April 27, 2012 | 1:58 pm

Learning from Massachusetts

Posted by Albert Fuchs, M.D.

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picture credit: thinkprogress.org

In 2006 Massachusetts passed sweeping health care reform which provided for insurance coverage for nearly all of its residents. In 2010 the Affordable Care Act (ACA) was passed at the federal level which will enact very similar reforms nationally. While the US Senate was debating the ACA, the New England Journal of Medicine (NEJM) published one opinion article after another extolling the ACA’s virtues and making positive comparisons to the benefits that Massachusetts had experienced under its health care reform.

Since then, the data coming from the Massachusetts experiment has not been encouraging, and I was gratified to see this week a NEJM opinion piece which gives a very frank appraisal of the state of health care in Massachusetts.

The one incontrovertible measure by which the Massachusetts plan has met its goals is that nearly everyone, 98% of the state’s population, has insurance. That has come at a cost which even the article’s authors admit is unsustainable. Massachusetts is now among the highest states in the country in per-capita health care spending, and health care is taking up a larger fraction every year of the state’s budget, crowding out other priorities. The growth of health care spending in Massachusetts is also consistently higher than economic growth, another indicator that the current system is unsustainable.

One of the justifications of the Massachusetts plan (and of the ACA nationally) was that it would make insurance more affordable for the middle class, but in Massachusetts insurance premiums have become more expensive, and have done so faster than in the rest of the nation.

Other sources, including the Massachusetts Medical Society, inform us that wait times for a primary care physician have skyrocketed and the number of doctors accepting new patients and accepting state insurance plans have dropped. That makes sense and was predicted by critics of the plan. If the number of patients who can seek care at little cost to themselves is suddenly increased without a corresponding increase in the number doctors, longer wait times are bound to result.

So Massachusetts has shown us how to build a system in which everyone has insurance but only few can get to a doctor. One would think that the authors of the NEJM article would conclude that it is a well-intentioned but unsustainable failure and a sobering warning about what we are about to impose on the nation. Instead, they are so wedded to the mirage of universal insurance coverage that they spend the second half of the article discussing desperate ways to save the plan through various cost-cutting measures. These schemes quickly degenerate into an alphabet soup of bureaucratic names like ACOs and the AQC. If any of these manage to cut costs without worsening care, I’ll eat my stethoscope.

I’ve explained before how the health insurance market broke and why buying routine care through insurance is the problem, not the answer. Universal insurance coverage simply universalizes a terrible way to acquire care. We should give that some thought before the ACA rolls out nationwide.

Learn more:

Controlling Health Care Spending — The Massachusetts Experiment (New England Journal of Medicine perspective article)
Kaiser Family State Health Facts – Massachusetts
Massachusetts Medical Society Releases 2011 Study of Patient Access to Health Care (Massachusetts Medical Society)
Six ways Romneycare changed Massachusetts (Washington Post)
Three Lessons from Massachusetts (National Center for Policy Analysis)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

April 20, 2012 | 12:41 pm

Measles Cases in 2011 Highest in Fifteen Years

Posted by Albert Fuchs, M.D.

rash due to measles
(CDC / PHIL / Wikipedia)

Three years ago I wrote a post alarmed that measles was on the rise in the US. Little did I know then that this was only going to get worse.

This week the CDC released data in its Morbidity and Mortality Weekly Report and in a telebriefing for the media reviewing the measles statistics for 2011. The numbers are worrisome. (The picture on the right shows the typical rash caused by measles.)

There were 222 cases of measles in the US in 2011, the highest number since 1996, and much higher than the average annual case count in the last decade, 60. This may not sound like a big deal, since most cases of measles are mild, but a third of the patients with measles are hospitalized. Fortunately, there were no deaths in the last year.

Because the US population vaccination rate for measles is very high, most of these cases (200 of the 222) were linked to importations of measles from abroad, either due to a US traveler being infected while outside the country, or a foreigner traveling to the US while contagious. Half the cases from abroad were from Europe, primarily France, Italy and Spain. (This proves that despite their fiscal challenges the European Union can still export something.) Unlike the US, Europe has never eradicated year-round person-to-person transmission of measles, so it continues to act as a reservoir of disease. In fact, last year, over 37,000 cases of measles were reported in Europe.

So the CDC is stressing two points. The first is that the MMR (measles, mumps, rubella) vaccine is effective and safe, and all children should have two doses of it. Some of the measles cases last year were among patients who could have received the vaccine but claimed exemptions due to philosophical or personal beliefs. Unvaccinated people don’t only run the risk of being infected with measles themselves; they also risk infecting those around them, particularly infants too young to have been vaccinated.

The second message promoted by the CDC is that travelers abroad should make sure they’re immune to measles. Those born before 1957 are presumed to be immune because that was before the vaccine was widely used and everyone was exposed. Everyone born since 1957, however, should be sure they’ve had two doses of MMR. For those who are not sure, the CDC simply recommends revaccinating. An additional MMR is safe even if unnecessary and is more reliable than checking a blood test to determine immunity.

