Moving Beyond Cancer Survival Statistics

--Also published in Medical Economics

Primary Care Crisis Will Doom Universal Coverage and You

Eric R. Braverman, M.D. was recently appointed the Clark Randt Memorial lecture and has accepted an appointment as Clinical Assistant Professor of Neurological Surgery at New York Presbyterian Hospital/ Weill Cornell Medical Center in the Department of Neurosurgery.

He is the author or more than 120 papers and has been practicing medicine for more than 22 years. He started in medicine at the Princeton Brain Bio Center in 1976. He performed post-graduate work in Internal Medicine at a Yale Medical School affiliate and conducted research as a member of a team at Harvard Medical School in 1979. He graduated from NYU Medical School with Honors in 1983, and graduated Summa Cum Laude, Phi Beta Kappa from Brandeis University in 1975.

Eric Braverman--

Today’s Health Care Isn’t Helping Us Live Longer

Conventional American medicine is like a Ford assembly line; each specialist looking at one of our “parts” without considering the rest of the body. But this approach is a medical disaster that’s affecting our health and longevity. We all know that our entire body, from the top of our head to the soles of our feet, is intricately interconnected. Our internal organs do not function independently either. Yet every single day people go to specialists and they are told they are “fine,” when their doctor only looked at one “part” without considering the health of the other “parts.” Months later, they are surprised to find that another part has completely broken.

Part of the problem is that doctors are not taking the aging body and brain into account as they diagnose us. Aging occurs throughout the entire body from the moment you are born until the day you die, but to various degrees. As children, we call these changes “development.” As adults, we refer to them as “illness.” The difference is purely semantic. Every time an internal system changes for the worse, or stops working the way it should, whether it is the heart, bones, kidneys, brain, or ovaries, we age. As one system begins to fail, it sends an aging code to the rest of the body, transmitting a signal that things are falling apart. This code is a death signal that the rest of the body responds to in kind.

Simply put, every disease that you get after the age of 40 is essentially an accelerated form of aging. Wouldn’t it be helpful to know the age of every part of your body, so that you can fix your oldest parts and stop them from pulling the rest of your  health down? That’s what my goal is. In my office, diagnostic testing pinpoints with incredible accuracy, the aging code of every organ in the body. With this kind of practice, I don’t have patients who have “surprise illnesses” or “shocking diagnoses” because I can treat them proactively.

Preventative treatment is exactly what “anti-aging” medicine is all about, and let me tell you, it’s definitely shaking up the medical establishment. In my office I take an integrative approach, which means that I combine the best medical protocols available for each of my patients. Once their oldest parts are identified, our goal is to reverse aging in these parts through a combination of lifestyle changes, nutritional supplements, diet modification, bioidentical hormones, and when necessary, medicines.

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R. Morris Coats is a Professor of Economics at Nicholls State University in Thibodaux, Louisiana. He was educated at Louisiana State University and at Virginia Tech. He taught at Lynchburg College and at Marshall University before coming to Nicholls State where he teaches classes on environmental economics, health economics, public economics and managerial economics. He has authored or co-authored numerous articles in peer-reviewed journals, such as the Southern Economic Journal, Journal of Public Economics, Public Choice, Public Finance Quarterly, Legislative Studies Quarterly, National Tax Journal, the Journal of Marketing for Higher Education, and Applied Research in Economic Development. He has co-authored several papers on sustainable economic growth and common-property resources. In addition, he has performed various impact and forecasting studies for the South Louisiana Economic Council and various tax studies for local and state governments. He has also published papers on cigarette smuggling, bribery of politicians and wasteful spending on homeland security. He takes special pride in now having at least one economic advisor for both the presumptive Republican nominee and the presumptive Democratic nominee for President of the United States for 2008 cite his research.

Before anyone gets too excited about the prospect of universal healthcare insurance, we should stop to think about what this will really accomplish. First, we should acknowledge that the very poor and the old are mostly covered, and that the largest part of the uninsured really are people who expect to have little use for medical care, and so, take the risk upon themselves. This is the group of 18-35 year old males.

We should note that universal health insurance, by itself, will do nothing to reduce healthcare prices, and in fact will tend to increase prices of health care and the premiums for health insurance because it will serve to increase the demand for healthcare while doing nothing to also increase the supply. Any increase in demand for healthcare because doctor’s visits may suddenly appear to be less costly (paid for through premiums or payments from the government) will merely push up the basic price of healthcare. Healthcare premiums will be pushed up as a result to cover the extra demand.

