Americans Can't Do The Basic Health Care Arithmetic

A minimum of $300 billion dollars saved.  That is what I thought could be achieved by eliminating insurance companies from the American health care system.  It turns out the savings are a lot bigger than that.  Just looking at countries where the per capita health care costs are at least $2500 and comparing the USA to Switzerland - the country with the next highest per capita health care costs we get the following equation:

$2640 (the difference) x 320 million (current population the the US) = $844.8 billion

That is what converting the US health care system to single payer would involve.  No more managed care companies (MCOs)  pretending to be efficient.  No more pharmaceutical benefit managers (PBMs) rationing medications in order to make profits.  No more outrageous Obamacare premiums that seem to be rising with no end in sight.  No more MCOs, and PBMs making your doctor's life miserable and burning him or her out.  The writing should be on the wall by now for all Americans.  The US Congress and their healthcare lobbyists fully intend to continue the unsustainable health care bureaucracy to every American until the last possible moment.  That is as true for Republicans as it was for Democrats.

What do I mean by unsustainable?  According to KFF.org in 2016 employer purchased health insurance policies averaged $18,142 per year ($12,865 paid by the employer and $5,277 paid by the employee).  For retirees the situation is even more stark.  I used the AARP calculator to look at estimated health care costs only in retirement for a theoretical couple retiring at 66.  The result was an estimated $225,463.  Of that total only $121,529 was covered by Medicare and that left a shortage of $103,934 in out of pocket costs.  To me that means the average Social Security dependent senior citizen in this country cannot cover their health care costs even with Medicare.  Some of them are telling me their supplemental policies are as high as $20,000 to $25,000/year.  For any couple trying to stay in their own home in retirement - health insurance premiums and property taxes will easily absorb most if not all Social Security income.  The gross estimate by this calculator varies from state to state but some sources have given the gross average amount for a retired couple to be about $260,000.

And where does all of that money go?  That is easy.  It goes to bad management.  In a country that has fewer doctors and fewer hospital beds than most countries in the above graph - it should be obvious that rationing medical care to make profits for Wall Street does not work.  Two recent experiences will illustrate the problem.  I heard a presentation given by a speaker from one of the major physician run medical clinics in the  US.  For some reason she started talking about the ratio of administrators to physicians in their organization.  The number given was 50 administrators to every physician.  That is an absolutely stunning number.  With that number of people in hospitals and clinics - it should raise the question "What are they doing there?" and "Why does it take this many people to administer the most accountable professionals in the US?" Not only that but what has all of this administrative oversight accomplished?  The answer is in the graph at the top of this page - the most expensive and most inefficient health care system in the world.  It is basically an expensive jobs program for managers and bureaucrats, and bad technology.

The second scenario was a physician talking with me about his speciality clinic of 5 physicians.  He recently learned that they were being administered by 15 mid level administrators reporting to a single higher level administrator.  When he questioned this practice, he was asked why he was concerned about the number of administrative staff.  I guess according to the previous estimate he was doing quite well with a ratio of 16 administrators for 5 medical staff.

The real impetus for this post occurred as I was doing some exercises at home before work this morning.  The Today show was playing in the background.  Matt Lauer and Katie Couric were interviewing Trump advisor Kellyanne Conway about a number of issues.  I heard the question: "Have they (Republicans) come up with something to replace Obamacare?"  Ms. Conway responded with the typical free market solutions - buying insurance across state lines, health savings accounts, etc, etc.  None of these are solutions to bad management and what is basically corporate welfare for the army of healthcare administrators in this country.  The only correct response to that question is:

Single-payer health insurance.

Get rid of the unnecessary managers and save a trillion dollars in mismanagement.



George Dawson, MD, DFAPA


Attribution:

The figure on per capita health care spending is from the Kaiser Family Foundation accessed on January 1, 2017 and this is their citation:

OECD (2016), Health spending (indicator). doi: 10.1787/8643de7e-en (Accessed on 01 January 2017).

 I have no affiliation with the Kaiser Family Foundation or the OECD and their graphic is used here per their terms of use for non-commercial, non-profit sites.