So when you go to the London Olympics this summer, keep in mind that the adorable Parisian child in the next seat might be a biohazard. Defend yourself.

Learn more:

In 2011, U.S. logged the most measles cases it’s had in 15 years (LA Times Booster Shots)
CDC Telebriefing on Measles – United States, 2011
Measles — United States, 2011 (Morbidity and Mortality Weekly Report)
WHO issues Europe measles warning (BBC News, December 2011)

My previous posts on measles and vaccinations

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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April 6, 2012 | 11:37 am

Healthcare That You Should Avoid

Posted by Albert Fuchs, M.D.

Photo by Wikipedia

Why wouldn’t you want an EKG every year as part of your check up? Why would you not want to be screened for prostate cancer at the age of 80 (or maybe at any age)? Why should you decline the annual chest X ray that your doctor keeps ordering? Is it because you’re eager to save money for your insurance company? Is it because you think going without the test will help others who are more needy get the test in some complex rationing scheme? No. You should forego the above tests because they are much more likely to harm than help you.

Unfortunately, some of the care physicians deliver is entirely without benefit. I’m not saying merely that some care hasn’t been proven to be effective. That can be excused, since in many fields the scientific evidence is scant and the individual doctor’s judgment is our only guide. I’m saying that much of the care that is delivered has been rigorously proven to be ineffective or harmful.

Why are doctors ordering so many useless tests and treatments? Some blame “defensive medicine” the practice of ordering tests or treatments not for the patient’s benefit but to protect the physician from liability. Some blame unsophisticated or demanding patients. Neither of these explanations is fully persuasive.

Whatever the cause of this pervasive delivery of care that is worthless or worse, a group of American physician specialty societies have partnered with the American Board of Internal Medicine Foundation to do something about it. Their initiative, Choosing Wisely, lists 45 tests and treatments in nine different specialties that physicians should stop ordering and informed patients should decline. These tests and therapies have been definitively found to have no value and yet remain widely utilized.

Some of the 45 recommendations of Choosing Wisely are:

• Don’t order sinus CT or prescribe antibiotics for uncomplicated acute rhinosinusitis.
• Don’t screen for osteoporosis women younger than 65 or men younger than 70 with no risk factors.
• Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
• Don’t repeat a colonoscopy for colon cancer screening sooner than 10 years after a normal screening colonoscopy.
• Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.

I strongly encourage you to explore the website and read the recommendations yourself.

Of course, physicians who have been trained recently or who keep abreast of the medical literature already know most of these recommendations, and patients going to doctors who practice evidence-based medicine have already been taught many of them.

But if these treatments and tests are known not to help patients, why are they still performed so frequently? The “defensive medicine” excuse rings false. After all, the best legal defense is ordering what’s best for the patient. Some use of ineffective tests and treatments could be attributed to ignorant and demanding patients, but where would the patients initially have learned to ask for an annual EKG or an annual chest X ray if their prior doctor had not been ordering these tests?

I think the only convincing explanation for the misuse of most of these tests and treatments is economic. Doctors make much more money in ordering these tests than in educating patients that they’re bad for them. Moreover, the patients don’t suffer the economic consequences of this misuse, since the cost is frequently borne by insurance. Our broken healthcare system insulates patients from the costs of their healthcare decisions and thereby encourages the use of expensive therapies that have little value. In other marketplaces, in electronics, or transportation, or clothing, or food, expensive goods that have little value are usually called rip-offs. A few unsuspecting customers might fall for them, but word soon spreads and consumers soon learn to watch their wallets. But in healthcare the patient isn’t paying, so he doesn’t bear the price of the rip-off but redistributes it to the other enrollees of his insurance company (or to taxpayers if he has Medicare or MediCal). The insurance company can then try to limit the utilization of these tests, but the insurance company isn’t in the examination room. The highly “motivated” doctor can simply add a word or two to the patient’s symptoms to have the test approved. The EKG can be billed for chest pain even if the patient doesn’t have any. The chest X ray is indicated for a cough that the patient doesn’t have.

The doctor gets paid. The patient is fooled into thinking that he got a useful test for free. Someone else gets the bill. Costs keep skyrocketing. Any efforts by the insurers to limit payment are answered with emotional shouting about “rationing”. Rationing is when you don’t use something so someone else can have it. We’re talking about things that simply have no benefit and shouldn’t be given to anyone.

Choosing Wisely is a welcomed effort. I hope it succeeds, but I predict it will not. As long as the perverse economic incentives persist so will the useless but expensive therapies and tests. I’ve written before about how our healthcare marketplace broke and what I think will be needed to fix it. Until then, we are wise to remember that we get what we pay for. And we’re all paying for expensive and ineffective healthcare.

Learn more:

The Choosing Wisely website

Doctor Panels Recommend Fewer Tests for Patients (New York Times)
Doctors seek end to 5 cancer tests, treatments (Chicago Tribune)
Doctors unveil “Choosing Wisely” campaign to cut unnecessary medical tests (CBS News)

WolframAlpha U.S. healthcare expenditures time series (click on “linear scale” by the graph to get a clear picture)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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