For most of the years while I was coming up in the world of public health and social policy, it was accepted truth that medical intervention made only a small contribution to population health. Quantifying "population health" as a single entity is obviously highly problematic. There are many components that people will value differently. There is mean life expectancy at birth, which is a common measure that is not terribly difficult to calculate; although as I have explained here before and won't bother to do again right now it's a fictitious construct that does not predict how long you actually have to live. Rather it's a snapshot of the ages at which people are dying today.
Regardless, there's a lot it doesn't tell you. Even with regard to lifespan, a few people living to a ridiculously old age will pull it up but maybe we care more about how many people get to live whatever we might consider to be a "full lifespan," which conventionally has been three-score years and ten, i.e. 70. Maybe we care more about relatively early deaths rather than extremely long lives, in other words. It also doesn't say anything about inequity. And of course it doesn't say how healthy people are or how rewarding or happy their lives are. There are measures called Quality Adjusted Life Years and Disability Adjusted Life Years that try to provide aggregated measures of longevity and well-being combined, but they are highly value laden and controversial. (Again, I've discussed these before, you can look them up.)
Nevertheless, people would try to quantify the contribution of medical intervention and you'd typically see estimates ranging from 20% to 50%. The remainder is a consequence of the social and physical environment (given that genetic heritage isn't really controllable and is taken as given). Since the social environment strongly determines our physical environment -- including diet, exposure to pollution, occupational risk, psycho-social stress and so on -- these are often summarized as Social Determinants of Health, or SDH. One respected thinker, Ivan Illich, even made an argument that many found convincing, that medical intervention was a net negative for humanity (mostly in a book titled Medical Nemesis).
It is still true that SDH are probably more important than doctors, and even more strongly if you compare rich and poor countries and counties within the U.S. Nevertheless the relative contribution of medicine has increased somewhat, in many people's opinion which I largely share. It's been a slow process with plenty of two steps forward and one step back; and plenty of bad mistakes along the way including treatments which indeed do more harm than good. Nevertheless the general direction has turned out to be positive in the long term. Bad news: It's gotten more expensive, which means that medical services eat up more and more of the economy and there's a cost to that. We might get more bang by spending some of the bucks elsewhere, which is no contradiction to the claim that medicine is now contributing more to health and well-being.
An important case in point is the cancer death rate. You can read all about it here. The overall age adjusted cancer death rate has fallen steadily since 1991 through 2017, resulting in 2.9 million fewer deaths from cancer than had the peak rate persisted. (This is the age adjusted rate, which they don't bother to mention most of the time. Actually the raw number of cancer deaths has increased because there are more people and they tend to be older, but you have to wipe those facts out when you think about this.) The rather novel message is that most of this is due to improved treatment. Yes, the biggest contributor is lung cancer deaths and yes, lower smoking rates are part of that, but better treatment is just as important. Better treatment for myeloproliferative disorders (leukemia), melanoma, breast cancer and prostate cancer also contribute. Lots of cancer is now definitively curable, and lots more has greatly increased survival time, though not necessarily with great quality of life. All of this means a cancer diagnosis doesn't have to be as terrifying and final as it used to be.
On the other hand a lot of this treatment is very expensive. On the one hand that means that universal access to affordable health care is more important than ever, on the other hand it means it's harder to pay for. But that's the way it is. We'll keep this context in mind in future discussions of public health and health care policy.
Subscribe to:
Post Comments (Atom)
11 comments:
One of your finer posts.
While the politicians make boogeymen out of insurance companies, they're just the administrators of the risk pools. The real problem, as you mentioned, is the high cost of delivering the services, themselves.
Manufacture of goods have been outsourced elsewhere for decades. I believe that market forces will ultimately force the outsourcing of services such as medical as well.
It just makes sense.
https://www.nytimes.com/2019/08/09/business/medical-tourism-mexico.html
"The real problem, as you mentioned, is the high cost of delivering the services, themselves."
How do those other developed countries do it?
The answer is: universal, single-payer, comprehensive health systems.
The insurance companies are NOT just "the administrators of the risk pools."
What nonsense.
But I've lived and worked in socialistic/capitalistic countries and received their health care. Dr. readers such as Porkenheimer have not. So they keep spewing the common talking points, against basic knowledge. Somebody has to pay for all those insurance agents' homes and pools, and those big insurance company buildings, and those insurance stocks.
Capitalists are full of drivel. And willfully ignorant.
This commenter seems to believe that management of risk pools is the only variable in comparing costs in different places. That's the viewpoint of someone who has had no business training.
One of the largest variables is the law.
Can physicians in one area invest in hospitals and clinics and then self-refer patients to those same clinics for treatments at the expense of his insurance and others can't?
Who here thinks that unlimited punitive damages in medical malpractice suits in some areas don't drive up costs?
AND...there will be someone managing the risk pools. If not private companies, then it will be government at taxpayers' expense.
Again, it is "at taxpayers' expense" that health care worked so well in the countries I lived in.
