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Anti-Rationing

Ceci Connolly has a nice piece explaining that the imaginary problem of centrally rationing health care -- which is to say, underusing health-care services -- has totally obscured the actual and current problem of overusing health-care services.

The sort of rationing that health-care reform's critics worry about -- where a government bureaucrat says you can only have one MRI a year -- does not actually happen in this country, but gets a lot of attention anyway. The sort of rationing that health-care reform's critics don't worry about -- where you can't afford even one MRI a year -- does happen, and also gets a lot of attention.

But then there's the third problem, the one that doesn't get any attention: Overuse. This is, in a way, the anti-rationing. Concerns about rationing focus on the possibility that someone or something will keep you from getting care you don't need. Concerns about overuse focus on the probability that someone or something will try to convince you to get care you don't need and that isn't likely to work. And this isn't like buying an extra DVD player. Care you don't need is care that will cost you, care that will hurt you, care that will have side effects, care that will require recovery time, and care that could even, in some cases, kill you.

We know that's happening now. We think 15 percent to 30 percent of the treatments being prescribed in the country aren't helping anyone. There are a lot of explanations for this -- insufficient evidence, defensive medicine. But one of the big reasons is a word that doesn't appear in Connolly's article: profit.

Drug makers, device makers, hospitals, and even doctors make more money by providing more care. Sometimes they respond to those incentives consciously, as when drug makers saturate us with ads attempting to redefine melancholy as a treatable illness. Sometimes they respond unconsciously, as when doctors begin to think only in terms of what might work rather than what is worth trying. But it happens. And it hurts us, and it costs us, and unlike the dreaded bureaucrat standing between you and your doctor, the money flowing from you to your doctor to the health system is actually real.

By Ezra Klein  |  September 29, 2009; 12:00 PM ET
Categories:  Health Reform  
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Comments

American women have a 63 percent chance of living at least five years after a cancer diagnosis, compared to 56 percent for European women.

American men have a five-year survival rate of 66 percent — compared to only 47 percent for European men.

Posted by: nathanjfscott | September 29, 2009 12:25 PM | Report abuse

One of the biggest steps which could be taken to deal with overuse would be to ban prescription drug advertising, which I do not believe is allowed in any other country. What is the rationale for allowing ads for something which you cannot legally go out and decide by yourself to buy? We take the position that only doctors are capable of deciding when a prescription drug can appropriately be used, so there is no logical case for mass market advertising - do you really trust your doctor with your medical care if he/she is too dumb to know which drug you need unless you come in and tell him about it? (If you are suffering from the tragedy of 'hypotrichosis', he should certainly note that and provide you with a prescription to thicken your eyelashes forwith, even blindness if a possible side effect!)

Posted by: exgovgirl | September 29, 2009 12:28 PM | Report abuse

nathanjfscott....very true. But be careful about cherry picking your statistics. There are many many others that would show the reverse to be true---that European systems are superior to ours.

Posted by: scott1959 | September 29, 2009 12:34 PM | Report abuse

It's very difficult to tell if survival rates are due to different rates of detection, different treatment or what.

For example, if you detect earlier and treat the same, you'll show longer survival rates, even though treatment is no better. In the extreme case, treatment can be worse, yet earlier detection can show longer survival rates.

That's why overall statistics such as life expectancy are more useful.

Posted by: fuse | September 29, 2009 12:35 PM | Report abuse

anyone that has seen me around here knows that one of the tenents I have a problem with is medical necessity. I fell off my chair this weekend when I saw the drug "Latisse" advertised on TV. This drug after I checked into it makes women's lashes longer and thicker. How long before insurance is asked to cover this?? Is there any reason there is a cost issue? Infertility, baby formula, gambling addiction couseling are just 3 ridiculous benefits that are covered in my state of NJ that adds to the cost. At some point enough is enough.

Posted by: visionbrkr | September 29, 2009 12:48 PM | Report abuse

Uh, melancholy? Are you singling out depression as a fake illness, along the lines of "social anxiety"?

Also, in this sentence -- "Concerns about rationing focus on the possibility that someone or something will keep you from getting care you don't need." -- I think that "don't" is a typo.

Posted by: vancemaverick | September 29, 2009 12:51 PM | Report abuse

Seriously? You're saying depression is a trivial, non-medical problem? Prepare for the backlash!

Posted by: albamus | September 29, 2009 1:04 PM | Report abuse

Overuse IS a problem, and becomes a more critical issue as government becomes increasingly involved. Japan provides a prime example of hospital overuse: the tendency to _want_ to stay in the hospital longer, coupled with a subsidized, guaranteed ability _to_ stay in a hospital longer is a leading factor forcing the Japanese health care system into insolvency.

So, while I agree with the conclusion, the term "profit" is elusive enough to cause me to question several proposed solutions. Even "non-profit" hospitals implicitly or explicitly promote overuse and creating a larger "non-profit" system tends only to conceal (or launder) the hands of those who actually receive profit from arguably bad behavior.

Posted by: rmgregory | September 29, 2009 1:23 PM | Report abuse

The comment about "melancholy" was almost certainly meant specifically to exclude depression. The point was that we are increasingly medicalizing less than optimal or fully pleasurable performance.