Supplementary 1:

I would be remiss in not pointing out the mountain of fake news that goes into getting Americans to believe that some kind of government led "reform" that concentrates market power into a few for-profit proxies is a good idea.  There is the associated fake news from both parties that just happens to leave the pricing power to private industries,  In that context the fake news by Ms. Conway this morning is all part of an unmistakable 30 years of nonsense stretching back to the Clinton administration and their idea about "managed competition".  We have had nothing but mismanaged competition ever since.  The dynamic in health care is an obvious parallel to the financial services industry and their guaranteed profits from the work of Congress.  In both cases, all Americans foot the bill.


Supplementary 2:

Let me remind the free market advocates that there is not now and there will never be a free market in health care or anything else in the USA.  It is (largely) a Republican fantasy.  The major markets in the US all depend on government intervention and the sector with the best lobbyists gets the most favorable deals.  It is the only way to explain a trillion in waste, just based on "free market management" not including other boondoggles like a highly regarded electronic health record that is less functional than 1990s database software and paying $300 for 29 cents worth of epinephrine.

Worst Mass Shooting in US History

I got up Sunday morning and the CNN headlines stated: "50 dead, 53 injured.....".  What appears to have been a single shooter entered an Orlando nightclub last night  at about 2AM and shot 92 people with an assault rifle.  I saw Dr. Michael Cheatham  of Orlando Regional Medical Center say that a mass casualty incident was declared and an additional 6 trauma surgeons and a pediatric trauma surgeon were brought in.  The FBI is investigating it as an act of terror or a hate crime.  The shooter was a 29 year old man who had been investigated by the FBI for possible ties to Islamic extremism.  He had been working as a security guard for a company who provides services to the federal government.  He was licensed to purchase firearms.  He purchased two firearms shortly before the shooting - a Sig Sauer MCX Carbine 0.223 cal on June 4 and a Glock 19  9mm pistol on June 9 from the same gun shop.  Some reports suggest he was also carrying a Walther P22 .22LR pistol, purchase date unknown.  Prior to this incident the worst mass shooting incident was the Virginia Tech incident in 2007 that killed 32 people.  

At the time of the attack the shooter called 911 and pledged allegiance to ISIS and mentioned the Boston bombers.  President Obama came on the networks at 2PM and referred to the incident:  "This was an act of terror or hate."  He pointed out that this was an attack on all Americans and he encouraged solidarity.  In an earlier commentary (posted above) he discussed solutions.  He used the example of highway traffic fatalities and how they were approached from a scientific and public health standpoint.  Vehicle safety improved.  Driver behaviors especially driving while intoxicated was confronted.  Although he did not mention it, the drinking age in the United States was increased to age 21 largely by political leverage using federal highway money granted to individual states.  He pointed out that these same public health measures cannot be used in the case of firearm violence because Congress has blocked research on firearm deaths and violence. He discussed a situation that he had just encountered, where people being tracked by the FBI for frequenting ISIL web sites could be put on the no-fly list but they could not be prohibited from purchasing firearms. That legislation is blocked by a gun lobby with a primary thesis that some members of the government want to take away Second Amendment rights and firearms from law-abiding citizens.   The President points out that nothing could be further from the truth and cited the fact that more firearms have been sold during his administration that practically any other time of the Republic.  I think the manufacturing statistics might back up that claim at least based on a chart I created during the first half of his administration.  Further information corroborating this statement is available at the document Firearms Commerce in the United States 2015 on the ATF website.  There is plenty of data there to corroborate both the President's remarks and the potential financial conflict of interest of the firearms lobby.  I am sure that the gun advocates will be the first to say they deserve credit for gun commerce rather than the President.  My speculation is that they would deflect the conflict of issue by either wrapping themselves in the Second Amendment or as advocates for all of the law-abiding gun owners.

I think that most physicians agree with a public health approach to gun violence and would like to see more data and strategies.  The existing data shows that gun availability is the single largest determinant when it comes to firearm deaths either due to suicide or homicide.  It accounts for the greatest correlation with adverse outcomes from gun violence.  By comparison psychiatric diagnosis does not.

