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The new Rand health care study
The authors offer up two main points:
1. We get only 55 percent of recommended medical attention [TC: hey, didn't an earlier Rand study show us that more care doesn't translate into better health care outcomes?]
2. "Those with annual family incomes over $50,000 had quality scores that were just 3.5 percentage points higher than those with incomes less than $15,000....insurance status had no real effect on quality."
This should make everyone uncomfortable, but most of all those who think that access to health insurance is a panacea. Here is the press release, the piece is in The New England Journal of Medicine. Am I supposed to believe the following?:
- Overall quality scores for blacks were 3.5 percentage points higher than for whites.
- Overall quality scores for Hispanics were 3.4 percentage points higher than for whites.
- Blacks had higher scores than whites for chronic care (61 percent vs. 55 percent).
- Blacks had higher scores for treatment than whites (64 percent vs. 56 percent).
- Hispanics were more likely to receive screening than whites (56 percent vs. 52 percent).
The authors say yes this really is true. Previous studies usually focused on expensive and invasive one-time procedures, such as bypass operations, where whites do have a (narrowing) advantage. If nothing else, this piece should convince us how little we understand the health care sector.
Posted by Tyler Cowen on March 19, 2006 at 08:13 AM in Medicine | Permalink
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Comments
Joe Doyle has a very interesting study which uses a clever instrument and finds a large effect of insurance on health outcomes:
http://www.mit.edu/~jjdoyle/research.html
"Previous studies find that the uninsured receive less health care than the insured, yet differences in health outcomes have rarely been studied. In addition, selection bias may partly explain the difference in care received. This paper focuses on an unexpected health shock-severe automobile accidents where victims have little choice but to receive treatment. Another innovation is the use of a comparison group that is similar to the uninsured: those who have private health insurance but do not have automobile insurance. The medically uninsured are found to receive twenty percent less care and have a higher mortality rate compared to patients with health insurance. It appears that the ability-to-pay of patients has a significant effect on treatment decisions and additional treatment yields large improvements in health outcomes."
Posted by: Commenterlein at Mar 19, 2006 12:34:52 PM
Recommended care is judged according to this document: http://www.rand.org/pubs/working_papers/WR174-1/
and related to patients' medical records as follows:
"Using computer-assisted abstraction software, 20 trained registered nurses abstracted data from photocopies of participants' medical records of tests, treatments, use of inpatient and outpatient services, and other clinical events to determine whether the participant was eligible for care as listed in the QA Tools indicators and whether the indicated care had been received."
If this is really a good method to judge quality of care, shouldn't nurses be using a system like this for every patient visit? (I don't doubt that software could be a powerful tool for diagnosis. Even Google will frequently provide answers where doctors fail.)
Posted by: gundryggia at Mar 19, 2006 12:46:58 PM
"This should make everyone uncomfortable, but most of all those who think that access to health insurance is a panacea."
Oooooh, one of my pet peeves ...
WHO says that access to health insurance is a "panacea"?
A panacea is a cure for all ills. It doesn't exist.
Thus, saying that X is not a panacea is NOT an argument.
Whenever you are tempted to write "panacea," write "magic fairy dust" instead & then decide whether the sentence should stand.
Posted by: Anderson at Mar 19, 2006 5:57:03 PM
So, reading the thing... quality of care is measured by the percentage of recommended procedures that the patient undertakes or agrees to? That's laughable. They did a lot of work predicated on a bad assumption.
The Joe Doyle study looks much better, though to be fair it's apples and oranges to compare preventive care and treatment of chronic conditions with handling of a single traumatic accident.
Posted by: bbartlog at Mar 19, 2006 7:59:05 PM
Even under the Doyle study, where there's a 20% less favorable outcome for the uninsured, my guess is that hospitals lose far more than 20% of what they bill to uninsured patients (or even more than 20% of the costs incurred serving uninsured patients) because such patients tend to not pay their bills.
For those who don't mind getting 20% less good health care for, say, 50% less cost, there's a strong incentive to remain uninsured. Even moreso for the healthy population that doesn't want to subsidize the unhealthy population, and for the lower wage workers who don't want to pay insurance rates for health care that is basically designed for middle class standards and costs regardless of whether the patient can afford it.
