Rational Arguments

My parents live in Nevada.  Sharron Angle is running for the Senate there.  This makes me sad:

“I think we get confused a little bit. Our healthcare system is the best in the world. There’s nothing wrong with our healthcare system. Our doctors are the best,” says Angle.

“But how many people get access to the best healthcare in the world,” asks Action News reporter Marco Villarreal.

“The access is not what is being denied. It is the cost that has become prohibitive and that’s what we need to address,” she answers.

The fact that I even need to type any of this – at this stage of the game – is maddening.  Ms. Angle? First, the prohibitive cost is what is denying access.  Also, the subsidies?  The exchanges?  The other stuff in PPACA?  That is what they were addressing.

Second, no one, and I mean no one, is saying we need to fix the healthcare system because our doctors aren’t good enough. Can you please point out one person who made that claim?

Third, do you really believe there is nothing wrong with our healthcare system?  Really?  Really?

I am OK with people who think the PPACA is the wrong way to address the problems that exist in health care.  There are other solutions.  But I’m getting a little tired of politicians who have no idea what they are talking about.

The debate continues.

As I said before, I think debate is good.  And I don’t think there is necessarily a right or wrong here.  Research is, more often than not, baby steps.  Each study adds a small amount to our understanding; each study is only so generalizable.  Avik believes that the research speaks to the harm Medicaid is doing.  I think that the evidence is not so clear.  But I come from the pediatric world, and the research in pediatrics and Medicaid isn’t necessarily the same as the research in surgery, which Avik cites:

As to Carroll’s point about the fact that the uninsured aren’t getting mammograms and colonoscopies, but Medicaid patients are: that isn’t true, because Medicaid patients can’t get appointments to see doctors (see above). If Carroll was right, it would only render even more striking the fact that the uninsured have their cancers detected earlier than do Medicaid patients. With breast cancer specifically (since he brings up mammograms), Medicaid patients were 31% more likely to have late-stage breast cancer than the uninsured. With surgical resections for colon cancer (since he brings up colonoscopies), in a separate study, Medicaid patients had a 27% higher risk of mortality than the uninsured, and a 9% higher risk of surgical complications.

I freely admit I’m not as well versed in the surgical literature as I am in the pediatric literature.  There are only so many hours in the day, and I really do have a full time job.  But I think we are fundametally interpreting this literature differently.  I have trouble understanding the idea that Medicaid patients have more trouble seeing doctors than uninsured patients because of Medicaid.  The pool of physicians uninsured people can see is equal to the ones they can afford to pay out of pocket.  The pool of physicians a patient a on Medicaid can see is equal to the ones that accept Medicaid plus the ones they can afford to pay out of pocket. So the pool of physicians a Medicaid patient can see is actually a superset of those that the uninsured can see.

Of course, it’s entirely possible that those on Medicaid can’t afford to see the same physicians that the uninsured can, because the Medicaid population if often poorer than the uninsured.  That would be a key difference, and not the fault of Medicaid.

This should not be taken as any sign that the studies Avik cites don’t show Medicaid is flawed.  It absolutely is. Not even single payer advocated believe that we should have Medicaid-for-all.  YES, Medicaid is flawed.  It’s state based, so it can run out of money.  It reimburses too little.  It needs to be improved.

But because Medicaid is state based, it can differ in quality from state to state.  It ranges in its benefits from state to state.  The number and quality of docs who accept it differ from state to state.

Contrary to what some believe, I welcome high quality research no matter what the outcome.  The only way we can improve the system is to first find out what is wrong with it.  And so I hope Avik is not talking about me when he says:

Skeptics of the study are setting themselves up for disappointment if they hope that the detailed results will exonerate Medicaid.

I’m not skeptical of this study.  I’m skeptical of all studies until I can personally evaluate their methods.  And I won’t be disappointed no matter what the final outcome because I have no vested interest in Medicaid.  I have a vested interest only in a high quality, cost-effective health care system.

As I have said before:

You can’t ignore [research] because it doesn’t fit your ideology… [w]hen you do science, you agree to accept the results…

That’s how it goes in research.

I’ve been away the last few days and trying to relax.  Now that I’m catching up, I see Austin Frakt and Avik Roy are having a slight disagreement as to the association of Medicaid on outcomes.  Long story short, Avik points to the literature that shows that Medicaid is associated with worse surgical outcomes.  Austin asks the important follow-up question: if you believe that’s true, are you suggesting that we make those on Medicaid more like the uninsured?  I don’t want to wade into this too deep.  I will make a number of small points:

-Insurance doesn’t equal care.  Insurance can affect how likely you are to get care and how quickly you might get it.  But any study that looks at insurance has to adjust for many, many other variables in order to get the true effect of insurance.