What is happening now, though, with partial coverage is a problem as well. Here is what happens. Some are covered, and some are not. Those covered are able to access health care at subsidized prices (that they pay for in fixed monthly payments), while those who are not covered pay full price. I think of it like making beer insurance available to college students, insurance that pays their beer tabs. This boosts the beer consumed relative to the full price, or in economics lingo, it boosts the demand for beer. If beer were like medical care, the problem would suddenly become very serious, because the supply of medical care is tightly limited, by medical schools, professional associations, licensure, and even government limits on supply.

But medical care is not quite like beer, because getting poked, prodded, probed, stuck, bled and disrobed, is not as appealing to most as a few cold ones. Many go to the doctor only reluctantly, just as many leave the pub only reluctantly.

The problem is that when some get their health care at some subsidized price, the demand ends up increasing and the full price to the uninsured increases. Some get healthcare a little cheaper perhaps, while others find it difficult to afford.

But what happens when we all are covered with healthcare insurance? It is much like the problem when we all stand to get a better view of a play in a football game–none of us end up getting a better view. When we all get healthcare insurance, we end up paying very high premiums and doctor visit fees much like we would have faced without coverage for doctor visits.

When we have privately paid for health care, or privately paid insurance and managed care plans, the managers of such plans cover certain treatments and do not cover others, bringing to mind the 1997 movie, “As Good as It Gets,” with Jack Nicholson, Helen Hunt and Greg Kinnear, where a boy’s asthma treatment was not covered by his mom’s HMO. At least there is some competition between plans, and employers do most of the “picking” amongst plans, but do so as an alternate means of paying their employees. As a result, though, legislators then have an incentive to mandate coverage of treatments that have political support.

The decision as to what is covered and what is not comes about as a political decision, with the benefits going to small concentrated groups and the costs spread over the premium payers. Politicians can point to greater coverage as an accomplishment of theirs, and since payments are not coming from tax payers but rather from premium payers, politicians can also point out that the government spending and the tax burden was not increased, laying the blame of ever higher premiums on the shoulders of the health insurers and HMOs. The politicians are ordering greater coverage, but someone else is paying for it off budget.

What differs with government health single-payer plans or nationalized plans is that it becomes clear that the politicians are responsible for the costs—they no longer have private firms on which to lay the blame for mounting costs. Then, they act much like the HMO Helen Hunt faced in “As Good as It Gets,” but now without competition. Then we start to see both tough choices and questionable choices being made. For instance, this summer stories (see these at Fox and KATU, Portland, OR) began to pour out of Oregon of cancer patients being denied chemotherapy, but offered physician assisted suicide instead, because easing the pain and bringing about earlier death of patients too costly to treat is the right thing to do.

So it goes.

Then there is this recent story from Britain about Baroness Warnock, a medical ethicist and an advisor to the British government, who has even suggested that dementia patients may have a “duty” to die.

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WASHINGTON, D.C. -– As part of a new federal project funded by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality, RTI International will develop, implement, and evaluate four computer-based decision support tools that will help clinicians and patients better use genetic tests to evaluate and treat breast cancer. 
 
"Patients at risk for breast cancer, or those diagnosed with breast cancer, need tools that help in accurate understanding of their genetic information and its impact on their treatment options," said AHRQ Director Carolyn M. Clancy, M.D. "Understanding and applying the evidence on these questions is vital to achieving the best possible outcomes and improve patient care."
 
The first pair of tools will assess whether a woman with a family history of cancer should be tested for BRCA1 and BRCA2 gene mutations. Knowing whether a woman has inherited these gene mutations may help determine her chances of developing certain kinds of cancer, especially breast cancer.
 
The second pair of tools, for women already diagnosed with breast cancer, will help determine which patients are appropriate for a Gene Expression Profiling (GEP) test. GEP test results can help evaluate which patients are at a high risk of cancer recurrence and therefore are good candidates for chemotherapy, in addition to other appropriate treatments.
 
"We're excited to partner with AHRQ to develop these decision tools," said Linda Squiers, Ph.D., a senior health communication analyst at RTI and the project’s manager. "Our goal is to develop tools that are accurate, usable, and easily integrated into clinical workflow. If effective, these tools could change the clinical practices of both primary care physicians and oncologists."

The $1 million project is expected to take about 16 months. The project responds to recent recommendations from the U.S. Department of Health and Human Services’ (HHS) Secretary’s Advisory Committee on Genetics, Health, and Society. The committee concluded there are extensive gaps in knowledge about genetic tests and their impact on patient care. 