Some ADHD is severe. All hyperactivity and inability to focus is disruptive. It does not follow that all hyperactivity and inability to focus for extended periods should be medicalized as ADHD and treated with drugs.

Same goes for depression vs. melancholy. Extreme social anxiety vs. shyness. Etc.

The point then is: when a drug manufacturer profits from medicalization regardless of whether that medicalization is good from a social perspective, expect the drug manufacturer to keep pushing the envelope to use the drug in more circumstances. That's why you need controls on advertising, etc.

Pretty elementary, and no need for alarms that Ezra doesn't believe in treating depression.

Posted by: jdhalv | September 29, 2009 1:36 PM | Report abuse

It's also worth reminding everyone that the problem with care as a source of profit goes deeper than just overutilizing once people are sick (or are being screened for illness). It also creates a lack of incentive to stop people from getting sick through non-medical means, namely throgh better nutrition, lower stress and more exercise.

Every physician knows these things play a huge role. For most chronic diseases, even cancers, the best prevention by far is to have a good lifestyle. But if (1) physicians aren't reimbursed for the person living a healthier lifestyle and (2) people having less illness as a result of a healthier lifestyle means there is less reimbursement later, then it is no wonder why physicians don't put a lot of emphasis on lifestyle and instead focus on treatment.

I can probably count on one hand the minutes in which physicians have counseled me on lifestyle and health over the last 20 years (probably 40 physician visits, and that included visits after having been identified with a chronic disease exacerbated by stress and after having been identified with high cholesterol).

Physicians can reply: "It's not my job to get you to live a healthy lifestyle." And it's true, in that we don't pay them for it and don't hold them accountable for not doing it. But that needs to change. And sooner or later it will. The old guard will fight it, but signs are pretty clear that it is coming.

Posted by: jdhalv | September 29, 2009 1:46 PM | Report abuse

I'm pretty sure EK did not mean to suggest depression is not a medical condition worthy of treatment. However, "melancholy" doesn't unambiguously mean "low mood, short of serious depression" -- Burton's "Anatomy", and Duerer's famous image of "Melencolia", aren't just about feeling wistful.

Posted by: vancemaverick | September 29, 2009 1:53 PM | Report abuse

"The sort of rationing that health-care reform's critics worry about -- where a government bureaucrat says you can only have one MRI a year -- does not actually happen in this country"

I don't think that's entirely true - adult Medicaid recipients in some states, including Pennsylvania, have strict limits on their ability to access some services, e.g. doctor's visits. They can go outside the limits but only if they can demonstrate a pressing medical necessity. If a doctor certified that their health would be at risk if they didn't get that extra MRI, they could get it, albeit maybe only after a protracted and discouraging appeal process.

Posted by: blynch201 | September 29, 2009 2:35 PM | Report abuse

Jdhalv makes a great point to pre-empt some of the flaming. I've noticed myself that advertising for mood altering medications has been shifting lately to cover a broader swath of symptoms. If there were no advertising of drugs, this would be less of a problem because you wouldn't have people watching TV, saying "well I feel sad sometimes" or "I do feel nervous" and thinking they have the actual medical condition. Sure, doctors have their own incentives to overprescribe, but when patients are demanding that overprescription, it sure is easier.

Posted by: etdean1 | September 29, 2009 3:23 PM | Report abuse

@nathanjfscott:
In addition to the good responses by scott195 and fuse, most conditional statistics like the ones you site show selection bias.

For example, cancer survival rates in the US may be higher because a significant percentage of the people who would have had cancer in the US if they had lived that long, ended up dying as children. To whit, european nations tend to offer more comprehensive and high quality child care.

Or it may be the case that the distribution of cancers are different in Europe versus the US. The rates of smoking are much higher in Europe, so survival rates may be in the US may be an epiphenomenon of a lower incidence of lung cancer which can be very difficult to treat.

Conclusion: Unless you condition your statistics for selection bias or apply a reasonable control, your statistics are meaningless.

Posted by: zosima | September 29, 2009 4:58 PM | Report abuse

Mr. Klein - Did you happen to read Horwitz's "The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder"? (i.e., redefining "melancholy" as a 'disorder') Not that this shift hasn't been readily transparent but Horwitz provides a thorough, if dry examination of the phenomenon. And as an LPC licensed to diagnose DSM-IV 'disorders', I can personally attest to the "rush to prescribe" I see in clients; historically endemic, if trying life experiences have been culturally pathologized leaving an increasingly narrow range of affect and behavior as "normal." A little off topic for the thread, but what is the result when a society decides that any emotional state which demands effort and attention (non-clinical 'depression' is, after all, a signal that something in one's life is out of balance and needs attention) is to be banished with a pill? What happens to the character of folks who preemptively elide naturally occurring extremes of human experience? I don't think it's hyperbole to say that our deepest and most important learning, in terms of who we are individually and as a society, occurs in exactly these states of extreme experience. The shift towards pathologization of historically normal functioning might be THE critical issue in the field of mental health, and at this point the forces of profit and inertia show no signs of slowing.

Posted by: sblaisdell | September 29, 2009 9:04 PM | Report abuse

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