-There is a large body of literature out there on insurance.  A lot of it shows that people with private insurance do better than those with public insurance or those without insurance; that should not be a surprise.  Most people (and most of your docs) would rather have private insurance than Medicaid.  But would you really rather have no insurance than Medicaid?  If so, that is everyone’s right.  Don’t get the Medicaid.  I wager few would make that choice.

-I find it interesting that most of the literature that Avik cites is about surgery.  Surgery is different than other types of care (like emergency care) in that it is harder to refuse.  So it may be that the uninsured are getting care on a compassionate basis.  Few would provide a screening mammogram or yearly colonoscopy to someone uninsured, however, and you would get that with Medicaid.

On the whole, I think the debate is healthy and good.  No one is claiming that Medicaid is perfect, or that we should all just get Medicaid.  There is always room for improvement.  I also don’t necessarily think that Avik is arguing that we should just dump all the Medicaid people on the street, which is what I think some (not Austin) are implying he is saying.

And I’m stopping there.  Were I on the radio, I would be happy to debate this.  But blogging is too asynchronous when I’m joining in so late.  Except for one thing, and here I’m going to take a tiny issue with Avik’s first post.  It was based on (as far as I can tell) a meeting abstract.

I have a long-standing beef with promoting research that is presented in abstract form at scientific meetings.  It makes for great press and lots of splash, but I think it’s a real problem.  So much so that I have refused to participate in media events or press releases that about my work unless it has already appeared in the peer-reviewed literature.  Why?  It’s not rigorously reviewed.  Here is the total amount that we are able to know about the methods of the study Avik cites:

Methods: From 2003-2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n=491,829), Medicaid (n=40,259), Private Insurance (n=337,535), and Uninsured (n=24,035). Multivariate regression models were applied to assess outcomes.

That’s it.  Was it a good study?  Valid?  How can you tell?

This ticked me off so much as a fellow, that I actually studied it.  Specifically, we looked at abstracts presented at the Pediatric Academic Societies meeting, which is the largest pediatric research meeting.  You can read the full paper, but here’s the abstract:

OBJECTIVE: The validity of research presented at scientific meetings continues to be a concern. Presentations are chosen on the basis of submitted abstracts, which may not contain sufficient information to assess the validity of the research. The objective of this study was to determine 1) the proportion of abstracts presented at the annual Pediatric Academic Society (PAS) meeting that were ultimately published in peer reviewed journals; 2) whether the presentation format of abstracts at the meeting predicts subsequent full publication; and whether the presentation format was related to 3) the time to full publication or 4) the impact factor of the journal in which research is subsequently published.

METHODS: We assembled a list of all abstracts submitted to the PAS meetings in general pediatrics categories in 1998 and 1999, using both CD-ROM and journal publications. In each year, we chose up to 80 abstracts from each presentation format (“publish only,” “poster,” “poster symposium,” “platform presentation”). We chose either 1) all abstracts in each format or 2) when there were >80 abstracts, a random selection of 80 of them. We assessed each selected abstract for subsequent full publication by searching Medline in March 2003; if published, then we recorded the journal, month, and year of publication. We used logistic and linear regression to determine whether publication, time to publication, and the journal’s impact factor were associated with the abstract’s presentation format.

RESULTS: Overall, 44.6% of abstracts presented at the PAS meeting achieved subsequent full publication within 4 to 5 years. There were significant differences between the rates of subsequent full publication of abstracts submitted but not chosen for presentation at the meeting (22.2%) and those that were chosen for presentation in poster sessions (40.0%), poster symposia (44.1%), and platform presentations (53.8%). There were no meaningful differences between the presentation formats in their mean time to publication and their mean journal impact factor.

CONCLUSIONS: PAS meeting attendees and the press should be cautious when interpreting the presentation format of an abstract as a predictor of either its subsequent publication in a peer-reviewed journal or the impact factor of the journal in which it will appear.

I know that can be overwhelming, so here’s the gist.  We looked at a sample of all abstracts sent in to the meeting, and whether they were ever published in peer-review journals.  The first thing I always remind people is that 87% of abstracts that were sent in were presented.  That’s a lot; very few were refused.  So I wouldn’t necessarily assume that just because an abstract is presented, it’s totally valid.  Second, less than 45%of the research presented was published in a peer-reviewed journal in the next four to five years.  So over half of what was presented at the meeting never was “really” published.