The President's comments on the further political aspects of gun control legislation in the US especially people being investigated by the FBI, like the perpetrator was on two occasions cannot be prohibited from obtaining firearms.  That speaks directly to the pro-gun argument that all we have to do is focus on existing laws and get the guns out of the hands of the bad guys.  This law potentially puts guns directly into the hands of the bad guys and nothing is being done about it.  The Obama video was posted 10 days prior to the Orlando attack.

I won't belabor the points I have already made in a series of posts on this blog.  We are still seeing the same microanalysis and political opportunism that has become a routine part of mass shootings.  We are still seeing the lack of solutions like we have seen in the past.  The way it looks I can continue to post on the issue on out into the future it will probably be a problem long after I am gone.  I heard a gun advocate on public radio this morning and what he said after this incident was not only depressing and disingenuous, but it typifies a rigid illogical stance that no place in science, medicine, or the 21st century.  It illustrates why the gun lobby has Congress enact laws to stifle funding for epidemiological work on gun mortality and morbidity.   I suppose at this point it is just a question of when we hit the tipping point.  When will the majority of Americans start to reject this illogical philosophy?

If the gun advocates hit the street with this hard line attitude after the scope of a mass shooting like we witnessed in Orlando - I shudder to think of what the eventual human cost is going to be.




George Dawson, MD, DFAPA




Attribution:

Embedded video per PBS and the instruction on their site.  Original video was from June 2, 2016

POTUS Tweets Measures To Address Opioid Epidemic

In 2014, nearly 21,000 deaths in the U.S. involved prescription opioids. Here's what @POTUS is doing about it: https://t.co/M2HgnDDN6a

— The White House (@WhiteHouse) March 29, 2016

I happened to be on Twitter last night when I caught the above Tweet from POTUS.  Having a professional interest, I decided to follow the link at the White House blog to look at the proposed measures.  They were listed as:

1.  Increasing a key drug for medication assisted treatment.  That key drug is buprenorphine in a number of formulations for treating severe opioid dependence.

2.  Preventing opioid overdose deaths.  This appears to be $11 million in funding for various forms of treatment and increasing access to naloxone to reverse the effects of an acute overdose.

3.  Addressing substance use disorder parity with other medical and surgical conditions.

These are very modest and in some cases unrealistic proposals about about trying to stop a drug epidemic that is killing 20,000 people a year.  Let me tell you why:

1.  Increasing a key drug for medication assisted treatment.  That key drug is buprenorphine in a number of formulations for treating severe opioid dependence.

Buprenorphine as Suboxone and Subutex have been available for the treatment of opioid addiction in the US since 2002.  The current evidence suggests that buprenorphine has superior efficacy for abstinence from opioids and retention in treatment.  There is also evidence that patients on buprenorphine have fewer side effects and that they is a less severe neonatal abstinence syndrome in mothers maintained on buprenorphine versus methadone.   Buprenorphine is also used for acute detoxification and treatment of chronic pain.  One of the limitations of maintaining opioid addicts on buprenorphine is that a special license is required to prescribe it.  Physicians can obtain that license by by attending CME or online courses.  Even then, expansion to primary care physicians has been slow because they may have no colleagues in their practice with similar certification and that makes on call coverage problematic.  In addition, many clinics that are medically based are reluctant to provide this type of service to people who have opioid addictions.  Apart from the technical requirements of prescribing the various preparations of buprenorphine certain physician and patient characteristics may also be important.  Physicians have to be neutral and not overreact in situations where the patient exhibits expected addictive behaviors that may include relapse.  As an example, younger opioid users are frequently ambivalent about quitting and in some cases, use other opioids and reserve the buprenorphine for when their usual supply dries up.  They may sell their buprenorphine prescription and purchase opioids off the street.  It may not be obvious but physicians prescribing this drug need an interpersonal strategy on how they are going to approach these problems.    On the patient side,  there is the biology of how the opioids have affected the person.  Do they have severe withdrawal and ongoing cravings?  What is their attitude about taking a medication on an intermediate or long term basis in order to treat treat the opiate addiction?

