Map of life expectancy at birth from Global Education Project.

Wednesday, September 02, 2009

Dream On

Reading medical journals and our mainstream political discourse is to inhabit alternate universes. Case in point, the new JAMA, which you, as a mere citizen, are not allowed to read. So, I will do my usual service and tell you some of what's in it.

First, another one bites the dust. Another widely performed operation, that is. A few weeks back we learned that vertebroplasty, a widely used procedure, is worthless. Now it turns out that a procedure called Laparoscopic Uterosacral Nerve Ablation, used to treat chronic pelvic pain, is equally useless. The data are clear in fact -- it does absolutely nothing. Chronic pelvic pain is a big problem -- it affects a lot of women, usually has no identifiable cause, and can really bring you down. So surgeons would cut some of the nerves thought to transmit pain signals from the affected area. Sounds logical, doesn't work, according to a very well designed and carefully analyzed randomized controlled trial using sham surgery as a comparison, done by Jane Daniels and a multitude.

Okay then, we ought to do a lot more of this kind of research, right? That's what the president wants to do and that's what's got profound policy analysts from George Will to Sarah Palin screaming that he wants to murder you.

Not only should we do the research, we actually ought to, you know, use it, according to Dr. Robert H. Brook. The RAND Corporation, which brought you the <sarcasm>highly successful counterinsurgency tactics used in the Vietnam War</sarcasm> has also done some reasonably commendable work. One totally brilliant idea they came up with, which I could not possibly have thought of, is to classify medical procedures as:

necessary (the care produces substantially more health benefit than harm and is preferred over other available options), appropriate (produces more good than harm by a sufficiently wide margin to justify use of the procedure), equivocal (potential health benefits and harms are about equal), or inappropriate (health risks are likely to exceed health benefits).

Absolutely brilliant. Only a think tank with megamillions in government funding could have come up with that. Anyway, Brook proposes setting up expert panels within non-profit organizations to review the available evidence and come up with clinical scenarios in which various procedures are and are not appropriate; then set up a web based application so that doctors and patients can enter information about the patient's situation and get an appropriateness rating on a particular procedure to help them decide if it's worth it. In other words, according to Senator Grassley, Dr. Brook wants to murder you.

Finally, Victor Fuchs reviews the reasons why we pay 2 to 3 times as much for health care as the civilized nations do, and have nothing but grief and pain to show for it. It's the same stuff I've told you about here, with mind-numbing repetition, but Victor Fuchs is famous and stuff and I'm not so I'll just repeat it all with the benefit of his immense gravitas:

  1. Higher administrative costs: Hundreds of insurance companies (sucking up profits and executive salaries, which Fuchs is too kind to mention), millions of employers buying insurance, 50 states administering rules, clinicians having to bill separately for every individual service -- you get the picture.

  2. Too many specialists, not enough primary care docs: In Canada, half of physicians are in primary care; in the U.S., even with generous counting, it's less than 1/3. Right now, in many parts of the country, it's literally impossible to get an appointment with a primary care physician.

  3. Too many expensive machines: Hospitals compete with each other by buying MRI scanners and whatnot. "On average, each Canadian . . . scanner accounts for 48% more scans than each U.S. machine."

  4. Open ended funding: No overall budget to assure value for the dollar.

  5. More malpractice claims: This is a complicated issue which I won't go into here but some proposals for malpractice reform would be a good thing. Won't have much effect on overall costs, however. Sorry Victor.

  6. Less social support for the poor: Now you're talking. If we actually try to do something about the extreme inequality in this country, we'll save money on medical interventions for socially caused disease. Among other benefits.

  7. Higher drug prices: "The United States has been subsidizing the rest of the world by allowing the drug companies to practice price discrimination by charging higher prices in the United States than in other countries for the same drug." Victor, you f'ing commie.

  8. Higher physician incomes: Okay, here they have to borrow a quarter million dollars for tuition, which in the civilized world they don't. Still, we could ameliorate a big part of this problem by not overpaying those overabundant specialists.

Now you can probably figure out for yourself where the title of this post comes from.

We need universal, comprehensive, single payer national health care. Everything else is idiotic blather designed only to confuse and mislead you.


roger said...

"....idiotic blather designed only to confuse and mislead you." it's well enuff designed to fool quite a few.

nice comment on #7 above.

robin andrea said...

I'm still dreaming on.