BBC News - Do doctors understand test results?

Don’t cheat!

But it's not just that doctors and dentists can't reel off the relevant stats for every treatment option. Even when the information is placed in front of them, Gigerenzer says, they often can't make sense of it.

In 2006 and 2007 Gigerenzer gave a series of statistics workshops to more than 1,000 practising gynaecologists, and kicked off every session with the same question:

A 50-year-old woman, no symptoms, participates in routine mammography screening. She tests positive, is alarmed, and wants to know from you whether she has breast cancer for certain or what the chances are. Apart from the screening results, you know nothing else about this woman. How many women who test positive actually have breast cancer? What is the best answer?

• nine in 10
• eight in 10
• one in 10
• one in 100

Gigerenzer then supplied the assembled doctors with some data about Western women of this age to help them answer his question. (His figures were based on US studies from the 1990s, rounded up or down for simplicity - current stats from Britain's National Health Service are slightly different).

1. The probability that a woman has breast cancer is 1% ("prevalence")
2. If a woman has breast cancer, the probability that she tests positive is 90% ("sensitivity")
3. If a woman does not have breast cancer, the probability that she nevertheless tests positive is 9% ("false alarm rate")

In one session, almost half the group of 160 gynaecologists responded that the woman's chance of having cancer was nine in 10. Only 21% said that the figure was one in 10 - which is the correct answer. That's a worse result than if the doctors had been answering at random.

The fact that 90% of women with breast cancer get a positive result from a mammogram doesn't mean that 90% of women with positive results have breast cancer. The high false alarm rate, combined with the disease's prevalence of 1%, means that roughly nine out of 10 women with a worrying mammogram don't actually have breast cancer.

I’ve often argued, when consumer choice and consumer driven health care are brought up as the solution for our health care woes, that doctors don’t even know how to make reasonable decisions so how can we expect lay people to do it?

 

BBC News - Do doctors understand test results?

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Patients’ Costs Skyrocket; Specialists’ Incomes Soar - NYTimes.com

 

CONWAY, Ark. — Kim Little had not thought much about the tiny white spot on the side of her cheek until a physician’s assistant at her dermatologist’s office warned that it might be cancerous. He took a biopsy, returning 15 minutes later to confirm the diagnosis and schedule her for an outpatient procedure at the Arkansas Skin Cancer Center in Little Rock, 30 miles away.

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000.

“I felt like I was a hostage,” said Ms. Little, a professor of history at the University of Central Arkansas, who had been told beforehand that she would need just a couple of stitches. “I didn’t have any clue how much they were going to bill. I had no idea it would be so much.”

Ms. Little’s seemingly minor medical problem — she had the least dangerous form of skin cancer — racked up big bills because it involved three doctors from specialties that are among the highest compensated in medicine, and it was done on the grounds of a hospital. Many specialists have become particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenues by offering new procedures — or doing more of lucrative ones.

Patients’ Costs Skyrocket; Specialists’ Incomes Soar - NYTimes.com

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‘Ground Control to John Goodman’ – A Uwe Reinhardt Appeal | A "HealthTweep" Pulse Check

‘Ground Control to John Goodman’ – A Uwe Reinhardt Appeal | A "HealthTweep" Pulse Check

This is a couple years old, but I just found it and since it has some Uwe "gold," it's worth reading!

John Goodman of the conservative Dallas based think tank National Center for Policy Analysis (NCPA) issued a “William Wallace-esque’ FREEDOM pitch today on his blog entitled Reforming Health Care the Right Way.
This is a man who previously claimed that there are ‘no uninsured’ (from a health insurance point of view) in America; after all Goodman posits that everyone has access to the ER, so what are you complaining about? (paraphrased).
In his blog post today one day after the historic Senate vote to advance the health care bill, Goodman opines on the ‘right’ and ‘wrong’ way to reform US healthcare.
What I find most insightful is his post is the rebuttal comment proferred by Uwe Reinhardt as to the fantasy world this man, and unfortunately many other ideological predisposed converts, apparently inhabit. The health care industry defies over simplification, yet ‘sound byte’ disingenuous over-simplification is the prima facie basis on which the ‘anti-reform crowd has stimulated emotive misunderstanding of the nature of the malady as well as it’s appropriate and quite comprehensive remedies.

