Health Care Reform – Don’t be fooled.

Health Care Reform – Don’t be fooled.

Yesterday members of the House of Representatives introduced another health-care plan which brings the total number of health-care plans introduced by Congress up to three. Besides the plan introduced yesterday by the House there are two plans coming out of the Senate. These plans come after President Obama addressed the American Medical Association providing his vision of health-care reform. Once again health-care reform is taking center stage as everyone struggles with how to make health-care affordable.  While there is a great deal of debate as to the pro’s and con’s of these plans, one thing is certain with nearly 16% of our nations GDP at stake the fight for health-care reform won’t easy.

Given that diabetes is growing at epidemic rates and is one of the more costly disease states patients with diabetes and the companies in the diabetes market will be watching this debate with great interest. Realizing that the plans being offered today will change dramatically as they move forward Diabetic Investor will not comment on which plan offers the best hope for the millions of patients with diabetes. Instead we prefer to examine how some recent trends in diabetes fight in the health-care reform debate.

As a frame of reference for this debate Diabetic Investor believes everyone should read two outstanding articles. The first written by Richard Kahn, PhD and John Anderson, MD appearing in the June 2009 issue of Diabetes Care entitled “Improving Diabetes Care: The Model for Health Care Reform.” The second appearing in today’s Wall Street Journal by ABRAHAM VERGHESE entitled “The Myth of Prevention.” These two excellent articles are not think pieces which propose what an ideal health-care system would look like. Rather the two pieces deal with what happens in the real world and outline the difficulties facing health-care reform.

According to the article in Diabetes Care the authors correctly note; “Much of the discussion on “health care reform” is really centered on reforming health care financing and not improving the organization and delivery of care.” Diabetic Investor could not agree more with this statement. Throughout the recent Presidential campaign we heard a great deal about the cost of health care and about which candidate had the best plan to get the most people insured. To Diabetic Investor this focus on cost missed the entire point. Where is it written that if a person has health insurance this fact will allow them to receive quality care? Just because the person has health insurance, subsidized or not, guarantees nothing more than the care they receive will be paid for, nothing more.

Both articles also take a swipe at one the most commonly held myths about health care, that somehow we can save millions perhaps billions through preventive care. As Mr. Verghese points out in his article; “Prevention is a good thing to do, but why equate it with saving money when it won’t? Think about this: discovering high cholesterol in a person who is feeling well, is really just discovering a risk factor and not a disease; it predicts that you have a greater chance of having a heart attack than someone with a normal cholesterol. Now you can reduce the probability of a heart attack by swallowing a statin, and it will make good sense for you personally, especially if you have other risk factors (male sex, smoking etc).. But if you are treating a population, keep in mind that you may have to treat several hundred people to prevent one heart attack. Using a statin costs about $150,000 for every year of life it saves in men, and even more in women (since their heart-attack risk is lower)—I don’t see the savings there.

This is also true with diabetes. Long ago Diabetic Investor wrote that the terms pre-diabetes or metabolic-syndrome were nothing more than attempts by pharmaceutical companies to sell more of the drugs they make. With all we know about diabetes it still mystifies many as to why someone who looks pre-disposed to diabetes never actually develops full blown diabetes and others who seemingly have no predisposition to diabetes develop full blown diabetes. As with so many myths prevention sounds really good but in reality focusing on prevention may actually increase health care costs.

Looking over the various plans and how things actually work in the real world Diabetic Investor also agrees with another statement made by Mr. Verghese “Which brings me to my problem with the president’s plan: despite being an admirer, I just don’t see how the president can pull off the reform he has in mind without cost cutting. I recently came on a phrase in an article in the journal “Annals of Internal Medicine” about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us—doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others—are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not?—it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal. The good news is that the AMA, representing perhaps 15% of active practicing physicians, is not as powerful as it was in Truman’s time, and in the eyes of the public and many in medicine, it’s identity in the reform debate, is that of a protectionist, self-serving, organization; as a result, even their most progressive statements are viewed with suspicion. I’ve found the views of the American Medical Student Association particularly exciting—the next generation of physicians I sense has a deeper commitment to affordable health care for all than ours; they are, simply put, better people.

As Diabetic Investor pointed out in our most recent issue when we discussed the trend toward greater connectivity between all the various devices a patient uses. The theory has always been that armed with information the patients healthcare team would be able to intervene before a small problem becomes a bigger, more costly problem. While this may or may not be true, no one has been able to answer a simple question; Just who will pay for all this data analysis?