In clinical trials, buprenorphine seems to be ideal medication for medication assisted treatment (MAT) of opioid dependence.  Like most medications, there are issues in clinical practice that are not answered and possibly may never be answered.  The issue of life-long maintenance is one.  Many people with addictions are concerned over this prospect.  Long term maintenance with buprenorphine has advantages over methadone in that it is easier to get a prescription rather than show up in a clinic every day to get a dose of methadone.  Most addicts are aware of the fact that withdrawal from both compounds can be long and painful.  This deters some people from trying it and relapse risk is high if a person attempts to taper off of it.  Despite the current consensus about use. there is still the problem of young addicts who feel that they are "not done using" and who go between using heroin and other opioids obtained from non-medical sources and buprenorphine.  

2.  Preventing opioid overdose deaths.  This appears to be $11 million in funding for various forms of treatment and increasing access to naloxone to reverse the effects of an acute overdose.

Naloxone kits that would allow for rapid reversal of opioid overdoses have been shown to be effective in partially decreasing the death rate.  At some treatment and correctional facilities opioid users are discharged with naloxone kits for administration in the event of an overdose.  Opioids are dangerous drugs in overdose because they suppress respiration and that can lead to a cardiac arrest.  There are several properties of opioids that heighten the overdose risk.  Tolerance phenomena means that the user eventually becomes tolerant to the euphorigenic and in some cases therapeutic effects of opioids and needs to take more drug.  If tolerance is lost when the user is not taking high doses for a while, using that same high dose can result in an overdose.  Taking poorly characterized powders and unlabelled pills acquired from non-medical sources compounds the problem.  The exact quantity of opioid being used is frequently unknown.  Adulterants like fentanyl - a much more potent opioid can also lead to overdoses when users do not expect a more potent drug.

In addition to the pharmacology of the drugs being used there is also a psychological aspect to overdoses.  Users often get to the point where they don't really care how much they are using in order to get high.  They will say that they are not intentionally trying to overdose, but if it happens they don't care.

The available literature on making naloxone available suggests that it is effective for reversing overdoses in a fraction of the at risk population that it is given to.  I would see at as the equivalent of an Epi-pen in that the majority of patients with anaphylactic reactions get these pens refilled from year to year but never use them.  When they are required they are life-saving.  The problem with a naloxone kit is that it assumes a user or bystander can recognize an overdose and administer naloxone fast enough to reverse the effects of opioids before the user experiences serious consequences.  Unfortunately addiction often leads to social isolation and not having a person available makes monitoring for overdoses much more problematic.  Naloxone kits should always be available opioid users, first responders, family members, and anyone involved in assisting addicts.  Detailed long term data on the outcomes over time is needed.  

3.  Addressing substance use disorder parity with other medical and surgical conditions.

The is the most critical aspect of the President's tweet.  One of the main reasons for this blog is to point out how people with addictions and severe mental illnesses have been disproportionately rationed since the very first days of managed care - now about 35 years ago.  Some of the first major changes involved moving medical detoxification out of hospitals.  So-called social detoxification was available with no medical supervision.  These non-medical detox facilities were very unevenly distributed with only a small fraction of the counties in any state running them.  Any admissions to hospitals were brief and "managed" by managed care companies.  In the case of addictions some of the management practices were absurd.  A standard practice was to determine how many days a person could be in residential treatment.  That often required a call to an insurance company nurse or doctor who had never seen the patient.  They could determine that the patient could be discharged at any time based on arbitrary criteria.  In some cases that involved just a few days and the patient was leaving with active cravings and in some cases an an active psychiatric disorder.  This practice continues today, despite party legislation that suggests that addictions and mental disorders should be treated like any other medical problem.

This is where the President's tweet is on very shaky ground.  His legislation  focuses on large systems of health care and yet these systems don't seem to be able to supply adequate treatment with either buprenorphine or naloxone kits.  The President is fully aware of the The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).  That act was supposed to provide equal treatment for mental illnesses and addictions that was on par with medical and surgical conditions.  I think it is no secret that special interests have shredded the intent of this bill to the point that it is useless.  Managed care systems still ration care for these disorders in their best financial interest.  The resources for treating these disorders are still not equal to the task. In the case of prescription painkillers the same system of care not providing adequate treatment for addiction is often where that addiction started.

All three of the President's points could be addressed by forcing health care companies to provide adequate care for addictions and mental illnesses instead of grants to provide services that they should be doing in the first place.  In an interesting recent twist the President (1) suggested that this discrimination was based on race.  He implied that as a result the police rather than doctors have been used to address the problem.

