Atul Gawande the New yorker Article

[NeuResurgens]

How would they even do a study like that? There would be no control here in the States for environments that lack a fear of litigation. I've seen a study that demonstrated no significant change in test ordering in states with tort reform, but the problem with that is that there is still significant fear of litigation in those states, even if they've capped the payouts for pain and suffering.

I think it would need to be a comparative global study of healthcare systems and legal systems by country and states/provinces.

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[NicMouse64]

I think it would need to be a comparative global study of healthcare systems and legal systems by country and states/provinces.

Can't do that, because when single payer comes out on top republicans will start the next mccarthy era of anti "socialist" healthcare policies.

 

[Petrichor1]

What in gods green earth are you even talking about?

I don't understand which part you don't understand. My argument correlates what the article mentions which is unnecessary test ordering. If you don't get that, then I can't help you.

 

[username456789]

I don't understand which part you don't understand. My argument correlates what the article mentions which is unnecessary test ordering. If you don't get that, then I can't help you.

Just as I suspected, you have no idea what you're talking about.

 

[LizzyM]

I understand why they chose those dates, but this does not explain the justification for using 1994 as the baseline concerning the effect of changing marijuana laws on possible marijuana related car crash fatalities. There are a 15 years between 1994 and 2009 when the commercialization of marijuana expanded. There could have been other causes in those 15 years that contributed to the rise of possible marijuana related car crash fatalities that could have been better controlled for if they chose the first six months of 2008 (or even 2005) as a baseline instead of the first six months of 1994.

Because they used all the dates. See the paper for:
Fig. 2.
Proportion of drivers in a fatal motor vehicle crash who were marijuana-positive in Colorado and 34 states without medical marijuana laws from 1994 to 2011
Fig. 3.
Proportion of drivers in a fatal motor vehicle crash who were alcohol-impaired in Colorado and 34 states without medical marijuana laws from 1994 to 2011.

 

[Petrichor1]

Just as I suspected, you have no idea what you're talking about.

I'm presenting one facet to the argument available in the article. I have better credentials to be slighted.
article mentioned, "....The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit..."
I presented an example where doctors may call unnecessary tests to be done, that leads to waste and increased cost to patient. However, a more sensible reason behind it is the practice of defense medicine, for which I still find some common tests to be inappropriately ordered. I wish reform could focus on restraining insurance, not the doctor (maybe educating them more but not increasing the loads of paperwork they deal with). I for one take a more defensive approach towards doctors so I see their side too.

 

[mehc012]

It was long! Since I'm at work it took me half the day to read, haha. But yes, I'm surprised he didn't at least mention litigation as one of the reason doctors behave in the manner he described. I read another book recently which basically put the legal climate in America as the single central reason our healthcare is so expensive and inefficient. This writer didn't present much data, but I tend to believe this claim. Anyone know any good studies that gauge the relationship between litigation and defensive medicine/healthcare expense?

Check out that vid, and then click through his links for sources/data.
I know it's not hugely in depth, but it's my go-to for a quick review on things.

 

[NeuResurgens]

Check out that vid, and then click through his links for sources/data.
I know it's not hugely in depth, but it's my go-to for a quick review on things.

Wow, that guy is totally spastic!

He makes good points though. Healthcare costs are the result of many factors. I would disagree with him on tort reform - he basically assumes Texas' reform laws are exactly what is needed and bases the result on those assumptions. It sounds like they weren't particularly successful. The thing with malpractice is its not only economic - it's cultural. Even if the threat of lawsuits was severely diminished today, I think it would still take a while for the medical field to adjust to more efficient medicine again, simply because it's so engrained. Plus, the public at large still believes lawsuits are the go-to when something goes wrong, so there are still attempts. It's a complex problem that's hard to explain so I hope the logic I followed comes across right

 

[mehc012]

Wow, that guy is totally spastic!

He makes good points though. Healthcare costs are the result of many factors. I would disagree with him on tort reform - he basically assumes Texas' reform laws are exactly what is needed and bases the result on those assumptions. It sounds like they weren't particularly successful. The thing with malpractice is its not only economic - it's cultural. Even if the threat of lawsuits was severely diminished today, I think it would still take a while for the medical field to adjust to more efficient medicine again, simply because it's so engrained. Plus, the public at large still believes lawsuits are the go-to when something goes wrong, so there are still attempts. It's a complex problem that's hard to explain so I hope the logic I followed comes across right

I agree with you that it is more complicated than a single law could demonstrate, and largely comes down to culture. However, I'd like to point out that the TX tort reform point was only an example, and not his main point. The malpractice discussion was twofold - one was that in states (like TX) with tort reform, you see a decrease of ~0.1% in healthcare spending. He then went on to state that the biggest estimates of the impact of malpractice are actually 2.4%, or 55 billion dollars. That figure seems to have come from this source: http://content.healthaffairs.org/content/29/9/1569.abstract and was not based on the assumption that TX's tort reform efforts are the ideal model.

