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Unsustainable

Unsustainable

Health Affairs

This picture shows changes in the cost of treating colon cancer, from 1993-2005. It shows unsustainable growth in these expenditures:

By unsustainable, however, I do not mean unjustifiable. Patients with colon cancer have much better prognoses in 2005 than 1993, in large part due to advances in chemotherapy. Instead what I mean by unsustainable is that the rate of growth in spending can’t continue.

If we continue to grow at this rate, we will overwhelm our ability to pay for such care, even if the care continues to improve. We must keep the unsustainability of the spending trend in mind when we set expectations of pharmaceutical executives – and what we look for in the growth of their annual earnings.

We should keep this unsustainability in mind, also, when remembering that healthcare spending threatens the financial stability of governments, corporations, and individual citizens. We should celebrate improvement in treatment for diseases like colon cancer. But we should remember that at some point in time, spending more on such patients, even if it improves their health, might be beyond our means.

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Why Trumpcare Is DOA: It Doesn’t Address Outrageous Healthcare Prices

Paul Ryan is “excited” that the American Health Care Act, as Republicans call their bill, will trim the federal budget by several hundred billion dollars over the next decade. The 24 million people who are expected to lose insurance under the AHCA aren’t excited about the bill, which will cut government spending at their expense, with potentially fatal consequences for those who go without timely medical care.

Debates over healthcare reform often ask us to pick our poison. We either save money or we save lives.

But these debates ignore an antidote to this poisonous choice. If we tackle high healthcare prices, we can insure Americans at the same time as we curb healthcare expenditures.

This antidote is not theoretical conjecture. In fact, most developed countries provide universal insurance to their residents while spending far less per capita than the U.S. This affordable coverage exists in countries where healthcare payment is socialized, like the UK and Canada, and where it is privatized, like Germany and Switzerland. That’s because all these healthcare systems work to rein in high healthcare prices. As a result, appendectomies cost half as much in Switzerland as in America; and knee replacements cost 30% less in the UK than in the U.S.

Unfortunately, prices have been largely absent from healthcare reform debates in the U.S., whether those reforms are crafted by Democrats or Republicans. It’s true that politicians from both sides of the aisle occasionally speak out about pharmaceutical prices. Both Donald Trump and Hillary Clinton criticized pharmaceutical CEOs, like smirking Martin Shkreli, who made the news after enacting outrageous price hikes. But after a public scolding or two, discussion of pharmaceutical pricing usually ends.

Meanwhile, politicians rarely debate the often high price of hospital and physician services in the U.S., which constitute a much larger proportion of healthcare spending than do pharmaceutical products. When is the last time you heard a prominent politician question the lofty incomes of cardiologists, orthopedic surgeons or hospital CEOs?

Perhaps Republicans are hesitant to address high healthcare prices, so as not to galvanize special interests against their current legislation. But the American Medical Association already opposes the Republican healthcare plan, citing the harm vulnerable patients will experience “because of the expected decline in health insurance coverage.” The American Hospital Association also criticized the proposal for not “ensuring that we provide healthcare coverage” to the people dependent on subsidies for their insurance.

(To read the rest of this post, please visit Forbes.)

 

 

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Healthcare Unaffordable? Perhaps Your Doctor Is Partly to Blame

Here is a news article from Canada, experiencing the kind of healthcare inflation that causes them to call experts in the U.S. for advice—people like me, but also some actual credible authorities!

Some see it as an eternal struggle: the goodhearted doctor championing the best treatments, no matter the cost, while doing battle against the tightfisted insurance company denying claims for expensive but life-saving medications.

But when you get down to it, their goals often dovetail: the best care for patients at affordable prices.

After all, even if a plan sponsor or insurer picks up part of the tab, the cost of pricey medications may convince them to increase their deductibles or copayments, which will have an impact on future patients.

But at a time of increased concern about the sustainability of benefit plans, what’s the role of the doctor in helping to contain drug costs?

