On Tuesday, there was a full page ad in the WaPo signed by various economists about the issue of chronic diseases, including Douglas Holtz-Eakin of the center-right and David Cutler of the center-left. The ad did not say much, and it referred the reader to this page.
Our health care system needs reforms that align incentives to encourage payers, providers, employers, and individuals to better prevent, detect, treat, and manage chronic diseases – both physical and mental – before they become an acute problem. Special attention should be paid to patients with multiple chronic conditions who consume the majority of the nation’s health care spending.
Read the whole page. I am afraid that all I could take away from it is that a few chronic conditions generate a lot of health care spending, and public policy should deal with this. When I see a phrase like “special attention should be paid,” I note two things.
1. It is in passive voice.
2. It seems to say, “We know there is a problem, but we have no idea what to do about it.”
The cynic in me thinks that what these economists want is more funding for their research into the impact of these diseases on health care spending.
The cynic in this reader notes: 1) the president of the Partnership for Chronic Disease Prevention recently released a report critical of Sanders’ single payer health plan (http://www.scribd.com/doc/296831690/Kenneth-Thorpe-s-analysis-of-Bernie-Sanders-s-single-payer-proposal#scribd); 2) The partnership includes many diverse organizations, two of which are labor unions (http://fightchronicdisease.org/about/partners); 3) said labor unions have endorsed Sen. Sanders’ opponents in the Democratic presidential primary.
Aha! Nice detective work. I think that any time you see a full-page political ad in the WaPo, you have to take an uncharitable, cynical view of the motives. So I think you probably have it right.
Where were these guys when we spent the better part of the near depression screwing up actuarial insurance?
Yes, passive voice oft hides intentions. Also, when I see (in the site you link to) “America needs health care that…” I become wary because such statements, based on ontological confusion, carry no meaning: collections of humans are not humans; collections cannot need, want, hunger or feel. Metaphoric use of groups with human qualities often clouds clear thinking. Sometimes usefully so, when employed as propaganda.
My favorite example (from long ago): “San Francisco needs a new baseball stadium.” The statement sheds it clothes when you ask “which San Franciscans want a new ballpark, and which oppose?”
I am currently leading a large chronic disease initiative to divert waste in medical specialty services. (This is in Canada, but I’ve also consulted with American colleagues.) The authors are right that the impact of the issue is huge, but there are many problems.
First, it is a politically beloved topic because it allows people to talk using terms like prevention, root causes, social determinants, etc. These might be important concerns, but mostly they are opportunities for people to signal that they are “long-term thinkers”, moving beyond the medical model, and other rhetoric that is meant to suggest that other people are short-sighted, technocratic, and greedy. This gets us nowhere, and there is rarely any follow-up pointing to changes that would actually reduce the prevalence and burden of disease.
Jobs in primary care are low-status within healthcare. A large study in the NHS showed that these initiatives often failed because they can’t attract staff, partly because healthcare systems have little to gain politically by priorizing the issue. My own experience is that improvements in primary care are limited mostly to government-run systems that are in periods of severe budgetary stress and have a political mandate to make cuts and reduce specialist utilization, an occurrence that is not common.
The issue of chronic disease attracts a lot of very smart people who lean left, but they reach a cognitive barrier when confronted with the huge role that poor individual behavior plays in outcomes. For example, many large studies have shown that roughly a third of all prescriptions are never filled (for good or bad reasons), and of the remainder only about half (that is, another third) are taken correctly. This is an average of all types of Rx, and the lowest rates of adherence are in chronic disease. Uncomfortably for many wonks, this problem appears impervious to funding interventions: I know of one large study showing that the rate was just as bad in a group with 100% coverage (US veterans) as in uninsured patients, and another showing that moving people from low to high payment coverage (reducing their costs) also did not affect compliance.
Smoking, lack of exercise, and poor diet are notoriously difficult to improve through specific policy interventions. They are both inherent problems and major aggravators of other diseases.
While chronic disease is distributed across the demographic spectrum and affects the sexes about equally, men are much more unresponsive to policy interventions than women (who are more socially adept at consuming care and are more anxious about the impact of their health on others). More specifically, older, less educated men with low-status job histories are the least likely to do much about chronic diseases and are least likely to seek intervention. If you can find a large cadre of smart social scientists and bureaucrats who are excited about putting lots of attention into that demographic, please let me know.
http://www.ncbi.nlm.nih.gov/pubmed/22017787
etc.
One man’s “chronic diseases” are another man’s “expensive treatments that keep people alive indefinitely.”