Let me be the first to say that President Obama is wrong.  There is no doubt that racial discrimination exists.  There is no doubt that it occurs in systems of health care (2,3).  There is also no doubt that all it takes is a diagnosis of addiction or mental illness to trigger highly discriminatory health care coverage - irrespective of a person's race.  It is all about how health care businesses make money in this country by rationing or denying treatment for these disorders.

To reverse that discrimination,  the government needs to take the MHPAEA seriously.  So far they have failed miserably and that is the problem on the treatment side in trying to address the opioid epidemic.  

George Dawson, MD, DLFAPA

References:

1:  Sarah Ferris.  Obama: 'We have to be honest' about race in drug addiction debate.  The Hill March 29, 2016.

2:   Eddie L. Greene, MD and Charles R. Thomas, Jr, MD.  Minority Health and Disparities-Related Issues: Part I.  Medical Clinics of North America July 2005; 89(4).

3:   Eddie L. Greene, MD and Charles R. Thomas, Jr, MD.  Minority Health and Disparities-Related Issues: Part II.  Medical Clinics of North America July 2005; 89(5).

  

Is President Obama Reading This Blog?

Not really, but you can find the mass shooting links on this blog at this link.  They extend back three years and they overlap with a number of posts on homicide prevention.  They also overlap in many areas with the President's speech.  This was President Obama's 15th address to the nation following a mass shooting incident.  A couple of other landmarks - this was the 40th time this year that a gunman opened fire in a school and the 294th mass shooting incident this year.  Both of these markers illustrate how tragic but absurd this problem is in America.  How can responsible people allow this to happen?

The President is coming to the only logical conclusion that a person can come to about mass shootings and the relationship to firearms.  That point in this speech was when he said that our thoughts and prayers for the families and survivors are not enough.  We cannot keep making these pat statements in response to continuous mass shootings as though nothing can be done to prevent them.  We cannot treat mass shootings like they are routine:

"Earlier this year, I answered a question in an interview by saying, “The United States of America is the one advanced nation on Earth in which we do not have sufficient common-sense gun-safety laws -- even in the face of repeated mass killings.”  And later that day, there was a mass shooting at a movie theater in Lafayette, Louisiana.  That day!  Somehow this has become routine.  The reporting is routine.  My response here at this podium ends up being routine.  The conversation in the aftermath of it.  We've become numb to this."

 The familiar refrain about condolences to everyone and now it is time to move on needs to stop.  With governments that regulate what a lot of us do at work every day - right down to how we cross the Ts and dot the Is - it is difficult to believe that more functional gun control laws cannot be passed.  In his speech he points out that this is possible and there are laws that have been shown to work in other countries and in specific counties and municipalities in the United States.

At one point he speaks to the mind of the perpetrator:

"We don't yet know why this individual did what he did. And it's fair to say that anybody who does this has a sickness in their minds, regardless of what they think their motivations may be. But we are not the only country on Earth that has people with mental illnesses or want to do harm to other people. We are the only advanced country on Earth that sees these kinds of mass shootings every few months."

People tend to get hung up on whether specific perpetrators have a diagnosable mental illness and whether it is treatable.  They tend to get hung up on whether the behavior of violent individuals can be predicted over time.  They tend to be very pessimistic about the nature of the problem and whether insightless people will ever be able to get the kind of help that they need to prevent mass shootings.  It might be easier if there was some education about the types of situations that lead to these problems and the fact that in most of those cases, help is available.  That specific help will prevent homicides and prevent the unnecessary loss of lives of both the perpetrators and the victims.  

The President ended with a comment on the political process and an appeal to gun owners on the issue of whether they are being supported on this issue by an unnamed organization or not.  It was a compelling speech and the arguments are powerful.  As a politician, he is focused on political action and on common sense gun safety laws.  I have stated that it might be best to proceed from a public health standpoint and a focus on violence prevention and forget about legal approaches largely because there has been no political will on this issue.  President Obama has given one of the most compelling speeches on this issue that I have ever witnessed and it will be interesting to see the result.

From the medical and psychiatric side, our advocacy still needs to be on the public health side of the equation.  For me that comes down to seeing the problem to a significant extent as violence and homicide prevention.  We need more public education on the predisposing mental states and how to get assistance when these states are recognized.




