Tag: Healthcare

GoFundMe For Healthcare

GoFundMe for Healthcare

Posted on by jabittan
We all complain about our personal healthcare costs and we know that healthcare spending in the US is a huge percentage of GDP, but what isn’t clear is that the vast majority of spending and healthcare costs come from a small minority of patients. Cancer care, treatment for severe trauma, and therapy for rare diseases can be incredibly costly and unpredictable. For many people who face such substantial challenges, GoFundMe ends up being a huge support, and I think it is worth asking ourselves if that is a reasonable way for people to be able to afford medical care in the United States.

 

As Dave Chase writes in The Opioid Crisis Wake-Up Call, “In 2013, more than 1.5 million Americans lived in households that experienced a health-related bankruptcy. More than three-quarters of those people had insurance. Some say medical bills may also be the top cause of homelessness. Nearly half of all GoFundMe crowdfunding campaigns are to pay for medical-related expenses.”

 

Our health insurance, what we pay for and what our employers offer us to help ensure that if necessary, we can afford medical care, does not actually help us afford medical care in the case of an emergency or major diagnosis. Medical related bankruptcies are not a rare occurrence, even for those who have insurance, and if Chase’s quote is accurate that a large cause of homelessness is medical bills, then the cost of care that is supposed to help someone be healthy, likely pushes people into incredibly unhealthy living circumstances. The fact that people have to turn to crowdfunding moonshots for treatment is a clear indication that the healthcare system in America is failing those who need it most.

 

I would argue that much of the social unrest in our country is related to stagnated wages. Chase argues that wages have stagnated as businesses cope with increasing costs for providing healthcare to employees. Americans don’t see their wages increase, but do see the cost of healthcare rising, and many face bankruptcy and must turn to GoFundMe for healthcare related expenses. It is not hard to imagine how healthcare costs contribute to an unhappy populace that doesn’t trust public officials and elected leaders who have not been able to remedy the situation, or business leaders who have not provided real value in the health benefits they offer employees.
Healthcare Pricing Failures and Overtreatment

A Story of Healthcare Pricing Failures and Overtreatment

Posted on by jabittan
I don’t know anyone who would not agree if I said that there was a pricing failure with the way that healthcare operates in the United States. My personal favorite example of this was a story about a person who wanted some type of medical care, but couldn’t get it due to complications with payment between what he would pay and what his insurance provider would pay the provider. The individual one way or another found out what the charge was for someone who was uninsured, and asked if he could just pay that amount instead, but the provider couldn’t offer him the same rate because of the complications involving the private insurance, contracts, and all the confusing legal structures involved. The price of healthcare in the United States is not just high, it is completely opaque to even the people on the inside, it is apparently arbitrary in some instances. It is a pricing failure that is detached from the costs that anyone involved actually seems to face.

 

One of the worst parts of the pricing failure of healthcare, however, is that it isn’t even connected with the services we receive. Because no one knows what anything costs at a pure base level, consumers can’t easily shop around, and providers have no incentive to make sure they are actually providing value for the service they provide. I’ll use an example from my own life:

 

I had been getting vision checks and contact prescriptions done at Costco for several years, but thought I ought to actually get in for a full eye exam at an office a couple years back. Costco was cheap, it was easy, the service was quick, and the optometrist was a good communicator. In other words, the service and the value of the care I received were excellent. At the other office I paid substantially more for an eye exam, did a bunch of tests that seemed unnecessary and needed to be repeated, never got a great answer about why I was doing the tests, why I failed them, and if it was a problem with my eyes or the machine in use. The optometrist was less friendly, didn’t communicate as well, offered me fewer contacts to try on and conducted what felt like an unnecessary contact fit exam rather than letting me try out the contacts for a couple weeks before making a purchase. Where Costco gave me my prescription and sent me out the door, the office I went to had no intention of letting me have my actual prescription, in an effort to force me to purchase contacts through their office rather than someplace cheaper.

 

Dave Chase in his book The Opioid Crisis Wake-Up Call writes, “Broadly speaking, the two biggest problems in the U.S. healthcare system are pricing failure (no correlation between price and health outcomes) and overtreatment.”

 

I experienced both of these in the example above. I (and my insurer) were billed for unnecessary services at the more expensive office. The services provided were worse, less convenient, and didn’t seem to be related to my actual eye health outcomes.