The project also reflects the goals of HHS Secretary Mike Leavitt's priority initiative on personalized health care, which aims at increasing the effectiveness of medical care by more precisely matching each patient’s conditions and needs with therapies that will be effective for them.

 Development of these tools will support AHRQ’s work of translating research into clinical practice in the areas of genetic tests, health information technology and patient care.  For instance, the AHRQ-sponsored U.S. Preventive Services Task Force has recommended that women whose family history is associated with an increased risk for BRCA1 or BRCA2 gene mutations are referred for genetic counseling and evaluation to measure the need for BRCA testing.  AHRQ has also published an Evidence-based Practice Center report on the impact of GEP tests on breast cancer outcomes.

The new project to create decision-support tools is funded through AHRQ’s DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) research network, of which RTI is a part.

The Effective Health Care Program sponsors the development of new scientific knowledge through studies on the outcomes of healthcare technologies and services.  For more information about AHRQ’s Effective Health Care Program and the DEcIDE Network, visit the Effective Health Care Web site at http://effectivehealthcare.ahrq.gov. To learn more about the project to create gene-based clinical decision-support tools for breast cancer patients, visit: http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=nr&ProcessID=68.

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According to the Center for Health Workforce Studies, eight counties in New York State have no obstetricians: Essex, Greene, Seneca, Tioga, Washington, Yates, Schoharie, and Hamilton. The center also found that 18 of New York's counties have fewer than five practicing ob-gyns. If these trends continue, it may get to the point where we have to ask: who will deliver the babies of New Yorkers? New York is not alone: in fact, more than 1,500 counties in America — about half of all counties — do not have even a single obstetrician.

It has never been a safer time to have a baby, or a more dangerous time to be an obstetrician. During the past 30 to 40 years, technological innovations like ultrasound and electronic fetal heart rate monitoring have revolutionized obstetrical practice, while a variety of other advances have led to the virtual elimination of some potentially devastating fetal conditions and substantial improvement in the outcome of many pregnancies complicated by medical disorders. This has occurred despite the fact that increasing numbers of women are waiting to have their first child until they are considerably older than the generations that preceded them.

For the physicians and midwives who deliver babies, though, the news has not been so good. According to a 2006 study by the American College of Obstetricians and Gynecologists, nearly 90% of obstetricians report that they have been sued at least once in their careers, up from approximately 75% in 1996. Furthermore, about 40% of obstetrical residents have at least one claim filed against them during their four-year training period. That same survey found that almost 65% of ob-gyns made one or more changes to their practice as a result of the risk or fear of professional liability claims or litigation.

By far, the biggest source for malpractice lawsuits against ob-gyns is neurological damage to newborns, particularly manifested in the development of cerebral palsy. Families who have an infant with cerebral palsy almost always have substantial financial needs, for medical care, therapy, and other services for their children. With options for support often limited, it's no surprise that these families frequently seek recourse in the tort system. The problem is that few cases of cerebral palsy actually have anything to do with the process of giving birth. Indeed, experts suggest that apart from taking steps to avoid exposure to associated risk factors in a small percentage of cases, there is little evidence to suggest that cerebral palsy can currently be prevented.

Not that efforts haven't been made. The rate of caesarean deliveries in America has soared during the last 30 years, at least in part due to defensiveness on the part of physicians seeking to avoid birth-related lawsuits. But it hasn't helped much. Despite a national c-section rate of close to 30% in 2005 — almost 5 times the rate in 1970 — the incidence of cerebral palsy has remained rock stable throughout that period, about one in every 500 births. Today, the tort system is like a lottery for medical injury victims. A few win large amounts, but most receive nothing. Most injuries go uncompensated, as shown by the Harvard Medical Practice Study, based on claims data from New York hospitals and follow-up studies. The system's administrative costs are also very high, as much as 60 cents on the dollar, which means that whether a case is won in court or settled much more money goes to legal fees, expert witnesses, and other costs rather than to patients and families.

But the costs of raising neurologically impaired children are enormous for all those who face this challenge, not just those lucky enough to win the legal lottery. Moreover, obstetricians consistently face liability for adverse outcomes that they could not have prevented from occurring. This helps to drive up malpractice insurance premiums, and to create an environment which is increasingly unfavorable for all providers of care to pregnant women. With today's high practice costs and relatively fixed reimbursements, obstetrical practitioners are leaving early at the far end of the pipeline — and fewer of our medical school graduates are entering today at the near end.