I’m not saying the results of Avik’s discussed study aren’t valid.  I’m saying I can’t tell.  And neither can you, without more information.  The peer review for a meeting just isn’t the same as for full publication.  You have less time, different criteria, and almost nothing by which to judge the work.  Ideally, meetings would stop publicizing abstracts as if they were full studies, but neither they, nor the press, seem likely to do so.

A reader writes:

We Canadians like to brag about our health care system but we often forget that while we look good compared to the US, compared to the rest of the world we’re not quite so good.  The chart on your June 23 post seems to confirm that, with Canada placing last (7th) in several categories including timeliness of care, effective care, and quality care (overall.)  Even in most of the other categories we place well down the list with lots of 5′s and 6′s, including a 6th place standing for Overall Ranking.

Yet on Long, Healthy, Productive lives (which I would argue is truly the best metric) we place 2nd!  Given our dismal performance in so many of the other categories, this seems particularly out of place.  Can you shed some light on this apparent contradiction?

(Don’t get me wrong, I’m quite happy with my health care.  I’m just very confused by the chart.)

Lots of good stuff in here.  The simplest explanation is that “long, healthy, productive lives” are due to much more than just the health care system.  I can think of any number of public (or private) things that could improve this metric that have nothing to do with the health care system.

This illustrates a larger point.  We shouldn’t focus on any one metric to measure anything.  It’s very easy to cherry pick one statistic and then claim victory.  For instance, I bet we do more pancreas transplants in the United States than anywhere else in the world.  If we use that as the only metric, then we can hold a parade today; we’re number one!  Similarly, if you use only “long, healthy, productive lives”, then Canada is number 2.  Go celebrate.

This is why whenever you hear me talk about the quality of the US health care system, I rattle of a host of different metrics.  You can’t pick any one.  They are all flawed in some way.  But, when together they paint a pretty consistent picture (as they do in the chart I posted), you have to start believing that picture is true.  To quote myself about the US:

Last in efficiency.  Last in equity.  Last in long, healthy, productive lives.  Last overall.

Next to last in quality care.  Tied for last in access.

So I repeat.  Tell me where the good news is in there.

Here’s another point that’s often overlooked.  It’s not by chance that people who want to demonize health care reform in the US always pick on Canada.  It’s because you’re not the best in the world, either.  You’re #6 to our #7 in this case.  If they want to look for someone to pick on, they are certainly not going to turn to #1 or #2.

This isn’t to say your system isn’t better than ours in many respects.  It’s just got room for improvement, too.

Wow.  I’m taking a beating over at HuffPo.  Who knew I was such a corporate shill?

Anyway, I was giving a class today on quality in health care systems, and I added a few new slides.  I thought they might be of interest to all of you, as well. As always, these are OECD Health Data for all available years since 1993.  The US is in bright red.

First up, the number of people who die every year of a myocardial infarction (heart attack) per 100,000 people:

Not so good, huh?  With all the talk about how we get the best drugs and technology – plus the way other countries have “wait times” or “rationing”, you’d expect them to have much more death.  How about deaths from cerebrovascular illness (strokes):

Well, at least we do better here.  Of course, France is still beating us.  Socialists.  We must be the best at respiratory illnesses like asthma, right?

Um, no.  We do really poorly, actually.  But cancer?  Everyone knows that’s our thing.  That’s where we really have the goods.  Hmm?

Now remember how poorly the US did on those other metrics of quality?  Think of these when someone retorts that in the US we focus on curing disease and preventing death.  Not so much.

Yesterday on the radio I talked about quality in the United States’ health care system.  I mentioned a handful of metrics that could be used, and that they showed our quality to be surprisingly poor.  And – inevitably – I got an email like this:

According to an article I read not to long ago (sorry, can’t remember the publication)We are so far down on that certain list because of the way the different countries report those numbers. Supposedly some of the countries don’t count infant deaths that occur within 24 to 48 hours of birth. While some count those but do not count deaths as a result of certain parent induced problems like Fetal Alcohol Syndrome. According to the article I’m referring to the U.S. counts all infant deaths regardless of the time frame or reason. If I remeber correctly most of these “ranking” lists were coming from the WHO and each country had its own reporting standards as to how they counted infant mortality rates.