It's no surprise then that many remain uninsured -- especially the young, the healthy, and the lower wage workers. This will remain the case until there's more legal discrimination based on the amount individuals (or their employers, same thing before tax breaks) are willing to pay and when insurances have more ability to discriminate based on health and age. If the insurance companies can't discriminate based on the likelihood of needing health care than young and healthy individuals will be choosing not to participate, and if they can't offer a low-price value product than the poor will choose not to participate.
Posted by: anonymous at Mar 19, 2006 8:42:55 PM
As far as I can tell the Rand study didn't look at spending on alternative health care such as homeopathy, acupuncture and naturopathy. These alternatives seem much more popular among higher-income people, at least in part because they're seldom covered by insurance. Some of the "missing" spending by more affluent people actually may be spent on alternative health care.
Posted by: Peter at Mar 19, 2006 9:12:55 PM
With government controlled prices set below the market clearing price most
physicians have more patients than we can handle and there is no incentive
to compete for patients by providing superior service. We only get paid
what Medicare allows therefore the only rational way to increase profits
is to reduce costs which leads to longer waits, shoddy offices, and
overworked doctors and nurses. If the medical sector were allowed to play
by the same economic rules as grocery stores,beer companies, the gambling
industry and most of the economy, you would find a much higher level of
satisfaction and service.
Posted by: WS Grizzard, MD at Mar 19, 2006 9:57:32 PM
The Rand study only looks at patients who actually went to the doctor at least once during that two-year period. So it doesn't necessarily say anything about the effect of the insurance gap - it may be that people who don't have insurance but still manage to make it to the doctor get good care, but there are lots of people who don't go at all due to not having insurance.
Posted by: Amanda at Mar 19, 2006 10:10:20 PM
I totally agree, Dr. Grizzard. I'm also certain that the single-payer system favored by many liberals would only further degrade service, as it has done in Canada.
I doubt that many outside the medical profession realize just how overworked are the doctors in this nation. Please know that some of us appreciate your dedication.
Posted by: JohnDewey at Mar 19, 2006 10:17:52 PM
Let us understand that the doctors are truly overworked but that part of the reason for that is the AMA's restriction of slots through limitations on entry to medical school. Those restrictions -- as all economists know are partially designed to keep supply low and salaries high. But competition doesn't go away, so hospitals and insurers compete by overworking doctors.
If the supply of doctors were doubled and the rules of employment were changed, I'm sure they would be worked less hard IF they were also paid a lot less -- say on average 35-50% less than they earn now.
Posted by: nn at Mar 20, 2006 12:11:20 AM
nn: a reasonable course indeed, but frankly, do you see a possibility of it? And I suspect it's illegal to practice without a diploma, even if you are qualified.
Posted by: A Tykhyy at Mar 20, 2006 4:32:34 AM
"We get only 55 percent of recommended medical attention..."
I imagine we get a similar percentage of mechanic-recommended repairs. Doctors tend to recommend care without regard to expected value, cost, or inconvenience. Is it any wonder we so often say "no thanks, I'll be fine"? I have a hard time believing my doctors anymore when they recommend treatment, simply because I know they've given only a tiny fraction of their mental bandwidth to the consideration of cost (and not just $ cost).
Posted by: Noah Yetter at Mar 20, 2006 2:46:22 PM
I appreciate your point, nn. But I gotta tell you, I want medical schools to have the highest possible admission standards. When I have that bypass surgery in 20 years, I want to know that the guy cutting on me stayed awake in all the classes.
High salaries attract the best and the brightest. There is no guarantee that an MBA or a rocket scientist will earn a top 3% salary. But earning that M.D. will do it.
I think we can devise better solutions to teh overworked M.D. problem than lowering admission standards and reducing pay.
Posted by: JohnDewey at Mar 20, 2006 5:28:36 PM
It's very unclear to me that setting standards higher than a certain point yields better outcomes. Rather, it may yield increased gamesmanship and less learning.
Posted by: michael vassar at Mar 20, 2006 7:10:37 PM
And John Dewey, you can have as high standards as you want, but I don't have to pay for them. I'd rather that the AMA had two levels of certification. Call them Doctor 1 and Doctor 2(sort of a PhD but non-research). Doctor 1 stats are set much lower than today though they still would have to pass a certifying exam. Doctor 2 regs are higher. Let both be certified but give the patient the choice of which one to pay for.