 

[ridethecliche]

How would they even do a study like that? There would be no control here in the States for environments that lack a fear of litigation. I've seen a study that demonstrated no significant change in test ordering in states with tort reform, but the problem with that is that there is still significant fear of litigation in those states, even if they've capped the payouts for pain and suffering.

Texas.

 

[NeuResurgens]

I agree with you that it is more complicated than a single law could demonstrate, and largely comes down to culture. However, I'd like to point out that the TX tort reform point was only an example, and not his main point. The malpractice discussion was twofold - one was that in states (like TX) with tort reform, you see a decrease of ~0.1% in healthcare spending. He then went on to state that the biggest estimates of the impact of malpractice are actually 2.4%, or 55 billion dollars. That figure seems to have come from this source: http://content.healthaffairs.org/content/29/9/1569.abstract and was not based on the assumption that TX's tort reform efforts are the ideal model.

Either way, there are many changes to require if we want to cut our costs. The thing is, America is a huge country with a big population, so I don't think it's realistic to try and spend as little money as these small European countries with socialized systems. There are just too many social, cultural and economic factors that increase our costs, including more advanced technology and private development of those technologies (costs of which are often passed to consumers), a culture of lawsuits (which cost a lot even if unsuccessful), practice of defensive medicine either because of the threat of lawsuits or just because it's taught that way (which probably accounts for a huge amount of our costs and is difficult to quantify) as well as a tendency to "overkill" as the OP's article suggests. Each of these factors will likely need to be addressed individually with different reform strategies - I don't think a single health care reform bill can accomplish this, admirable as the intentions may have been.

 

[mehc012]

Either way, there are many changes to require if we want to cut our costs. The thing is, America is a huge country with a big population, so I don't think it's realistic to try and spend as little money as these small European countries with socialized systems. There are just too many social, cultural and economic factors that increase our costs, including more advanced technology and private development of those technologies (costs of which are often passed to consumers), a culture of lawsuits (which cost a lot even if unsuccessful), practice of defensive medicine either because of the threat of lawsuits or just because it's taught that way (which probably accounts for a huge amount of our costs and is difficult to quantify) as well as a tendency to "overkill" as the OP's article suggests. Each of these factors will likely need to be addressed individually with different reform strategies - I don't think a single health care reform bill can accomplish this, admirable as the intentions may have been.

Neither I nor the guy in the video referenced a single health care reform bill (nor a particular, recent one, if that's what you're alluding to). It's definitely a complex issue which will require a complex approach.
I don't see why size has anything to do with it, as long as you're talking per capita numbers (which would make all the comparisons proportional.) If anything, having a larger patient population would give more leverage if we were to somehow negotiate effectively.

 

[deleted307836]

Gawande is always so on point that it's incredible. It'd be awesome to see him move into some type of public policy position but he'd probably despise that.

 

[Vain Brother]

It was long! Since I'm at work it took me half the day to read, haha. But yes, I'm surprised he didn't at least mention litigation as one of the reason doctors behave in the manner he described. I read another book recently which basically put the legal climate in America as the single central reason our healthcare is so expensive and inefficient. This writer didn't present much data, but I tend to believe this claim. Anyone know any good studies that gauge the relationship between litigation and defensive medicine/healthcare expense?

there was this study from a few months ago: http://www.nejm.org/doi/full/10.1056/NEJMsa1313308

explanation here: http://blogs.nejm.org/now/index.php/malpractice-reform-and-emergency-department-care/2014/10/15/

 

[NeuResurgens]

Neither I nor the guy in the video referenced a single health care reform bill (nor a particular, recent one, if that's what you're alluding to). It's definitely a complex issue which will require a complex approach.
I don't see why size has anything to do with it, as long as you're talking per capita numbers (which would make all the comparisons proportional.) If anything, having a larger patient population would give more leverage if we were to somehow negotiate effectively.

I wasn't accusing anyone of referencing one end-all be-all reform bill.. just observing that it will take multiple fronts to address some of the different issues facing healthcare, which is why the ACA probably won't completely correct the prices of medicine.