Uwe Reinhardt Says:
December 21st, 2009 at 1:12 pm
I hear Richard Branson of Virgin Air is seriously exploring space travel as a commercially feasible project.
Once he has that done, I shall be able to book a flight to the distant planet on which John Goodman lives.
It is the planet on which all physicians always are purely the agent of their patients and do not have any economic conficts of interest — such as making money on tests they prescribe to anxious patients or from referring patients to imaging centers in which they have a state or to collegues with whom they play gold, and so on. Such conflicts of interest do not crop up on John’s planet, not because government forbinds them (there is no government on that planet), but because such conflicts of interest just don’t exist there somehow. Remember: it’s another planet!
On John’s planet it is also easy to have price competition among physicians, because all ill health on that planet can be cured with just one standard, well defined “unit of health care.” What that is I do not know, but John does, because he lives there. He’s probable consumed some, rationally, I wouold assume.
Contrast that with an earthbound hospital charge master with 20,000 itsems in it or the physician fee schedule with 7,000 items in it. How would one make diffenetials in the elements of those huge vectors understandable to patients?
John took on a new religion on that planet to where he actually immigrated — he once lived on earth. On earth he always boldly talked for decades about “Consumer Directed Health Care,” but neither he nor his entire think tanks (the NCPA) every did a stitch of work to help develop the user-friendly price information that patients as “consumers” would need to make rational choices in health care ex ante.
Once on the new planet, John realized that he sinned on earth and swore to do better there. Of course, on his new planet it’s easy: there is only one type of health care and one price. The redemption was a piece of cake.
All people on John’s planet have the same income — in fact, they all have John’s high income and all also have Ph.D.’s. or M.D.s So the problem with poor people not being able to afford high deductibles and therefore stiffing doctors and hospitals for it does not exist on John’s planet. Nor is there a problem with health illiteracry, because everyone on John’s planet has a Ph.D. or M.D. Every patient on John’s planet knows exactly what he or she needs before going to a doctor and simple shops around for a low price.
For the most part, an individual’s need for health care in a coming year on John’s planet is certain and predictable and thus not really insurable. Only the need for about 20% of all health care is stochastic and hence insurable.
On John’s planet, 50% of any large group of people account for 50% of all health spending — 80% of the people account for 80% of all health spending. Here on earth, 20% of the sickest account for 80% of all health spending, and much of that 80% will also be insured. It will be managed by some insurance clerk coming between doctor and patient.
Oh how I long to go to the planet where John Goodman lives, where life is so easy and so simple. I am so tired of the mess here on our planet. Aren’t we all?
Small wonder that John just up and left Mother Earth for a planet where all his theories actually work.

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Market, insurers will keep premiums low, analysts say

Just how much premiums will change depends on the state you live in, Kingsdale said.
Individual premiums decreased when Massachusetts' health care took effect, he said, because the state already had high-priced and insurers were not allowed to turn away the sick and could not charge large premium differences based on age, gender and health.
"Other states will see exactly the opposite happen," he said. "Their premiums tend to be quite low, but they're getting skimpy insurance."
In Oregon, Ario said, large differences in premium prices have already appeared.
In one case, a 40-year-old non-smoker in Oregon could buy a low-cost or bronze-level plan for $162 a month from one company or the same plan from another for $400 a month, Ario said. Anti-trust laws prevented the insurers from comparing pricing before developing their premiums.
When the companies with the higher rates saw their competitors' lower premiums, he said, they asked the state to allow them to file for reduced premiums.
"The good news is that in most marketplaces, there will be some carriers that will be bold and price competitively to get more market share," Ario said.

Market, insurers will keep premiums low, analysts say

For a quick rundown on what the "gold, silver, and bronze" plans will cover, go here.

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Study: When health insurance costs rise, productivity drops

Study: When health insurance costs rise, productivity drops

A new working paper from Truven Healthcare’s Teresa Gibson, Harvard’s Michael Chernew and the University of Michigan’s A. Mark Fendrick find that as co-payments go up, productivity drops — most likely as a result of employees skipping out on care altogether.

The team focused on those with chronic pain such as arthritis. They then looked at how much employees had to pay for prescription medication under their various benefit structures. Previous research has shown that as the cost of health-care services increases, usage decreases — workers simply don’t fill as many prescriptions when prices get higher.

On average, employees with chronic pain had 76.7 hours absent from work. But with every $5 increase in cost-sharing for pain medications, they saw an increase in absenteeism somewhere in the ballpark of 1.3 to 3.1 percent.

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Why I’m skeptical that HSAs will work to reduce spending greatly – Parts 1 & 2 | The Incidental Economist

Why I’m skeptical that HSAs will work to reduce spending greatly – Part 1 | The Incidental Economist

You’ve seen a slide like this before, I bet. But basically, what it’s showing is that a small number of people account for a ton of personal health care spending. In fact, the bottom 50% of spenders account for only $36 billion in personal health spending. That’s less than 3% of all of it.