 

There are a ton of challenges to addressing these problems. Policies to reward good health outcomes often end up rewarding providers who serve more affluent populations, who tend to just be more healthy in general. Equating patient satisfaction and quality of services also are not always related to actual health outcomes, so measuring the quality of services from a patient standpoint is not always helpful and often full of bias. Nevertheless, it is clear we need more transparency, and more market mechanisms in the U.S. healthcare system so that quality, outcomes, and price can be taken into consideration and more directly linked to the services and products that medical providers offer.
Medical Technologies

The Problem with Healthcare Technology

Posted on by jabittan
In my last post I wrote about hidden costs of the healthcare system in America. I wrote about tax breaks for employers who offer health benefits, and I wrote about third party insurance preventing the healthcare system from working like a pure market. This post introduces one consequence of the hidden costs of our system and the ways in which our system fails to act like a market: the high cost of medical technologies.

 

In The Opioid Crisis Wake-Up Call, Dave Chase writes, “We ended up focusing on a certain type of high-technology, acute medical care – which we financially reward far more than lower-level preventive and chronic care – without regard for the quality of the outcomes or value of the care.”

 

When I took a healthcare policy and administration class along with a healthcare economics class for my graduate studies, I was surprised to see a critique of advancing medical technologies as part of the problem of American healthcare costs. I live in Reno, under the sphere of influence of the Bay Area, where technological solutions to global problems are hailed as the cure-all, deus ex machina that we need for a peaceful and prosperous world. I always thought that better medical technology saved lives, made us healthier, and ultimately reduced cost by being more efficient and precise than older technologies.

 

As it turns out, new medical technologies are incredibly expensive, and often times the benefits that patients receive are only marginally better than what existing technology offers. In some instances those marginal improvements make the difference between life and death, but in many instances, the new technologies might only add a few months of life to a terminal diagnosis, a few additional months lived in pain and fear. In other instances, the new technologies might add a little more comfort or certainty in a patient’s procedure or diagnosis, but it is fair to question whether its really necessary and worth the additional cost.

 

The quote from Chase reveals that when we are shielded from the costs of care, and when we remove market aspects from the healthcare system, we adopte a mindset that healthcare equals expensive interventions with high cost technology. I had clearly bought into this narrative prior to my graduate studies. The alternative that Chase highlights in his book, which we have underdeveloped in the United States, is to move upstream, and take care of people at a preventative level before they are sick and before they need expensive technological interventions. Developing systems, structures, and norms for healthy lifestyles will do more to reduce costs than the development of new magical cures and technological fixes. Our priorities and the focus of our system is flawed, and a as a result we focus on high cost interventions within a system no one is happy with. Rather than develop a system that actually supports healthy living, we have fished around for quick, high-cost technological solutions to our health woes.
Hiding the Cost of Healthcare

Hiding the Cost of Healthcare

Posted on by jabittan
In the United States, our current system of healthcare coverage is hiding the cost of healthcare. Anyone who has to go to physical therapy, get an MRI, has a child that needs treatment for a disability, or ends up in an ER knows firsthand that healthcare is expensive, but many of them probably don’t realize just how costly our healthcare system truly is. For the most part, in our country we have a system that pulls a third party into every payment scenario for healthcare, and as a result, the cost of healthcare is not reflective of a true market.

 

Many argue that our current system creates too much of a moral hazard, with people living unhealthy lifestyles because they know they won’t face the full cost of care if they need it. Some argue that the current arrangement leads to unnecessary care or over-treatment because people don’t pay the full cost of care, so they seek more of it. At the same time, groups argue that insurance and healthcare coverage are still prohibitively expensive, and that the stress of possibly having to go to a doctor and spend thousands of dollars (even if one is insured) genuinely harms people’s health.

 

I think all of these are true in their own way, and I think they are relatable because they are things that people have seen first hand or can easily imagine, but there is still a deeper level of healthcare costs in America that we don’t discuss. Our system of taxes is also hiding the cost of healthcare. As Dave Chase writes in The Opioid Crisis Wake-Up Call, “Today, the tax break for employer-paid benefits is estimated at over $600 billion, making it the largest tax break in the tax code, the nation’s second largest entitlement after Medicare, and the primary wage suppression driver.”

 

During World War II, wages to employees were frozen to prevent rapid inflation in the United States during the war. To attract and retain qualified employees, businesses turned to employer-paid benefits, and congress created a law which would allow those benefits to be tax-deductible for employers. This was a way to effectively give employees a bonus without paying them more, keeping inflation down, but still giving them something that economically and socially benefited them. Today of course, you are taxed on anything of value you receive from your employer as if it was straight cash, so your healthcare benefit basically still counts as wages, but that tax break for the employers is still in place for the health benefits they provide.

