death fuels medical spending.  Also our spending on biomedical research.  Medical care is pretty great currently, especially if you’re comparing statins and anti-retrovirals and insulin to leeches.  But people still die.  We haven’t reached the singularity yet (thank goodness).

Leeching-largeBiomedical research spending makes the population as a whole sicker, though.  Most research innovations — and certainly the most lucrative ones — are for managing chronic conditions, not curing them.  People who would’ve died — how many leeches do we prescribe for atrial fibrillation? — survive instead, lowering our population’s average health.  And raises average age, since those first few maladies aren’t killing people as often.

It’s not so difficult to imagine that, if these biomedical research trends continue, people might survive until a hundred and fifty, maybe two hundred years old … and health care spending will rise until it’s a third of the U.S. economy, or fifty percent, or more.

That could doom the country.

But the real tragedy, to my mind, is the way that health care money is being spent.

9781250044631I think a passage from Damon Tweedy’s Black Man in a White Coat gives an elegant summary of the problem.  The whole book is great — I’d highly recommend it to anyone who cares about either racial inequality or the U.S. medical industry.  Tweedy’s writing is so compassionate, always looking to describe the best in people even when his narrative compels him to shown them at their worst.

The passage I want to quote appears just after Tweedy describes a preventable medical tragedy brought on by poor lifestyle choices.  Tweedy grabs a hasty meal with some of his colleagues and is still mulling over what more could’ve been done to help the patient.  Ironically, this leads to a conversation about counseling patients to eat better, but Tweedy and the other doctors are scarfing extremely unhealthful meals.

It really is a great book — big-hearted and earnest, with Tweedy always clear-eyed about his own failings.  His descriptions of his own struggles with poor lifestyle choices really dramatize his efforts to address other black men’s unhealthy lifestyles.

(Oh, and, I fixed a minor typographical error in the following quote without marking it — I always think  sic erat scriptum sounds snarky, and Tweedy’s book was good enough that I’d feel like a total jerk if I made him look bad for what was probably someone else’s mistake.)

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Medical doctors should know better than to eat hospiteria (hospital cafeteria) pizza.

I asked them their thoughts on counseling patients about nutrition and exercise.

“That’s the responsibility of his outpatient primary care doctor,” he said.  “We’re here to deal with the life-and-death stuff.”

This focus on biomedical treatment over preventative care is not limited to Duke or similar schools.  Indeed, outpatient primary care physicians — the doctors that Mike felt bore the responsibility for counseling patients on diet and exercise — are often no more inclined than other doctors to have this discussion, even for diseases where these interventions are vital.  There are many barriers, among them money (dietary counseling is reimbursed poorly compared to medical procedures), time (physicians often see patients every ten or fifteen minutes), and the sense that nutrition talk is better left to dieticians, and that doctors should focus on their expertise (prescribing medications, interpreting tests, and performing procedures).  In addition, experience has made many doctors cynical about patient behavior and the likelihood for change.

The tragedy of U.S. health care spending isn’t just that we shovel too much money into it, which limits what we can spend on other, more important causes, but also that we pour huge sums of money into end-stage therapies that don’t increase quality of life nearly as much as cheaper, earlier interventions.

My father-in-law’s treatment is a great example.  By the end of his life, the federal government was spending hundreds of thousands on his care.  Medication for cholesterol and diabetes, high-tech surgery to replace arteries & restore nervous function in his hands after they’d been numbed by diabetic neuropathy, installing an internal defibrillator once his heart began to fail…

Those treatments helped.  Sure.  They kept him alive longer.  He was incredibly happy after the hand surgery — for months he’d been unable to play guitar because he couldn’t feel anything and could barely exert enough pressure to fret the strings, and after that surgery he could play again, invited everyone he knew for another potluck & jam session.

When K dropped her father off after that surgery, she realized our government’s medical spending on him was actually helping dozens of people — all his neighbors were outside waiting to greet him, and once he could use his hands well enough to cook again he resumed baking loaf after loaf of sourdough bread to give to them.

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I couldn’t find an image of any breads that look quite as dense as the whole-wheat loaves Mike used to bake for everyone, but David Jackmanson‘s seems close.

At the same time, our government could’ve brought K’s father — and everyone he helped — more joy by helping him earlier.  They spent nothing on him until his untreated conditions left him too disabled to work.  Only then, and even more so after he reached sixty-five, could he get help.

It’s crummy knowing that he would’ve been happier, and would’ve been able to give more back to his community, if he’d been helped earlier.  His childhood was rotten, but nothing was spent to overcome the scars left from hostile parenting.  Our government didn’t help him get counseling after a traumatic event in his early adulthood, either, and that was the root of so many of his later problems.  A few thousand spent to help him then could’ve kept him from becoming indigent. A few thousand spent on psychiatric counseling then would’ve staved off the need for the hundreds of thousands in medical care that were provided later.

This bizarre state of spending priorities is reflected very clearly in our federal budget.  For instance, there’s no money set aside for universal pre-K education.  This would only cost on the order of $10 billion dollars, though, whereas we spend something like $500 billion on health care for the elderly.  But if our goal is to produce good health, childhood education accomplishes much more than surgery and pharmaceuticals for the elderly.

As Tweedy wrote, simply teaching people to eat better would obviate the need for a significant percentage of our medical spending.  Maybe we’d need to spend some money subsidizing real food so that a better diet was within more people’s reach, but, still… that’s much cheaper than the life-and-death medical care that Tweedy was trained to provide.

After an education worth some hundred thousand dollars, after two decades of hard work & studying on his part, Tweedy served as part of a care team working arduous thirty-hour shifts … all to save people who might’ve stayed away from the hospital entirely if they’d been eating vegetables.