This is a common retort to the use of infant mortality as a metric.  Somehow the source is always real, but unknown.  But here, look at the data:

We are the worst.  Do you really think that every other country is massaging their data, year after year, in order to make themselves look better?  If so, why don’t we do the same?  What would be the motive behind the United States choosing to report their data in such a way as to make itself look bad year after year after year?  Can you come up with a reason?

And even so – I don’t care.  Every metric is flawed.  Pick another.  How do you account for our terrible maternal mortality:

Or percentage of kids immunized:

Or life expectancy:

Or number of physicians:

Or – most importantly – preventable years of life lost:

We do surprisingly bad in all of them.

Which is the more logical conclusion: (1) We have a separate excuse to explain why the measurements are wrong in every metric you might use, or (2) our system just isn’t that good?

*All of these are OECD health data comparing the 10 richest rountries in the world.  The United States data is self-reported.  Data are not available for China and South Korea.

Back from my vacation/trip.  No surprise – nothing has changed.  Lots of bluster, lots of politics, little substance.

But one bit of data caught my eye while I was away.  It has to do with life expectancy.

Before I show it to you, let me say that I know life expectancy is not a perfect metric of quality in a health care system.  There are other factors that can effect the life expectancy of a population.  That said, you would expect that we would do better than this:

That’s a slide I made using OECD Data that use regularly in talks about health care quality.  You’re looking at the expected life expectancy of the total populations (at birth) of 8 of the richest 10 countries in the world.  The United States not only has the lowest life expectancy, it has had the lowest consistently for a long time.

But this weekend, I saw something even more striking:

Here, you are looking at health care spending per person (on the left) versus life expectancy (on the right).  Here are the take home points:

1. The United States spends WAY more per person on health care than any other country.
2. The United States has a pretty poor life expectancy, especially when you see how much we’re spending.
3. The United States is the only country (besides Mexico) without universal health coverage.
4. The United States has some of the lowest average number of doctor visits a year.

Can someone justify this for me?  What’s the money for?

A reader pointed me to an excellent piece in The New York Times Magazine on efforts to improve quality in the heath care system.  It’s quite good, and I recommend you read the whole thing.  But, like Ezra, I actually noted that the article picked up on an important point; improvements in quality are often not accompanied by improvements in revenue:

But in our current health care system, there is no virtuous cycle of innovation, success and expansion. When Intermountain standardized lung care for premature babies, it not only cut the number who went on a ventilator by more than 75 percent; it also reduced costs by hundreds of thousands of dollars a year. Perversely, Intermountain’s revenues were reduced by even more. Altogether, Intermountain lost $329,000. Thanks to the fee-for-service system, the hospital had been making money off substandard care. And by improving care — by reducing the number of babies on ventilators — it lost money.

See, when I say we’re spending $2.5 trillion in health care, much of that is going into other people’s pockets.  We can only reduce health care spending by reducing the amount of money going into other people’s pockets.  This will make many people unhappy.  This will make them scream and shout.  It will be unpopular and hard.

And that’s why no one is talking about it.  Even waste is viewed positively by many sectors in the health care market.

I’ve been arguing for a long time that preventive medicine, while often producing good outcomes, does not always save money.  It’s something we should put in the quality column, not the cost column.  This hasn’t stopped lots of people, including President Obama and Larry Summers, from saying it’s one of the areas we could reduce cost.  But CBO director Douglass Elmendorf agrees with me:

“Some preventive medicine is cost-saving as well as health improving,” Elmendorf said, when asked to respond to Summers’ point. “A much larger share is health improving but cost increasing. And there is some share that is just terrible because it makes health worse and costs money.”

“Not everything that sounds good for health is good for the budget,” he added. “[A] general increase in preventive medicine may or may not have the sorts of favorable budget effects that people expect. That surprises many people. But the very important [point] here is that for somebody who ultimately gets the disease, it is cost saving as well as health improving to catch it early. But to catch it early in that person you generally have to deliver the treatment or administer the test to a much larger set of people, most of who will not ultimately get that disease.”

Look, I’m not saying preventive medicine isn’t a good thing.  It is.  It’s important to recognize, though, that when you make people live longer (a good thing) they can cost more money overall (a bad thing).  But let’s face it, the good of extending life is often worth the increased lifetime costs of care.  We have to abandon the idea that the only things worth doing are both good in terms of quality and cost-savings.  Trade-offs are natural.  Sometimes things are worth doing and worth paying for.