Diabetic Investor has examined several efforts to improve patient outcomes and have come to the conclusion the most effective efforts all have the same drawback, cost. As effective as the “Asheville Project” has been and other efforts that follow a similar protocol the major problem is cost. Even when advance technology is used no one has been able to achieve better outcomes without having a human element, normally a Certified Diabetes Educator, involved in the program. This begs the question can a program be cost effective and still achieve better outcomes?

These programs also have other drawbacks besides cost, namely they ignore what’s going on in the real world. There is no question that Diabetic Investor is a huge fan of CDE’s. CDE’s are the most over-worked, under-paid group of professionals who remain dedicated to their patients in spite of these facts. Still they are vastly outnumbered. Consider there are approximately 15,000 CDE’s and nearly 24 million patients with diabetes. Technology can help increase the number of patients these professionals can handle however technology does not change the fact that there are only 24 hours in a day and these professionals cannot work around the clock. Time is not a renewable resource.

Making even more complex and costly is something Diabetic Investor examined in our last issue and reinforced by the Diabetes Care article namely that effectively treating diabetes requires multiple medical disciplines. As Kahn and Anderson point out people with diabetes have on average five different medical problems. In their article the authors note;

The complexity of chronic diseases has led to the recommendation that such care be distributed across a multidisciplinary team (26), coordinated by a PCP or in some cases a specialist. This concept goes beyond case management, where treatment is tailored to patients’ conditions and centered on acute goals of therapy and often operates independently of patients’ primary physicians. This new model of care has been termed the “patient- centered medical home” (PCMH). Its primary elements are that it is team based and coordinated and directed by a single physician, resulting in well orchestrated, continuous, comprehensive, and timely care that (hopefully) reduces the overuse and misuse of services and leads to better outcomes at reduced cost (27,28).

 In the management of diabetes, a patient-centered multidisciplinary team has long been advocated (29) and its elements defined (30). But in practice it has been generally confined to an endocrinologist and diabetes educator(s). Many successful and innovative approaches to diabetes management that represent a hybrid between case management and the PCMH have been described and could serve as lessons for what could or does not work (31–34).

 Whether the PCMH or some version of it can produce the results it promises is unclear, and effective care coordination has had problems (26). Nonetheless, as chronic care supplants acute care as the dominant driver of health care costs, there is a groundswell of opinion that the current model of  physician-directed, visit centered care must be replaced.” 

Diabetic Investor agrees with this however we also understand such an approach is also a costly one.

This in essence is why this debate of health care reform is so misguided. The fact is health care reform really has nothing at all to do with improving care or producing better outcomes.  The reality is this debate is about one thing and one thing only, costs.  Try as they might to disguise this fact the reality is health care reform is really code for reducing health care costs.  Looking at the realities of our current health care system it’s counterintuitive to believe we can achieve better outcomes and cut costs at the same time.  As we said earlier the reality is a choice needs to be made; Do we opt for cutting costs which could ultimately lead to worse outcomes or do we opt for systems that focuses on better outcomes? To Diabetic Investor this is the real choice.

Even if every person in America had “affordable” health insurance this in no way means the health care they are receiving is any good. All that it really means is the care they are receiving is paid for.

Looking at the real world where we have an aging patient population that will require even greater care it’s difficult to see how “affordable” care can be achieved without some type of cost controls. Something Diabetic Investor believes would have disastrous consequences and not just for patients with diabetes. Would pharmaceutical companies remain committed to spending millions on drug development under such a system? Would physicians be penalized for taking the time to effectively treat a patient or by referring them to specialists? Is it even possible to achieve lower costs without also addressing the impact of malpractice or class action lawsuits?   

Diabetic Investor believes that no one would argue that our health care system needs reform. However, health care reform and lowering health care costs are not one in the same. These are two completely different problems each requiring a different set of solutions.  To somehow believe that lower costs for health care alone will lead to better outcomes is both foolish and dangerous. Diabetic Investor has not come across one study that proves this to be the case. There’s a great deal of theory but to date that’s all we have is theory and speculation.

When it’s all said and done some difficult choices need to be made. Yet don’t be fooled by all this talk about health care reform when in reality this is just code for cutting health care costs.  When it comes to health care reform it would wise to remember the words of Andre Gide who said; “The true hypocrite is the one who ceases to perceive his deception, the one who lies with sincerity.”