How do they do it? It must be MAGIC! If only Denmark, Sweden, Norway, Cuba, England, Spain, France, Switzerland, Luxembourg, Belgium, Canada ... etc., etc. ... would share their secrets with us.
Again, I've lived abroad. Dr. P. has not. He speaks in theoretical language, muddled at that. The proof is in the pudding: Countries that give a damn about quality of life for ALL--not just billionaires and traitors with orange hair who live off of laundered Russian money--manage to insure their people and keep the life expectancy rising!
But not the racist, greedy U.S. It's all where you place your priorities.
Where there's a will, there's health insurance!
If Elizabeth Warren is going down the tubes because liberal Democratic voters aren't buying it, imagine how this will play in the general election...
Dr. P. appears to be utterly tone-deaf to any perspective but his own, and so keeps spouting the same pablum. As if Elizabeth Warren is the only candidate offering health care for all!
Remember, Bernie Sanders is polling at the top! So he'll be elected, and we'll get universal, comprehensive, single-payer health care.
And one of the people who will benefit will be Dr. P.! But he'll find things to complain about after the fact, and tell us on this blog why he's bummed out about it.
So little imagination. Einstein said that imagination is more important than knowledge. There's a reason for that.
Here's something that I hope you will find interesting and will actually add value to the discussion of healthcare costs.
https://www.realclearhealth.com/articles/2020/01/10/rx_price_transparency_is_key_to_lowering_health_care_costs_110979.html
Porky, I do discourage personal squabbles among commenters and I often delete comments that I find too confrontational. The last one is maybe borderline but it does have some substance.
Price transparency may be helpful, it certainly seems right in principle. Unfortunately the structure of health care markets is such that I don't think it will do a whole lot. Consumers don't pay the sticker price so it really doesn't matter to them, and insurers do bargain with providers and they know what they're paying. PBMs also have to sell their services to payers so the potential to squeeze them more probably isn't all that great. Price disclosure can't hurt anything but won't go far to solving our problems.
For my part, I can do better in terms of not lobbing anything perceived to be an insult. I do get frustrated when I make a point that seems to be not only logical but drawn from my own experience and education, only to have the other party seemingly be unable to comprehend what I've written. I suppose people on the "conservative" part of the spectrum feel similarly.
I have to admit that I believe my point of view comes from education and experience, whereas conservative viewpoints seem to come from ideological thinking that is both divorced from any real-world experience AND any substantial corroboration--in other words, literature that supports their perspective, despite the fact that the "evidence" they trot out is faulty and disproven.
It is frustrating. Perhaps Paul Krugman doesn't feel that way because he is so authoritative and his findings are corroborated over time.
Is it perhaps a genetic thing? Conservatives are unable to change their thinking? And yet, some of them seem to do it. I honestly think it may just be an innate thing. But when the prime minister of a country like Australia can't come around to admitting climate change accelerated by humans is a real phenomenon, one has to wonder. Not to mention the bullshit that is passing for discourse on the part of Republican congresspeople here in the U.S. ...
While I'm on the subject:
In Stephen Colbert's devastating 2006 monologue/video presentation at the 2006 White House Correspondents' Dinner, he said something about G.W. Bush to the effect of, "Here's a man who believes the same thing on Wednesday that he did on Monday--no matter WHAT happened on Tuesday."
Hilarious. Yet G.W. Bush was not laughing (there's video of this). He was livid, stultified, furious.
It also seems that conservatives--by and large--do not have much, if anything, in the way of sense of humor or sense of irony. This also makes it hard for me to take their "discourse" seriously. A man like Mitch McConnell is basically dead, spiritually and emotionally. The horrors of a speech by Donald J. Shitler (I never use his real name, since it is a joke, truly ... changed from "Drumpf" by some equally bloviated ancestor) are jaw-dropping: nothing but narcissism, lies, hatred, mocking, insecurity.
I mention all this by way of my previous comment, that conservatives seem unreachable by discourse. Yet we're supposed to take seriously their comments and perspectives, even though they're not based in reality.
Why?
No one was saying that these problems with prescription drugs and how the system will solve the healthcare cost delivery issue. But there's a whole bunch of these issues that could add up to a very meaningful reduction in the cost of delivered healthcare.
Here's a few off the top of my head that I think (IMHO)would be meaningful in reducing healthcare costs and in the order of importance. These are all do-able and much easier to implement than Bernie's plan. Also, Bernie's plan will not address most of these problems. You'll just have someone else paying for all of it.
*Tort Reform - Limiting frivolous suits - limiting punitive damages - Loser pays other party's legal bills or a portion thereof.
*Waste - Harvard Study says 30% waste https://hbr.org/2015/10/how-the-u-s-can-reduce-waste-in-health-care-spending-by-1-trillion
*Incentive for patients to value shop for non-emergency health issues
*Prescription drug delivery system reform
*Self-dealing of heath professionals - Doctors owning hospitals and other facilities
*Fraud control (Huge, BTW in Medicare).Estimates of 3%-10% is what I've seen.
If all of this could be implemented, the savings could be more than half. This is worth considering.
Post a Comment