“I do think that physicians have a duty not just to the patient in front of them but to society at large,” says Dr. Peter Ubel, a professor of business, public policy and medicine at Duke University in Durham,

N.C. Just as he uses the strongest antibiotics only for the worst bacterial infections in order to protect public health, he’ll save expensive tests and medicines for occasions when cheaper alternatives aren’t successful. “I go right to an MRI rather than an X-ray, I’m burning through societal resources and that causes harm,” he says of the drawbacks of not keeping costs in mind.

Doctors should also consider the cost of drugs because unaffordable prescriptions lead to greater rates of non-adherence and, therefore, worse health outcomes. A 2016 study from Statistics Canada found that western Canadians with cardiovascular-related conditions who spend at least five per cent of their household income on drugs were three times as likely not to get the necessary medication as those who spend less than that amount.

“If patients can’t afford the medications, they don’t take them and then they don’t benefit from them,” says Dr. Yousuf Zafar, an oncologist and an associate professor of medicine at Duke University.

And that means they’re more likely to call in sick or, if they do make it to the office, work less productively.

While doctors wouldn’t prescribe a drug without making sure the patient understands the possible physical side-effects, they often don’t discuss the financial impacts with them. “To know what the best pill is for somebody, you need to know what they  care about,” says Ubel. “And if they care about their out-of-pocket expenses, that might change what you prescribe.” But few doctors know how much their prescriptions cost, he notes.

To read the rest of this article, please visit Benefits Canada.

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If Trump Wants to Do Better than Obamacare, He Better Pay Attention to This!

Donald Trump says he can improve upon the Affordable Care Act – promising to get everyone in the country “a much better healthcare plan at much lower cost.”

If that’s really what Trump wants to do, he should pay attention to one of the problems with Obamacare – the subsidies to purchase insurance might have been too stingy.

Let me explain. Before Obamacare, most people got insurance either with the help of their employers, or the government (if they qualified for Medicare or Medicaid). But some people had to buy insurance without such help, and the price of such coverage was usually – how do I say this nicely? – insanely expensive! Insurance companies charged extremely high prices for such policies, because they knew that many people shopping for such individual insurance were doing so because they were too sick to work, meaning their healthcare expenses would be higher than average.

Obamacare tried to make this kind of individual insurance more affordable. (They named it the Affordable Care Act for a reason!) The ACA accomplished this affordability, in part, by establishing insurance exchanges, which gave insurance companies a larger number of costumers to spread risk across, making it potentially easier for them to lower prices. In addition, Obamacare provided subsidies to people who otherwise could not afford insurance. The subsidies are quite generous for people with incomes close to the federal poverty level, and gradually diminish, dwindling to zero for people who make more than four times the federal poverty level. In other words, if someone’s family has an income near the federal poverty level, they get a lot of money to help them buy insurance. If a family makes 350% of the federal poverty level, they get a smaller subsidy. And if they make 450% of the federal poverty level, they don’t get any subsidy at all.

(To read the rest of this post, please visit Forbes.)

 

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What’s the Best Day to Die?

Among people receiving hospice care, the last few days of life can be intense, with progression of pain or breathing problems or other symptoms of their terminal illnesses. For those who die on Sundays, that means they are less likely to see doctors or nurses in the last days of life:

JAMA Internal Medicine

JAMA Internal Medicine

 

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Who Provides More Unnecessary Care: Physicians or Nurse Practitioners? (The Answer Is Surprising)

Shuttershock

Imagine you have been struggling for eight days with a bad cough, with what feels like a lifetime’s worth of secretions in your upper airways. When you called your primary care physician’s office, she wasn’t available, so you got an appointment with a nurse practitioner, who prescribed a course of antibiotics. Would you fill the prescription? Would you be confident the nurse practitioner was well trained enough to make that judgement? More generally, do non-physician primary care clinicians–like NPs or PAs–risk our health by ordering unnecessary tests and services?

Many Americans have a hard time getting timely access to primary care physicians. In response, some experts say we should expand the role of nurse practitioners and physician assistants in providing primary care. But many people are concerned that such clinicians will offer lower quality of care than their physician counterparts. They worry, for example, that nurse practitioners will refer many people to subspecialists who could have been taken care of by primary care physicians. They’re concerned that physician assistants will order unnecessary tests when patients present with signs or symptoms they don’t feel comfortable addressing.