It's like someone saying, I'll only buy a car that's as well designed and reliable as a Mercedes (hmm.., on 2nd thought, make that Lexus) and with 15 star crashworthiness. You have that right. But you shouldn't be able to ban small cars that are only 3 star crash worthy.
As it is, we live in a medical world where the equivalents of Hyundais, Chevys and Civics are simply unavailable or illegal. If we made sure the minimum quality car were as safe as a 2006 model Lexus LS or BMW 7 series, we'd have a lot fewer fatalities in car crashes. We'd also have a lot fewer cars.
Posted by: nn at Mar 20, 2006 10:49:06 PM
michael vasser,
I understand your thinking, but I think medical school admission requires one hell of a lot of advance learning. Have you ever looked at the questions on the physical science and biological science sections of the MCAT? These are not IQ tests. Here's some samples of the thousands of possible MCAT questions:
http://www.aamc.org/students/mcat/bssampleitems.pdf
http://www.aamc.org/students/mcat/pssampleitems.pdf
To even be considered, medical school applicants are also required to complete a full year of inorganic chemistry, a full year of organic chemistry, a full year of the hardest levels of sophomore physics, and several difficult biology courses. But it's not just completion of these courses that qualifies them. They will need to have extremely high GPA's - almost 4.0's - in all their work.
I just don't believe one can gain entrance to medical school through gamesmanship. These schools will only take you if you have a very high track record of learning, and then only after you prove your knowledge through what is probably the toughest entrance exam for any profession.
Posted by: JohnDewey at Mar 21, 2006 2:23:29 AM
nn,
You are correct in that you don't have to pay for the current high standards for U.S. physicians. You can always take a trip to a third world country. But I'm convinced the U.S. has no intention of relaxing its standards for M.D.'s any time soon. The public won't opt for that strategy as a means of reducing costs. Certainly those of us who are seniors or about to be seniors, the ones who must rely more on medical competence, will not support lower standards. Because we vote in big numbers, politicians will listen to us.
A form of B grade physician is already being used today to reduce medical costs. Physicians assistants admiinister medical care under the supervision of an M.D. There are only about 60,000 PA's in the U.S. Compare that with the 570,000 physicians and surgeons. From what my medical friends tell me, increasing PA's would certainly reduce the burden on MD's. But they also tell me it is difficult to find quality PA candidates willing to invest two to three years to master the very tough curriculum.
Certified Registered Nurse Anesthetists can also perform some minor work formerly done by MD's. But these folks are in even shorter supply than other registered nurses. We might see more if salaries were increased. But even if salaries rise, I cannot imagine hospitals wanting to take the risk of loading up on RNA's to replace many anesthesiologists. The flexibility MD's provide in being able to work on all cases makes them easily worth the higher pay.
If you argue for more PA's and RNA's, I'll support your cause. But please reconsider the idea that the MD supply could be dumbed down.
Posted by: JohnDewey at Mar 21, 2006 2:53:30 AM
The number of US granted medical licenses is not restricted based on quality of applicants. It is a numerical quota plain and simple dictated by admissions to residency programs. The number hasn't changed (give or take a 1000 since about 1978).
U.S. Medical degrees granted:
1980:14,902
1990:15,075
2000:15,286
Posted by: jaf at Mar 21, 2006 10:25:48 AM
>Doctor 1 stats are set much lower than today though they still would have to pass a
>certifying exam.
Exists today. Nurse Practitioner. The AMA hates 'em, because they cut into the AMA's monopoly, and so they are limited from practicing independently. They have to be 'supervised' by a doctor under current law, but this is completely unnecessary. They are ideal for General Practitioner-type work. Accredited Docs can do the specialist work and the hard cases on referral. Also think midwives vs. OB/GYNs.
Posted by: rvman at Mar 22, 2006 11:41:56 AM
JohnDewey,
I don't know what either you or Michael Vassar mean by "gamesmanship," and I suspect that you mean different things, but an important difference is that you seem to take it as an absolute, while he takes it as a marginal. That is, he didn't say, as you suggest, that people get into medical school by pure gamesmanship, but that it gives you an edge.
Here's something I mean by gamesmanship. Premeds, even at Harvard, where virtually all of them get into medical school, sabotage each others' lab work.
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