 

This is where we are hiding the cost of healthcare in America when it comes to private insurance. Most Americans receive healthcare through their employer, and the US government loses out on $600 billion in taxes to allow employers to offer health insurance. So the plan you are on that you might lose if you are fired, the plan you have this year that might not be offered again next year if the insurer changes, the plan that still has a $1,500 deductible and $4,000 out of pocket annual max, costs you and U.S. tax payers $600 billion per year.

 

Because this is a hidden cost, it is not something we discuss very often. We are afraid of the cost of a nationwide healthcare system, but we don’t discuss how much money is not being collected in taxes and being sheltered by a tax break that maintains a system that very few people are actually happy about. We face high costs ourselves, even if we are covered by a plan that fits within this $600 billion tax break system, and the system has warped the way that care is payed for and provided to the point where we don’t even know what knobs and levers to try to pull to get the who thing to be more transparent, provide real value, and to be less costly. We need to be honest about the ways that our current system is hiding the cost of healthcare in America, or we will never be able to make real changes to improve the system.
Opioids and Mental Health Disorders

Opioids and Mental Health Disorders

Posted on by jabittan
Opioids and mental health disorders probably do not seem like a good mix in anyone’s mind. I’m sure most of the general public would find it problematic to prescribe opioids to someone with a mental health disorder, but every day, physicians across the country prescribe large numbers of opioid prescriptions to these patients.

 

Dave Chase, in his book The Opioid Crisis Wake-Up Call, writes, “According to a recent study, more than half of all opioid prescriptions in the United States annually go to adults with a mental illness, who represent just 16 percent of the U.S. population.”

 

Why do we over-prescribe so many opioids to people with mental health illnesses? I can think of three potential causal models that lead to our over prescription of opioids for people with mental health disorders. 1: our system was never set up to treat health broadly speaking, 2: mental health has always been stigmatized and hidden in America, and 3: we have sabotaged ideas of community in the United States as we pursue our own self-interests and spend unreasonable amounts of time working and commuting.

 

1: The history of the American medical system was focused on interventions and solving health problems after the problem had popped up. Insurance companies were created to help people access different parts of the medical system, and over time private insurance has become more or less the only way to reasonably access affordable medical care in the United States. Our reliance on third party payers allowed prices to profligate, and it feels as though we are at a point where we can’t turn the ship around. If you have a mental health disorder, you are less likely to have stable employment, which means you are less likely to have quality health insurance provided through your job, and less likely to establish the mental health care that you need. As a result, you probably see your primary care provider and end up with an opioid prescription during your 10 minute appointment because your doctor doesn’t have time to really work with you on addressing your mental health challenges.

 

2: There are many examples throughout history of people hiding children with intellectual disabilities. Generations before us warehoused children in mental health institutions that did little to help improve health. We are mostly beyond that today, but nevertheless, we hide anxiety, depression, learning disabilities, and other mental health challenges from our friends, families, and coworkers. We still don’t do a good job of accepting that mental health disorders are not something that people should be ashamed of, and many people do not seek appropriate care but instead life lives that are less than healthy, where ending up with an opioid prescription, or self-medicating with something worse, is a less public alternative to dealing with mental health challenges.

 

3: Tying both points one and  two together, our lack of community makes mental health management almost impossible. We don’t have a lot of friends and family members that we can truly rely on for help with physical, mental, and emotional challenges. It may take a village to raise a kid, but we have run away from our villages to hide in our suburbs. We have dis-invested in the communities where we live and as a result, people with mental health disorders lack the social support systems necessary to truly address their needs. Even if people with mental health issues have some family and friends close by, those who they rely on probably lack the support they need to care for someone with mental health challenges. We spend too much time at work, spend too much time commuting to work, and don’t have time to help those who are more vulnerable. As a result, we simply shut people with mental health disorders out of our lives and out of society, and numb their lives with opioids.

 

Our country has not set up a system that truly takes care of our health, from before we are sick or have significant health challenges through to a successful recovery. We have overloaded the system that we built which was designed for people with the means to afford care after they were ill. We have ignored mental health and pretended we didn’t know it was an issue, until now, when it is too late and we don’t have the supports we need. Our communities are non-existent, and taking the steps to care for our community feels impossible.