Why is this important? Well, because the entire idea of health savings accounts and increased cost sharing is to encourage people to spend less on personal health spending. The idea is that people who don’t really need the care will choose to spend less. What we often ignore, however, are the high spenders. Those people, on the right side, would blow through their health savings account pretty quickly. At that point, they have no more deductibles and no more co-pays, and there are no more incentives to spend less. So the whole idea won’t work on then. It might, however, work on people who don’t spend as much.

But as the chart shows, there’s not that much to save there.

Why I’m skeptical that HSAs will work to reduce spending greatly – Part 2 | The Incidental Economist

Health savings accounts, and increased cost sharing, will likely work for those who don’t need the care and are healthy. But they spend so little, that even if they are influenced, we won’t save much. Those who are spending the real money are older, sicker, and need help. If they spend less, it’s more likely they will suffer. And it’s likely many won’t spend less, since there’s no chance of their keeping money in their accounts. If they don’t spend less, then we can’t save real money.

I get why people think cost sharing and HSAs will work. But when the theoretical possibilities meet the real demographics and patterns of spending, I can’t see how this will work.

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Navigating the Labyrinth of Medical Costs - Your Money - NYTimes.com

Navigating the Labyrinth of Medical Costs - Your Money - NYTimes.com

Hospital care tends to be the most confounding, and experts say the charges you see on your bill are usually completely unrelated to the cost of providing the services (at hospitals, these list prices are called the “charge master file”). “The charges have no rhyme or reason at all,” Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins Bloomberg School of Public Health. “Why is 30 minutes in the operating room $2,000 and not $1,500? There is absolutely no basis for setting that charge. It is not based upon the cost, and it’s not based upon the market forces, other than the whim of the C.F.O. of the hospital.”

And those charges don’t really have any connection to what a hospital or medical provider will accept for payment, either. “If you line up five patients in their beds and they all have gall bladders removed and they get the same exact medication and services, if they have insurance or if they don’t have insurance, the hospital will get five different reimbursements, and none of it is based on cost,” said Holly Wallack, a medical billing advocate in Miami Beach. “The insurers negotiate a different rate, and if you are uninsured, underinsured or out of network, you are asked to pay full fare.”

With the exception of Medicare and Medicaid, experts say, the amount paid for services — or the price your insurers pay — is based on the market power of the insurance company on the one side and the hospitals and providers on the other, and the reimbursement agreements they ultimately reach. So large insurers that command a lot of market power may be able to negotiate lower rates than smaller companies with less influence. Or, insurers can place hospitals or providers on a preferred list, which may help bolster their business, in exchange for a lower reimbursement rate. On the other hand, well-regarded hospitals may command higher prices from insurers.

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Health Beat: Herzlinger’s Meme on Switzerland and Consumer Driven Medicine

Health Beat: Herzlinger’s Meme on Switzerland and Consumer Driven Medicine:

"Yet even if the Swiss are not the world’s most conscientious health care shoppers, individuals in Switzerland spend about a third less on health care than the average American. How can that be? Time and again, Herzlinger repeats the meme that consumer choice accounts for Switzerland’s lower costs. And if she says it often enough, without citing evidence, no doubt many Americans will believe her. But it just isn’t so.

Even a cursory glance at Switzerland’s system reveals that government-enforced price controls on virtually everything from drugs to doctors keeps a lid on health care inflation. The fees that providers charge “are negotiated by the cartel-like associations of insurers and clinicians under the watchful eye and heavy hand of government” Reinhardt observes. And “since all insurers are bound to the same prices for ambulatory care, and prices are negotiated between insurers and individual hospitals for inpatient care,” there is little room for the consumer to affect prices by comparison-shopping.

Finally, when it comes to ensuring that the Swiss are receiving effective care, Switzerland's Federal Department of Home Affairs establishes the formulary for prescription drugs that it believes give good value, while the Federal Department of Home Affairs decides which lab tests and medical devices are to be covered by compulsory insurance.

In the end, Reinhardt suggests that “what is most impressive about the Swiss health system is the role tight government regulation plays . . . . One can plausibly argue that this regulation is chiefly responsible for both the high quality and (relative to the United States) low cost of Swiss health care.” Determined to make the case for consumer-driven care, Herzlinger takes the opposite view arguing, in today’s WSJ that the Swiss government’s web of regulations, requiring “an extensive minimum benefit package,” while “micromanaging” both prices and products is precisely what keeps Switzerland from becoming the unfettered consumer’s paradise that she would like to see. "

A nice overview of the Swiss system and a Bronx cheer to the crapola that is "Consumer Driven Healthcare". Thanks to Ian Welsh of Firedoglake for the link from his piece on the Baucus Plan...