I think size makes a difference, because if you think about it - the cost of healthcare per person in America is already 2-3 times more than in many countries, and we have a much larger population. While taxes on a larger number of people would somewhat even this out by bringing in more money in total, the large discrepancy between health costs per person can quickly escalate the expenses levied on the government (should healthcare be provided by the government). We already see that medicare might struggle to break even, and this program doesn't even provide for a majority of the population. A government-provided healthcare approach would require a lot of streamlining. I personally have liked the idea of a two-tiered system with private and public sectors. Have you heard about/investigated this topic?

there was this study from a few months ago: http://www.nejm.org/doi/full/10.1056/NEJMsa1313308

explanation here: http://blogs.nejm.org/now/index.php/malpractice-reform-and-emergency-department-care/2014/10/15/

I find this interesting:

"...if the authors’ conclusions are correct, that feeling driving you to pursue the additional test is probably not your fear of a lawsuit.
What is that force, then, that pushes physicians to order expensive tests? Perhaps it’s the uncomfortable uncertainty inherent in medicine. Maybe insecurity about the sensitivity of the physical exam. Or the fear of missing a rare or life-threatening diagnosis. Almost certainly, it is an amalgam of factors."

I do believe defensive medicine goes beyond "defense from lawsuit." Because of the caring nature of doctors, they may also try to defend against the chance of a significant pathology causing symptoms, which can lead to more negative patient outcomes. Certainly most doctors have either heard the story from a colleague or experienced it themselves, when patients were sent home with seemingly insignificant symptoms only to discover a more serious cause of those symptoms. While many conditions are more rare than common, no physician wants to miss that one time in a thousand when the symptom is indicative of a serious illness for which early detection is key.

 

[mehc012]

I wasn't accusing anyone of referencing one end-all be-all reform bill.. just observing that it will take multiple fronts to address some of the different issues facing healthcare, which is why the ACA probably won't completely correct the prices of medicine.

I think size makes a difference, because if you think about it - the cost of healthcare per person in America is already 2-3 times more than in many countries, and we have a much larger population. While taxes on a larger number of people would somewhat even this out by bringing in more money in total, the large discrepancy between health costs per person can quickly escalate the expenses levied on the government (should healthcare be provided by the government). We already see that medicare might struggle to break even, and this program doesn't even provide for a majority of the population. A government-provided healthcare approach would require a lot of streamlining. I personally have liked the idea of a two-tiered system with private and public sectors. Have you heard about/investigated this topic?

Yup. I'm still a vote for single payer atm...I don't think Medicare is a good example to look at, considering the jacked-up system it's tied to/working within.

I found this book pretty educational on the subject:
Amazon product

Also, check out Singapore's system...yes, it's for a very small population, but it's an interesting approach!

 

[NeuResurgens]

Yup. I'm still a vote for single payer atm...I don't think Medicare is a good example to look at, considering the jacked-up system it's tied to/working within.

I found this book pretty educational on the subject:
Amazon product

Also, check out Singapore's system...yes, it's for a very small population, but it's an interesting approach!

Oh, fantastic! I've been looking for healthcare reform books to read with different takes on the issue, so this is perfect, thanks. I'm going to add this to my list.

I somewhat distrust the idea of universal healthcare in America (not because of universal healthcare by itself, but because of the American government's propensity to screw things up - see medicare, education etc.) However, such a system might work if we have the right people design it. I think such an overhaul would need to come about in a different political environment - particularly, not to be done in a rushed manner. I would certainly like to see doctors of varying backgrounds involved.

I just read the sparknotes version about Singapore on Wikipedia, but I like what I see. It sounds like sort of a hybrid two-tier system with private and public options, with most choosing the public option. I do like that there are relatively small upfront costs to prevent overutilization while still generally being affordable, and the individual healthcare savings accounts sound like a good idea. The article specifically said it's difficult to replicate in other countries (although it didn't give reasons or examples), but a similar approach in America would not be a bad idea if some research could be done on its viability for our population.

 

[mehc012]

Oh, fantastic! I've been looking for healthcare reform books to read with different takes on the issue, so this is perfect, thanks. I'm going to add this to my list.

I somewhat distrust the idea of universal healthcare in America (not because of universal healthcare by itself, but because of the American government's propensity to screw things up - see medicare, education etc.) However, such a system might work if we have the right people design it. I think such an overhaul would need to come about in a different political environment - particularly, not to be done in a rushed manner. I would certainly like to see doctors of varying backgrounds involved.

I just read the sparknotes version about Singapore on Wikipedia, but I like what I see. It sounds like sort of a hybrid two-tier system with private and public options, with most choosing the public option. I do like that there are relatively small upfront costs to prevent overutilization while still generally being affordable, and the individual healthcare savings accounts sound like a good idea. The article specifically said it's difficult to replicate in other countries (although it didn't give reasons or examples), but a similar approach in America would not be a bad idea if some research could be done on its viability for our population.

I agree that instituting actual, effective healthcare reform in the US is greatly complicated by our #%$@$^$#^@$ political system. Thus, in these discussions it is always difficult to differentiate between "what do I think would be the ideal healthcare system if we could design it from the ground up" and "what steps could we realistically make in this country to improve our healthcare system from where it is right now."

And yeah, I thought you'd like Singapore!