 

The path forward involves a shift in how we provide, pay for, and think about healthcare. The systems we turn to for health need to move up-stream, where we focus on health before people are sick. To do that, we have to be honest about things like mental health, we have to be willing to provide spaces and community so that people can engage with healthy lifestyles and behaviors. We have to break out of our 40 hour work-weeks, and find ways to work closer to where we live, to end the soul sucking commutes that so many of us have. We have to give people time, and develop communities of support so that we can take care of our health and the health of those most vulnerable people in our communities. Without making these transformational changes, we will be stuck in our default of opioid prescriptions, unable to give people what they need to live healthy and meaningful lives.
Businesses and Healthcare Solutions

Businesses and Solving Healthcare Problems

Posted on by jabittan
We often overlook businesses when we think about the problems in American healthcare and how we can fix the issues that plague our system. But about half of all American’s receive their health insurance as a benefit provided by their employer. Businesses purchase and provide health insurance for millions of Americans, and must think about employers and the plans they offer when we think about the problems in the American healthcare system.

 

Everyone will tell you that healthcare is complicated. We know that insurance is hard, getting to a doctor can be hard, understanding what you have to pay is hard, and trying to guess what kind of plan you need for the next year is hard. All of this makes the solutions to our healthcare problems hard, but for a majority of Americans, the person who is shaping the structure in which they will make these decisions and figure out what is available to them is someone at their job. And for a lot of those Americans, the person at their job is probably in HR, and their main goal is not to find a great healthcare solution for the employees, but to just not get yelled at by the CEO for raising health insurance coverage costs and to avoid being yelled at by unhappy employees. Nevertheless, businesses can step up and play a role in making changes for the positive in the American healthcare system.

 

Dave Chase in his book The Opioid Crisis Wake-UP Call writes, “The opioid crisis is a complicated issue over 30 years in the making. But companies have played a major role in creating and sustaining the crisis. And a vanguard of employers are realizing that they have a major role to play in solving it, and that the solutions fall well beyond what the government alone can do.”

 

Companies, since they control the healthcare of half of Americans, can start making real changes to the care available to people. Employers who set up their own plans can make primary care access, physical therapy, and nutrition services virtually free to their employees. By providing a greater selection of preventative services, they can improve employee well-being and reduce the likelihood that an employee will deal with chronic pain and develop an opioid addiction. This is an over-simplified example of what companies can do, but it is important that we realize that the employer is a major player in the fight to improve the American healthcare system, and if we don’t step up to demand better from our employers, we won’t see the changes we want.
The Costs of High Healthcare Costs

The Costs of High Healthcare Costs

Posted on by jabittan
Dave Chase believes that healthcare costs have stolen the American Dream. Beyond that, Chase believes that our high healthcare costs have cost us more than just money. People stay in jobs they don’t like so that they can afford healthcare, people feel a wage stagnation as employers have to spend more on healthcare, and up to 70% of people who file bankruptcies due to healthcare costs have insurance. The high costs of healthcare come at a substantial emotional, psychological, and aspirational cost to Americans.

 

In his book The Opioid Crisis Wake-Up Call, Chase writes, “Had health care costs paralleled the Consumer Price Index, rather than outpacing it, an average American family would have had an additional $450 per month – more than $5,000 per year – to spend on other priorities.”

 

The money that families are spending on increased healthcare is not the only money that could be redirected toward other priorities. Employers are spending more on healthcare, which means they have less to use for business investment, less to use for retaining great talent, and less money for expanding into new areas.

 

The stagnation for individuals and companies is real, and it has serious costs beyond just the money going toward healthcare. Individuals who don’t see their take-home pay increase will feel discontent. If inflation picks up, and the amount of goods that can be bought diminishes, people will channel their frustration into social unrest. If businesses cannot invest in R&D because too much money is going to the healthcare costs of their employees, then the United States will not see new innovations inside our boarders, and the dynamic companies that we depend on for our jobs will not be able to compete on a global scale. The costs of our high costs of healthcare go beyond a loss of spending money for some people. The costs are real, and threaten our economy, our global standing, and our social contracts with each other and our institutions.
A Different Take on Chronic Pain

A Different Take on Chronic Pain

Posted on by jabittan
In his book Dreamland Sam Quinones includes a quote by Dr. John Loeser, Professor Emeritus of Neurological Surgery at the University of Washington in Seattle. Quinones spoke with him to better understand chronic pain and how chronic pain can be approached without the use of opioids. Loeser has an approach to treating chronic pain that doesn’t rely purely on drugs and is more centered around the patient, their environment, and their social supports. Loeser describes his approach as a bio-psycho-social approach and Quinones provides the following quote:

 

“Chronic pain is more than something going wrong inside the person’s body. It always has social and psychological factors playing a role.”