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Thomson Reuters Survey Finds Cancer Patients Forgoing Treatment

Thomson Reuters Survey Finds Cancer Patients Forgoing Treatment: "cancer treatment decisions of individuals.

Entitled “The Cost of Cancer,” the report aggregates survey responses from 1,767 adults currently being treated for cancer. It finds a clear link between patients’ annual income and their decisions to curb cancer treatments due to cost — even among patients with late-stage cancers.

The report notes that among the 569 survey respondents with late-stage cancer, 12.3 percent said they have passed up recommended treatment because it was too expensive. This figure varies dramatically by patient income level. Twenty-five percent of late-stage cancer patients who earn less than $40,000 a year said they have chosen not to undergo a recommended treatment due to cost — compared with 11.2 percent of those earning between $40,000 and $80,000 per year and 4.8 percent of those earning more than $80,000 annually.

Similarly, 65 percent of all respondents with late-stage cancer said the out-of-pocket cost of treating their cancer has caused them distress. Among all cancer patients earning under $40,000 per year, that number jumps to 77 percent.

“The physical and emotional burden of illness is not the only challenge cancer patients face,” said Bill Marder, PhD, senior vice president and general manager for the Healthcare business of Thomson Reuters. “Many also struggle to cope with medical costs. This survey shows that the cost of cancer treatment is affecting patients’ ability to get the care they need.”"

I think this research speaks volumes about the American healthcare system. This is why I have it categorized under so many topics (see links below and to right). It speaks to the de facto rationing by income in the US, it speaks to how consumers "drive" healthcare (i.e., decision making is not rational), how our waiting times are trimmed by not including those who don't seek care due to financial concerns, and how those who love to try to compare anecdote horror stories just don't geet how bad our system is for so many people.

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Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007 - RWJF

Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007 - RWJF:
(From the Robert Wood Johnson Foundation. Follow the link for the full report.)

"The number and proportion of Americans reporting going without or delaying needed medical care increased sharply between 2003 and 2007, according to findings from the Center for Studying Health System Change's (HSC) nationally representative 2007 Health Tracking Household Survey. One in five Americans—59 million people—reported not getting or delaying needed medical care in 2007, up from one in seven—36 million people—in 2003. While access deteriorated for both insured and uninsured people, insured people experienced a larger relative increase in access problems compared with uninsured people. Moreover, access declined more for people in fair or poor health than for healthier people. In addition, unmet medical needs increased for low-income children, reversing earlier trends and widening the access gap with higher-income children. People reporting access problems increasingly cited cost as an obstacle to needed care, along with rising rates of health plan and health system barriers."

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Six steps to bring about true health-care reform in Utah - Salt Lake Tribune

Six steps to bring about true health-care reform in Utah - Salt Lake Tribune:

Dr. Joe Jarvis of Utah has written a nice opinion piece for the Salt lake Tribune identifying six important areas to address in health care reform discussions. Some I have addressed here in the past, such as the Moral hazard myth. His number one is:

"Health underwriting: Every critically ill or injured person will be treated in our health system whether they have health insurance or not. Therefore, we should not waste resources trying to identify persons likely to have critical illness in order to exclude them by price or refusal from acquiring health financing. Community rating, guaranteed issue and risk-sharing will increase health system efficiency and eliminate the unfunded mandate that is cost-sharing."

After seeing the Frontline Sick Around the World Program and web site, and also after attending the Single Payer Debate at Duquesne University earlier this year, it may be that the path to reform in the US might have to be the path of Bismarckian universal healthcare. It seemed that even the far right Fraser Institute's spokesman at the debate was willing to grant that this might be a reasonable way to provide universal access in the US and not violating the hard charging laissez-faire types ideology too badly.

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FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung-mei cheng | PBS

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung-mei cheng PBS

Wow. I can't say enough about this interview. It is so on the mark in so many ways, and it is a pleasure to hear knowledgeable people discuss comparative international healthcare like this.

There are great bits on the real meanings of "socialized" medicine, vs socialized insurance, the German (!) perspective on the dignity of every person, the Canadian perspective on humanism, the leadership of Tony Blair turning around a system on the rocks, how terrifically well America does in training its healthcare providers (especially doctors), but the best is Reinhardt's take on "Consumer Driven Healthcare", quoted here:

We've heard some people have proposed that a solution for America is something called consumer-driven health care. How does it work? What is it?

... Well, the name "consumer-driven health care" at this time is a deceptive marketing label. What we're really talking about is an insurance policy with a very high annual deductible -- up to $10,500 per family, and less for an individual -- and then coupled with a savings account into which you can put money out of pretax income; you don't have to pay taxes on such income.