George Dawson, MD, DFAPA


References:

Statement by the President on the Shootings at Umpqua Community College, Roseburg, Oregon.  October 1, 2015.  Transcript

Assault rifles, high capacity magazines, background checks and reverting to form

That is what it is coming down to according to the talking heads on the Sunday morning TV circuit this week.  Both the NRA and several politicians agree that there are not enough votes for an assault weapons ban.  There may be enough votes for a high capacity magazine ban but both sides acknowledge that these clips are inexpensive and there are already a lot of them out there.  The background checks issue is also debatable.  The NRA and the pro-gun factions are talking a lot about mental illness and needing to have a mechanism to prevent people with mental illnesses from getting guns.  There is minimal discussion of improved mental health services.  On CNN Sunday  morning there was acknowledgement that during tough budgetary times the line items supporting mental health treatment are the first to go.

So basically despite all of the hype about how the Sandy Hook incident was going to energize politicians to actually solve a problem – they appear to be rapidly reverting to form and not solving anything.  The NRA President seemed confident that nothing would happen (the NRA opposes any assault weapons ban or high capacity magazine ban), but cautioned that the President has a lot of political capital and might be able to influence the high capacity magazines.

I wanted to file this post tonight before the final recommendations of the Vice President because I think that there have been two recent articles in the medical literature that are very relevant. At the legislative level Jerome Kassirer, MD has a recent article in Archives of Internal Medicine. Dr. Kassirer is a former editor of the New England Journal of Medicine and I corresponded with him on this issue nearly 30 years ago.  He clearly has not lost interest over the years and brings several concepts into focus in his editorial. The first concerns the fundamentals of screening and how any effort to identify potential shooters would result in the false positives greatly outnumbering the true positives and how that renders screening impractical.  His primary focus has to do with countering political initiatives.  As an example the National Center for Injury Prevention and Control at the CDC is currently prevented from studying gun related injuries.  He advocates for countering that.  He advocates for a comprehensive analysis of gun ownership.  He also advocates for resistance to any laws that restrict physicians being able to talk about firearms with their patients. He wants to see universal background checks from gun purchases, gun safety devices including coded weapons, and restrictions on large capacity magazines and sales of large amounts of ammunition. His article refers to firearms as "Weapons of Mass Destruction".  Small arms and light weapons are in fact a major global problem.  This Federation of American Scientists primer highlights the issue and the fact that there have been over 1 million deaths due to small arms in the past decade. Some advocacy organizations estimate that as many as 250,000 people per year are killed by small arms fire worldwide.

The second very important article comes from the Journal of the American Medical Association. The authors of this article emphasize the public health approach to curbing gun violence. This is a very important concept that people have a difficult time grasping. Whenever I bring up the issue of psychiatrists being involved at the level of primary and secondary prevention most people distill that down to whether or not psychiatrists can predict violence.  A public health approach to violence prevention is much more comprehensive and multidimensional.  The authors give several good examples in this paper including modifying sociocultural norms.  They use the example of tobacco being media symbol of “modernity, autonomy, power, and sexuality" and how that was changed.  They suggest an analogous campaign to equate gun violence with weakness, irrationality, and cowardice. The article has a table that has 18 evidence-based public health interventions that have been successful in other areas that could be applied to gun violence.  This is actually the preferred strategy that I have been advocating for the past decade and the authors of this article state it very eloquently.

At this point in time it will be interesting to see if the Vice President's recommendations include any of the interventions suggested by these two articles or the recommendations from the APA.

George Dawson, MD, DFAPA

1: Kassirer JP. Weapons of Mass Destruction. Arch Intern Med. 2012 Dec 21:1-2.  doi: 10.1001/jamainternmed.2013.4026. [Epub ahead of print] PubMed PMID: 23262523.

2.  APA Recommendations to the Biden Task Force

3.  Mozaffarian D, Hemenway D, Ludwig DS. Curbing Gun Violence: Lessons From Public Health Successes. JAMA. 2013 Jan 7:1-2. doi: 10.1001/jama.2013.38. [Epub ahead of print] PubMed PMID: 23295618.