 

[NeuResurgens]

I agree that instituting actual, effective healthcare reform in the US is greatly complicated by our #%$@$^$#^@$ political system. Thus, in these discussions it is always difficult to differentiate between "what do I think would be the ideal healthcare system if we could design it from the ground up" and "what steps could we realistically make in this country to improve our healthcare system from where it is right now."

And yeah, I thought you'd like Singapore!

You just perfectly summed up my feelings. There are so many good options that might not be realistic because of the stuff that's already ingrained where it is..

I think my support of a two tiered system comes from the latter mindset - it might be more realistic given America's current political and economic climate.

 

[meowfish6868]

I think it's interesting that (at least in the article about the study) they make no mention of any overall increase in the total number of fatal car accidents. Of course they wouldn't be able to show causation, but they aren't even suggesting a meaningful correlation!

The authors state in the study that fatal car accidents have been decreasing both in Colorado and the 34 comparison states during the time period examined. The authors also acknowledged that the results may just indicate increased marijuana use in Colorado, which I feel is the most reasonable conclusion they make in the paper.

Is it possible to ascertain the time period when that marijuana was consumed? This isn't something that gets flushed out the body like alcohol with a few days.

...But just to nerd out, is it possible to "breathalyze" marijuana accurately? (for lack of better terms).

There isn't a reliable way to ascertain time of marijuana use that is comparable to measuring alcohol intoxication with a breathalyzer. Detection times for marijuana use are variable, with heavy users having a much longer detection window. Blood tests are more likely to identify recent use, as they measure THC levels in a user's system, whereas urine tests measure a non-psychoactive metabolite. There also isn't a comparable, established measurement of marijuana intoxication with BAC.

 

[mehc012]

There isn't a reliable way to ascertain time of marijuana use that is comparable to measuring alcohol intoxication with a breathalyzer. Detection times for marijuana use are variable, with heavy users having a much longer detection window. Blood tests are more likely to identify recent use, as they measure THC levels in a user's system, whereas urine tests measure a non-psychoactive metabolite. There also isn't a comparable, established measurement of marijuana intoxication with BAC.

To me, this was always the only real, sound, argument against legalization. Not an insurmountable one, but one which I think has been woefully ignored by legalization proponents.

Come up with a way to legitimately test for MJ intoxication, and it's easier to make it recreational, with standards and regulations analogous to etOH (only the drug itself is less dangerous).

 

[NickNaylor]

Yup. I'm still a vote for single payer atm...I don't think Medicare is a good example to look at, considering the jacked-up system it's tied to/working within.

I found this book pretty educational on the subject:
Amazon product

Also, check out Singapore's system...yes, it's for a very small population, but it's an interesting approach!

It's interesting to me that you support single payer and then say that Medicare is "jacked up." It is a government run program. It is highly likely that in the small chance single payer is actually implemented in the U.S. it would be based off the Medicare model. And given that Medicare is a government run program, I'm not really sure what you'd expect to be different in a program that would almost certainly be similar to Medicare.

 

[mehc012]

It's interesting to me that you support single payer and then say that Medicare is "jacked up." It is a government run program. It is highly likely that in the small chance single payer is actually implemented in the U.S. it would be based off the Medicare model. And given that Medicare is a government run program, I'm not really sure what you'd expect to be different in a program that would almost certainly be similar to Medicare.

I didn't say Medicare is jacked up. I said that the problem with using Medicare as your example for assessing single-payer viability is that it is still forced to exist in the otherwise jacked up healthcare setup we have. Unless I completely misspoke earlier, in which case I apologize.

I just feel that it is better to draw conclusions about what single-payer would look like from actual single-payer systems, rather than half-measures.

 

[NickNaylor]

I didn't say Medicare is jacked up. I said that the problem with using Medicare as your example for assessing single-payer viability is that it is still forced to exist in the otherwise jacked up healthcare setup we have. Unless I completely misspoke earlier, in which case I apologize.

I just feel that it is better to draw conclusions about what single-payer would look like from actual single-payer systems, rather than half-measures.

But Medicare is effectively a single payer system for people aged 65 and older - it's not really a half-measure. It functions almost identically to other systems that have a primary single payer system with the option to buy additional private coverage to supplement be primary plan. I'm not really sure how the rest of the system is relevant.

 

[nRomaleos]

But Medicare is effectively a single payer system for people aged 65 and older - it's not really a half-measure. It functions almost identically to other systems that have a primary single payer system with the option to buy additional private coverage to supplement be primary plan. I'm not really sure how the rest of the system is relevant.

Yessir. This was also known as the "government option." An option that was favored by the majority of voters...but Mr. Obama was too scared to offend his managed care donors.

 

[ridethecliche]

I wonder if a full fledged single payer system in the U.S. Would force people to have more comprehensive social support programs due to the cost savings.