Now, this has the advantage ... that people faced with this deductible will think twice before going to the doctor for trivial issues or drugs they don't need, etc. But of course the problem also is that they may not go when they should or may skimp on the drugs they should be using, like a blood pressure drug, so that one would have to be solved by saying preventive services will have first-dollar coverage. So you could solve that problem.

But then what I argue is, yes, it may have the economic effect of cost control, because you then would have to know the prices different doctors charge, and hospitals and pharmacies, and something about the quality. And that information at this time exists only in a few areas. The insurance companies are beginning to work on Web sites that will give you that, but it's still very primitive and fairly unreliable information. So that is why I compare it really more like thrusting someone into Macy's department store blindfolded and say, "Go around; shop smartly." ...

The other problem that I see with it, though, is it has ethical dimensions to it that people don't appreciate. If I make anything tax-deductible, then a high-income person in a high tax bracket saves more than a poor [person]. So supposing a gas station attendant and I each put $2,000 into a health savings account, and we get a root canal -- about $1,000, just the drilling. It costs me about $550 because I'm in the 45 percent bracket. The gas station attendant may, in fact, not pay federal income tax because the income is so low but may only pay Social Security, so he saves 8 cents on the dollar. So a root canal will cost me $550; will cost him $920. ...

Secondly, think of a family of two professionals, each making $140,000, close to $300,000 income, and they have, say, a $5,000 deductible. Would they deny their child anything that they think the child needs over a lousy $5,000? ... But think of a waitress who makes $25,000 with a $5,000 deductible, and her kid is sick. It will certainly make her think twice. She's likely to say, "Maybe not." So therefore we're asking the lower half of the income distribution to do all the self-rationing through prices. ...

And the third issue is this deductible. If you're chronically healthy, you don't actually ever spend as much as that; you have a tax-free savings account. If you are chronically ill, on five drugs, you're going to spend that deductible year after year. So the proposal is to shift more of the financial burden of health care from the shoulders of the chronically healthy to the shoulders of the chronically sick.

And I would say, imagine a politician coming to the people with a platform that I just described in ethical terms. ... You think that would sell? So they say, "We've got to find a better name. Why don't we call it consumer-driven health care?," and have all these deceptive labels that even George Orwell wouldn't have thought of. That is what I find troublesome. Yes, it's an approach to health care, but could you please describe it to the American people honestly, in all of its dimensions -- not just economics but information and ethics? And that's not done. ...

One answer he gave about physicians income left me with more questions that when I started:

Yes, American doctors get paid more, relative to average employees, than doctors in other nations; that is true. It's about five times average employee compensation, and in England it's about two, and in Canada it's about three. So that's certainly true.

Given the unprecedented income disparity in this country, it is hard to know what to make of these figures. Comparison to the median would have been more helpful, but I think the most interesting would be to see in which decile physicians place in each country. I will try to find that data.

This Frontline Website is a gold mine. Thanks to the indispensable CPB.

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AlterNet: 10 Myths About Canadian Health Care, Busted

AlterNet: 10 Myths About Canadian Health Care, Busted:

"2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning -- and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I'm both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I'm in a unique position to address the pros and cons of both systems first-hand. If we're going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here's the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they're made of."

Read on...

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Experts See Peril in Bush Health Proposal - New York Times

Experts See Peril in Bush Health Proposal - New York Times

The economic rationale for Mr. Bush’s proposal is that too many people
have “gold-plated, deluxe” health insurance, which encourages them to use
excessive amounts of health care, driving up costs for everyone.
Many economists agree. But they doubt that Mr. Bush’s proposal would do much to hold
down costs or cover more people.

Really? Is that it? Too many people running up excessive bills for their healthcare?

Mr. Bush’s proposal differs radically from President Bill Clinton’s plan for universal coverage, but experts on health benefits said they were similar in one respect: In an effort to help the uninsured — about one-sixth of the population — they would upend the system that covers most Americans.

We have a system?

Representative John D. Dingell, the Michigan Democrat who is the chairman of the Committee on Energy and Commerce, said, “The president’s proposal would do little to help the uninsured, but would undermine the employer-based system through which 160 million people get coverage.”

Almost tempting to pass whatever Bush sends down the pike, let the system implode, and then start over. Of course, that's sort of how we got the country where it is right now, isn't it?

Cheers.

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The New Yorker:THE MORAL-HAZARD MYTH

Highly recommended reading:
The New Yorker: PRINTABLES:
"THE MORAL-HAZARD MYTH"
by MALCOLM GLADWELL
The bad idea behind our failed health-care system.

PDF Version: www.gladwell.com/pdf/hazard.pdf

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