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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Wednesday, July 10, 2002

    Healthcare Crisis Redux: I was going to write something about the renewal of the healthcare crisis, but DB's Medical Rants beat me to it. He’s right that the crisis never went away, it was just hidden for a while by the smoke and mirrors of managed care. I don’t share his optimism about the ability of retainer medicine to cut costs. People who pay big bucks to have a doctor at their beck and call aren’t likely to forgo an expensive test they’ve heard about and set their hearts on just because the doctor tells them it isn’t cost effective or worthwhile. They’ll only listen to that sort of reason if they have to pay for it out of their own pocket. And from what I understand of retainer medicine, the patient’s insurance still pays for things like testing and hospitalization. Our basic attitude toward healthcare has to change if we are to bring down costs. As the governor from Vermont (who, by the way, is a physician, put it:

    "The truth is Americans want everything and they don't want to pay for anything," said Gov. Howard Dean (D-Vt.), who is running for president on a health care platform. "We need to admit to ourselves that health care is expensive because we all want the best for our families."

    Having health insurance has only contributed to this attitude:

    Patients with health insurance are primarily insulated from the true costs, said Patricia Salber, medical director for Kaiser Permanente's General Motors team. That makes everything from full-body scans to the newest antihistamine irresistible -- and it pushes up costs overall.

    This is exactly right. That’s why generous Medicare coverage for prescription medication is a bad idea. If the government foots the bill for drugs, the patient has no motivation to choose the least costly. They are far more likely to demand drugs their friends or family have used with success, or ones they’ve read about or heard about in commercials. People make more responsible decisions when they have to shoulder at least some of the financial responsibilities for those decisions. I’ve noticed this in my practice when patients suddenly go from insurance coverage that provides for drugs to Medicare when they reach 65. Suddenly, they aren’t so attached to Celebrex or Vioxx; plain old ibuprofen or acetaminophen will do for those arthritis pains. Suddenly, they no longer insist that their drugs be brand name; generic will do. And you know what? By and large, they do just as well as they did before with the more expensive drugs.

    More and more, it seems that the solution lies not in government or employers providing more money for healthcare, but in them providing less. Let insurance cover catastrophic illnesses. Let the patient take responsibility for everything else. That’s the only way to get a more discriminating, and cost-conscious healthcare system.

    A Case in Point: As if to illustrate why the price of medicine is so high, Newsweek has as its cover story, insomnia, which is a symptom, not a disease. This is a personal odyssey, for the author has insomnia. In search of a solution, she goes to a sleep lab, where for $1200 to $1600 (don’t worry, it’s covered by insurance!) she sleeps under surveillance, her every breath and every heart beat and every movement monitored and recorded. They also ask her questions about her sleep habits, caffeine consumption, etc. and do a physical exam. What does all this get her? The advice to cut back on caffeine, try a prescription nasal spray for possible allergies, and behavioral therapies to help her deal with the nightly worries that keep her awake. Gosh! That’s what I often tell my patients, and I don’t charge them $1200 for the advice. But, then again, I’m just one of those ignorant primary care physicians the article refers to, who know nothing about sleep disorders because sleep physiology isn’t taught in medical schools. I guess that’s why my advice is only worth $50.

    Another Case in Point: Woman’s Day magazine, meanwhile, is urging its readers to ask for routine urine analysis to screen for kidney disease, even though it’s widely recognized that this is not cost effective. The simple office urine test can detect protein or blood in the urine that could indicate kidney disease. The problem is, those elements can be there when there is no kidney disease, too, and they often are. Depending on the study, blood is in the urine of anywhere from 10 to 20 percent of healthy adults. Protein is found in the urine of around 17 percent of healthy adults. In both cases, the presence of serious disease was only found in 2% or less of the positive testers. This may not seem like such a big deal because the office urine test is so inexpensive, but the tests that must be done to further evaluate it can become quite expensive. In the case of protein, the urine has to be collected for 24 hours and the amount of protein excreted in that time measured to determine if there is a disease. For hematuria, the testing is more expensive. That involves Xray imaging such as IVP’s and CT scans, and often a surgical procedure to look inside the bladder for tumors (which can easily cost upwards of a thousand dollars.) It can become quite expensive to chase down a false positive result, not to mention traumatic to the patient. If everyone followed the advice of Woman’s Day and their featured kidney specialists, our healthcare costs would be spiraling even further out of control than they already are.

    So why do the kidney specialists in the article recommend this approach? Because they are thinking only in terms of their speciality. As kidney specialists, they only see diseased kidneys. They think there is more of it out there than there really is. They’re blind to all the healthy people out there, and they fail to take into account the number of people without disease who would turn up on those screening tests. That, at least, is the kindest spin I can put on their position. I could also be cynical and say that screening everyone would be a boon to their business because a lot of those false postives would be referred to them for further evaluation.

    posted by Sydney on 7/10/2002 01:20:00 AM 0 comments


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