It is probably time to put these concerns aside. When it comes to reducing unnecessary healthcare services, primary care physicians are no better than their less-lengthily-trained primary care colleagues.

(To read the rest of this article, please visit Forbes.)

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Do Luxury Brands Benefit from Income Inequality?

I like to think that despite being wealthier than most Americans, I remain immune to materialistic desires. I drive a 17-year-old Honda Accord and wouldn’t know designer clothes if you wrapped me in them, head to toe. But it turns out that I’m wrong. I’m not above materialism despite my wealth and social status. I’m immune because of it. Since I don’t need to signal my social value, I can save my money for other purposes.

In places with great income inequality, those people with lower incomes live under great social stress. Their low position in the social hierarchy is more obvious and more consequential. In response, some poor people purchase the kinds of good that create the impression that they have social resources to spare, even when they are cash-strapped. And people living in low income neighborhoods – the ones who are relatively well-off compared to their neighbors – are nevertheless worried that they’ll be misperceived as resource poor. So they purchase expensive and conspicuous goods, to make sure their resources are visible to outsiders.

As an example of this behavior, researchers recently examined Google search trends across the U.S., and found that people in states with relatively high income inequality were more likely to search for luxury brands than those in other states. Looking for the latest from Ralph Lauren (who, I discovered, manufactures overly expensive clothes)? The frequency of such Google searches is higher in Mississippi than Iowa (relative to more generic Google searches, like for “weather” ), in Mississippi than Iowa, and in New York than Nebraska. Basically, people living amidst greater income inequality are more interested in luxury goods.

(To read the rest of this article, please visit Forbes.)

 

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Warning: Bicycle Helmets Could Be Hazardous for Your Health

Shuttershock

A bicycle helmet prevented me from experiencing a major head injury. But did it promote the very behavior that caused me to crash my bike?

It was autumn in Michigan, and I was riding my mountain bike along a lakeside pathway. I was heading towards a twisty boardwalk that led up to a bridge arching over a stream. Instead of slowing down, I accelerated through the twists and turns, enjoying the thrill of my maneuverings. Until…

Whisk! My wheels passed over a (predictable) patch of wet leaves, just as I was making a sharp turn. My body slammed violently into the boardwalk, the brunt of force absorbed by my left shoulder and the left side of my bike helmet. My body was scraped up, my neck was stiff for three weeks, my handlebars were ruined and my head…was fine. My helmet saved me from a potentially devastating head injury. Hurrah for bike helmets.

But would I have ridden so carelessly if I hadn’t been wearing a helmet?

Helmets change behavior. When we feel impervious to injury, we act in ways that increase our chance of bodily harm. Indeed, helmets can have powerful, unconscious effects on our behavior.

(To read the rest of this article, please visit Forbes.)

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Goodbye Crop Diversity

Here’s a picture from National Geographic showing a stunning decline in the genetic diversity of crops:

Photo Credit: National Geographic

Photo Credit: National Geographic

This is dangerous – diversity is key to avoiding crop failures from disease and pestilence.

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Rural Voters Elected President Trump. Is He about to Ruin Their Local Hospitals?

It’s not an easy time to be a small, rural hospital. Insurance companies aren’t willing to pay generously for your services, given your measly market share. You are increasingly forced to compete against large integrated healthcare systems – conglomerations of urban, suburban and rural providers armed with big marketing budgets and specialized (generously reimbursed!) services. But at least for the past few years, you’ve been able to count on a boon in the number of people who are able and willing to pay for your services, thanks to healthcare insurance they received through Obamacare.

That could all change soon. Republicans hope to reduce federal spending on healthcare. They want to roll back the Obamacare insurance exchanges, through which many people receive subsidies to pay for their coverage. They want to trim Medicaid spending, meaning that millions of people will no longer have the financial means to pay for medical care.

Obamacare was good business for many hospitals and medical providers. Under Obamacare, many states expanded Medicaid to larger numbers of people, and those people went on to seek out medical care. For example, in Oregon when people were randomly selected to be eligible for Medicaid expansion, those who received coverage became more likely to receive medical care – from primary care appointments to emergency department visits.

To read the rest of this post, please visit Forbes.

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