Modern medicine may be great at making money but not at making sense

Spending’s askew when billions go for unproven surgical robots while lack of affordable care leads thousands of poor, black, and brown patients to need diabetic amputations

 

amputations-300x171If U.S. health care leaders look ahead to 2020 and wonder why their sector of the economy will be one of the key concerns of presidential candidates and voters, they can only blame themselves for allowing the public to conclude that the industry’s big money and big profit drives have gone haywire.

If conventional wisdom holds (not with total accuracy) that economics is a dismal science, experts in health care finance and ordinary patient-consumers alike had to be baffled and bothered by recent news articles showing that medicine not only is awash in money but that it flows in ways that can be head-scratching, at best.

Doubts about robots for surgery

Take, for example, yet another call by medical scientists for more rationality with the burgeoning and costly field of robotic surgery. Bouncing off a new warning from the federal Food and Drug Administration that surgeons should not advance robotic procedures into unapproved areas like mastectomies, medical experts from Michigan urged in the Journal of the American Medical Association that doctors, hospitals, and insurers slow down and see if research supports the existing enthusiasm for this surgical approach. The doctors editorialized that:

The use of robotic-assisted surgery has increased more than 3-fold in the past decade, and the United States is now the largest market for this technology in the world—procedure volumes exceeded 600,000 in 2017 alone. The diffusion of robotic-assisted surgical procedures is concentrated within the fields of urology, gynecology, and general surgery. For these specialties, the technology is often marketed as a tool to mitigate some of the technical or anatomic challenges associated with specific surgical procedures. An additional justification for robotic-assisted surgery is that it increases patient access to safer, minimally invasive operations.

But they also review the limited and troubling studies around on the benefits, harms, and costs of these operations, examining as well whether surgeons get enough training on devices to take on the operations they do, and if they tell patients as much as they need to know about the procedures. They’re less than sanguine about what has become at least a $3-billion-a-year business, writing that, “Payers, hospitals, and surgeons can take immediate steps to ensure that certain safeguards remain in place until the evidence for or against the use of robotic-assisted surgery has time to mature.”

A ‘shameful’ measure

Even as billions of dollars may be available for supposed cutting-edge technologies in some parts of the health care system, the Kaiser Health News service (KHN) has reported on how inadequate care costs tens of thousands of mostly poorer Americans, too many of them black and Latino, their limbs. They lose them due to untreated diabetes and its complications, conditions that could be taken care of to avert the need for life saving but also life changing amputations.

Experts say the persistence of this radical surgery is ignored and is nothing less than shameful:

 Across the country, studies have shown that diabetic amputations vary significantly not just by race and ethnicity but also by income and geography. Diabetic patients living in communities that rank in the nation’s bottom quartile by income were nearly 39% more likely to undergo major amputations compared with people living in the highest-income communities, according to one 2015 study. A 2014 study by UCLA researchers found that people with diabetes in poorer neighborhoods in Los Angeles County were twice as likely to have a foot or leg amputated than those in wealthier areas. The difference was more than tenfold in some parts of the county. Amputations are considered a ‘mega-disparity’ and dwarf nearly every other health disparity by race and ethnicity, said Dr. Dean Schillinger, a medical professor at the University of California-San Francisco. To begin with, people who are black or Latino are more at risk of diabetes than other groups — a disparity often attributed to socioeconomic factors such as higher rates of poverty and lower levels of education. They also may live in environments with less access to healthy food or places to exercise. Then, among those with the disease, blacks and Latinos often get diagnosed after the disease has taken hold and have more complications, such as amputations. ‘If you go into low-income African American neighborhoods, it is a war zone,’ said Schillinger, former chief of the Diabetes Prevention and Control Program at the California Department of Public Health. ‘You see people wheeling themselves around in wheelchairs.’

Amputations cost taxpayers $100,000 or so (they’re covered by Medicaid) and they too often lead patients into a downward spiral because they lose mobility, chances of employment, and they suffer a cascade of infections and other complications because their already poor access and care worsens.

It cost how much?

Rich or poor, however, patients struggle to get clear, simple information on how much medical tests and treatments cost, with new data showing that price disparities in health care may be larger and different than what experts see in any other economic sector. The differences can be stark, not only within specified areas but also between markets.

This matters a lot to consumers, the New York Times explained:

Hospitals and insurers negotiate over prices in private, and they don’t want competitors to know about the deals they’ve been able to cut … Because these are prices paid by insurance companies, many experts say the differences between markets matter more, because they affect insurance premiums that all those with insurance in that area pay, even if they don’t get a blood test or an operation.

Consumers get stuck for the most part with paying for medical tests and treatments based on the savvy and skill of those who negotiate on their behalf—insurers and their employers, if they get work-based health insurance coverage. Patients, of course, mostly don’t get to see prices ahead of time, either.

They don’t buy or pay for ketchup, hotels, or any other goods or services in this way, experts say. Translation: The deck’s stacked against them on costs and pricing.

More alarms sounding

Most Americans get their health insurance from their employers, and political arguments have erupted already about how happy they are with the coverage, especially as presidential aspirants propose overhauls of the U.S. health care system.

Most of us are grateful to have it and give employer coverage a passing grade, the Henry J. Kaiser Foundation and the Los Angeles Times found in a new, deep national poll.

They also found that this satisfaction and the coverage itself is wobbling. A lot. That’s because employers have sought to shift onto their workers the huge and growing cost of health care, forcing even those with job-provided coverage to choose higher deductible policies with lower premiums.

This is hitting lower-paid workers hard, as well as those with chronic conditions themselves or who have covered family members with such illness. They can’t afford the out-of-pocket costs they must pay under the ever-rising thresholds of high-deductible plans, so they skimp on necessities and forego needed care. They soon can drown in medical debt, too, when less-than-generous employer plans fail to cover their needed prescription drugs and treatments.

As the newspaper reported:

Soaring deductibles and medical bills are pushing millions of American families to the breaking point, fueling an affordability crisis that is pulling in middle-class households with health insurance as well as the poor and uninsured.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become a greater ordeal due to the skyrocketing cost, complexity, and uncertainty of medical treatments and prescription medications, too many of which turn out to be dangerous drugs.

It’s unacceptable that doctors, hospitals, and insurers can throw billions of dollars at unproven, fancy technologies while tens of thousands of patients can’t get basic care that keeps them from the backward barbarism of diabetic amputations. Modern medicine’s sleights-of-hand with its costs and pricing can’t keep going — we all should press for greater transparency about secret deals and why inexplicable variances exist in what we pay for medical tests and treatments, as well as our health coverage. We all must open our eyes, too, to the rising problems with employer-provider health insurance. The post-World War II circumstances that caused companies to get into the health insurance and health care business have long faded, and, it appears, too, that so has the needed corporate commitment to Americans’ well-being. What’s the alternative? We may start finding it as we plunge on to the 2020 vote.

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