According to the chief of obstetrics at Oswego Hospital in Oswego, N.Y., Dr. Ronald Uva, a practicing obstetrician-gynecologist for nearly 30 years who has delivered seven thousand babies, "It is almost impossible for me or my colleagues to continue to practice obstetrics. I tried to stop practicing at age 55 to spend more time with family, but my group could not recruit a single obstetrician and my partners would have had to work every other night in the hospital. My group is still trying to recruit. No luck — not one decent candidate. There are really no obstetricians for hire. Also, high medical liability rates make it almost impossible for me to give care to the underserved."

This is happening in an environment which is problematic for the medical community. There are constant challenges, such as the administrative hassles of practicing medicine, which are provoking startlingly high levels of physician discontent and distraction. In a survey conducted last year by the physician recruiting firm locumtenens.com, 97% of the 2,400 physician respondents said they were frustrated by nonclinical aspects of medicine.

Physicians — and families — in this state deserve better. We propose an alternative approach: a new program, financed with provider and public support, to provide comprehensive benefits to all eligible children with substantial neurological injuries using an approach similar to workers compensation. Such a program would remove these cases from the tort system.

Rather than filing a claim in court, all eligible families would obtain financial support in this administrative system, with oversight provided by highly qualified independent experts, and a rational process for determining awards. A case management program would evaluate every child individually to determine the assistance that each family requires. Eligible beneficiaries would gain access to the services they needed for their entire lives.

In addition to providing financial assistance to all families with impaired children who met the eligibility criteria, the program would also address patient safety, by performing a comprehensive review of the standard of care in each case. The failings identified would then be used to discipline those found to be negligent, and to educate every obstetrical caregiver in the state about delivering better, safer care.

Such an approach would compensate more children, more quickly, and in a more equitable way, as evidence suggests that similar programs have done in Florida and Virginia. Those programs have dramatically reduced the administrative costs associated with compensating birth-related injuries, and program administrators suggest that providing financial support to eligible cases though this approach will result in substantial savings over time. Moreover, this type of program will provide access to a lifetime of needed health care and other services for these vulnerable children, and should help to stabilize liability insurance premiums while improving the quality of care throughout the state.

In Albany, legislation was introduced in the Senate this past session that would have begun the process of creating a program like this in New York. We hope that our elected officials will carefully consider endorsing this equitable and rational proposal that has the promise of benefiting patients, families, obstetrical health care providers and society as a whole.

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• Some analysts say much of those employer savings come because many HSA participants tend to forgo care. "There is a lot of evidence that suggests that when patients pay a higher percentage of the cost of their care they get less of it," says Michael Thompson, a principal at Pricewaterhouse Coopers, which advises employers on health plans.
• Self-employed attorney Jonathan Stein, 34, of Elk Grove, Calif., got an HSA in 2005. Because he is responsible for paying the entire bill, he didn't go to the doctor for a recent bout of flu and doesn't get annual physicals despite a family history of heart disease and cancer. "My doctor and I fight about that when I do see her because she wants me to come in every year," Mr. Stein says. "If it was covered by insurance I'd probably go."
• Watson Wyatt expects 54% of big companies next year to offer high-deductible health plans, many of which are HSA eligible, up from 39% in 2007. Since the plans were introduced in 2004, more than six million Americans have enrolled in HSA-eligible plans, although that represents a small percentage of the more than 200 million people with private health coverage.

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Dubbed “An Apostle for Fitness” in her profile in the Wall Street Journal, Carole has been a featured guest on more than sixty radio and television shows, including NBC’s Today show, CBS’s Early Show, MSNBC’s Countdown, and CNN News. Carole has been featured in magazines such as American Fitness, Diet & Exercise Magazine, and Today’s Health & Wellness, as well as in newspapers such as the Honolulu Star-Bulletin, Tampa Tribune, Sacramento Bee, Baltimore Sun and the Los Angeles Times. Carole’s book, From Fat to Fit, was named a finalist in the health and fitness category of the National Best Books 2007 Awards, sponsored by USA Book News.

Besides teaching and consulting, Carole has produced a weekly community television show, The Tipping Point and a reality show, Go Fat to Fit.