 

What I think is interesting with this quote is how far it is from the experience that many of us have with doctors and medicine today. Much of our medical care comes in tiny ten minute packets, where we go back and forth with a doctor for a few minutes before they write us a prescription for something and send us on our way. The providers often don’t end up doing much to help us through our current issue, and we rely on a pill to suddenly make our lives better. The approach completely misses many other factors of health.

 

Where we live matters. Who we have in our lives matters. What our diet is like, what stress factors exist around us, how easily we can get outside or to a gym for physical activity matters. A ten minute conversation and a pill cannot address these issues and certainly cannot change them.

 

I’m not introducing this all to suggest that chronic pain isn’t real, or that it is all in a person’s head. I’m also not introducing it to suggest that people suffering from chronic pain simply are not trying hard enough, need to take more personal responsibility, or just need to move to fix their pain. Often these social determinants of health are beyond the control of any one person. Before criticizing another person, and if we want to help them, we must also consider their environment, and whether we ourselves are a factor that helps or hinders the health of another.  Our world is too connected to say that someone’s health is purely a matter of their own choices and behaviors, even if personal responsibility does have a role to play in managing health. Approaching health from this angle helps us understand that an opioid is never going to be sufficient in truly alleviating chronic pain. There have to be more efforts to understand the bio-psycho-social realities of the person’s life and the chronic pain they experience.

Personal Medical Decisions?

Posted on by jabittan
A couple weeks back my grandma sent me a message on Facebook that was a picture of two very obese individuals eating a giant pizza and drinking soda. A caption on the photo read, “This is why I don’t want to pay for your healthcare.” As a person who is interested in and taken classes about public health and health policy, I actually think about these things all the time. I recognize the importance of making smart health choices, but I also understand that health outcomes can be a result of a complex web of social determinants of health. There are factors that are beyond our control in regard to living healthy, and there are some factors that seem like easy decisions to some people, that are monumental challenges to others. Despite the amount of time I spend thinking about these things, I don’t have a clear answer in my head for when people need a tough love kick in the pants versus compassion, and when a given outcome is generally more the result of poor individual decisions and habits or more the result of uncontrollable social determinants of health. There likely is no clear answer to this question, and I think it is reasonable to say, “I have thought about this a lot and I don’t know.”

 

This leads me to another factor that compounds the complexity of healthcare decisions: What choices, decisions, and behaviors are personal, and which ones should be considered public? If I chose to smoke, is that a personal decision even though there may be public consequences if I die early, have poor health overall, and require more emergency medical care which ultimately drives everyone’s healthcare premiums up? Do I have to exercise every day to stay healthy as a public good and not just as a private good? If I go get an x-ray on the ankle I sprained to make sure it isn’t broken, is that going to take time away from medical professionals who could help someone that really needs it when all I likely need to do is ice it a little bit?

 

In the book The Elephant in the Brain, Kevin Simler and Robin Hanson write about Steve Jobs and his decision to forgo cancer treatment as recommended by the American Medical Association’s best practices. Jobs is an interesting case because the fortunes of a company that many people love rested on his medical decisions. Beyond just his own health and the considerations of his family, people felt that they had their own money on the line if they owned apple stocks. If Jobs lived and survived his illness, it would be good for Apple, but if he denied standard treatment and died, what did that mean for the public?

 

“The point here,” write Simler and Hanson, “is that whenever we fail to uphold the (perceived) highest standards for medical treatment, we risk becoming the subject of unwanted gossip and even open condemnation. Our seemingly personal medical decisions are, in fact, quite public and even political.”

 

The kind of medicine we pursue and the lifestyle we live are never going to be restricted to just ourselves. We will at the very least be judged by others for our health and medical decisions. Our choices may or may not have major financial implications for other people, but that doesn’t mean that we can make our choices in a vacuum.

 

What is important to remember here is how complex the line is between personal and societal responsibility. Our individual decisions can have bigger impacts than we realize, and it is hard to keep something just within our own bubble. Added to that are questions about liberty and the authority of the state. It is not an easy question to ask if your diet should be controlled by anyone other than yourself, or if you should be forced to exercise and sleep a certain amount. Approach questions about healthcare understanding that these questions don’t have clear answers, and whichever choice we make is going to have strange consequences as a result of these complex inter-dependencies.