On August 28, 2008, the U.S. budget deficit reached an all-time high of $9,650,327,577,961.59 . Servicing this debt requires around $500 billion annually, give or take a few billion. And like the addict who needs another fix, we continue to spend. This year, experts estimate that an additional $410 billion will be added to the big fat American deficit. Moreover, because of the rocky economy, less revenue from taxes may cause these numbers to rise.

The United States is currently spending 16 percent of its gross domestic product on healthcare. This figure will probably expand in tandem with the expanding waistlines of overweight and obese Americans, whose numbers now total two-thirds of adults and one-third of our offspring. Surplus weight results in health problems that translate into additional medical costs. Consequently, the direct and indirect economic costs of the rising numbers on the bathroom scale are sobering. Individuals, insurers, employers, government programs (including Medicaid and Medicare) and county, state and federal governments pay for direct costs. And as most individuals and employers know too well, insurance premiums are rising. The average annual premium for a family of four is over $12,000 .

Indirect costs are harder to measure yet just as real. They reflect the loss of income resulting from absenteeism, sick days, restricted activity and premature death.

What are the solutions to the healthcare dilemma proposed by our presidential candidates? The views of the two presidential candidates are summarized in the article “Why Their Economic Plans Don’t Add Up” in the August 18, 2008, issue of BusinessWeek .

In summary, McCain proposes a $5,000 tax credit to help uninsured families afford coverage. He also proposes taxing employer-subsidized medical insurance. McCain believes that improved management of the healthcare system will trim costs.

In contrast, Obama’s priority is obtaining coverage for the 45 million uninsured Americans at an estimated annual cost of $65 billion. Like McCain, Obama assures voters that better management of the healthcare system and cost controls can lower the annual insurance premiums to an affordable level of $2,500 for a family of four.

Both of these candidates agree that the healthcare system needs attention. Although they disagree on the means, both want citizens to have access to affordable healthcare. Without being drawn into the merits of either candidate’s proposals, we can focus on three fixes that can help us become more fiscally and physically fit (FIT):

F: Fix the medical model. Instead of reimbursing physicians and hospitals $250,000 for a single heart surgery, fund wellness and prevention programs for 1,000 people at $250 each. Instead of reimbursing physicians solely for treatment, reimburse physicians for time spent on prevention and wellness programs.

That’s the perspective of Dr. Nick Yphantides , author of My Big Fat Greek Diet and the poster child for what an individual can achieve when lifestyle changes occur. Once a big man (he weighed nearly 500 pounds) with an even bigger heart, Dr. Yphantides now weighs 237 pounds. He uses his personal example with his patients and members of the community to promote healthy lifestyles even though it would be more lucrative to focus on the treatment of medical problems arising from lifestyle choices.

I: Intervene in the lives of individuals to cut through denial. Alabama is experimenting with a stick rather than a carrot. State employees will be fined $25 if they fail to make lifestyle changes that address health and weight issues. Although most of us prefer a carrot to a stick, some of us may need the sting of a stick to wake us up. The cost of gasoline provides a parallel example. When the price of gas became painfully high, more people chose to take public transportation, carpool or bike to work. Similarly, penalty payments deducted from paychecks may trigger decisions to adopt healthier habits.

T: Tackle the issue of fitness as a community. We need to change the environmental cues that encourage us to overeat and under exercise into ones that encourage us to eat more healthfully and exercise regularly. For example, the Board of Health in New York City recently mandated that restaurants post the caloric content of fast food next to the items because it anticipates that informed consumers will make different, healthier choices. This model could serve other communities. Church leaders are encouraging members to adopt healthier habits by promoting the idea that the body is God’s holy temple. Followers have a stewardship responsibility to care for their bodies to affirm their appreciation for God’s gift of life.

Parents can insist that healthier meals and physical education be provided to children in our schools. Communities can adopt successful group weight-loss programs such as the Nevada County Meltdown , where over 1,000 people lost nearly four tons in eight weeks. Or communities can introduce Dr. David Sabgir’s model, the Walk with a Doc program in Lewis Center, Ohio. Each Saturday at 8:30 a.m., Dr. Sabgir and other physicians and medical-care providers walk with about 175 to 200 patients, family and friends.

How I cast my ballot once inside the voting booth this November is a private matter. Publicly, however, I have no problem sharing my ideas on how we can enhance the health and well-being of friends, family and neighbors. As a by-product, we can reduce the cost of healthcare and help lower the national debt.

My own medical cost-containment program is to lead a healthful lifestyle to render expensive medical care and prescription drugs unnecessary. And my tongue-in-cheek goal is to die a natural death without the help of a doctor. 

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