In a book review, Chris Pope writes,
Unlike many politicians and pundits, however, Mr. Kaplan doesn’t pretend that the situation is simply the result of overpayment for services that could be easily remedied with mandatory price cuts. He suggests, instead, that America’s high spending is the product of a sicker population, a higher intensity of care and the over-medicalization of care at the end of life. The author is skeptical of the capital-intensive innovations that excite investors, and he observes that R&D spending on drug discovery has seen diminishing returns. “To achieve the kind of scientific progress we enjoyed in the early 1970s,” he writes, “takes 25 times as many researchers today.”
This makes More than Medicine, by Stanford medical professor Robert M. Kaplan, sound like a re-run of my own Crisis of Abundance. There I argued that capital-intensive and skills-intensive medical services with high costs and low benefits are the main driver of the poor performance of our health care system relative to that in other countries.
I also would agree with Kaplan that the really big improvements in health outcomes come from outside of the medical-treatment realm. Think of urban sanitation, reduced pollution, healthier and safer working conditions, and reduced smoking. To me, that argues for taking dollars away from subsidizing demand for medical treatment and trying to apply some those dollars to efforts to improve public health.
But Pope points out that Kaplan writes as if we know how to solve our public-health problems, and we just need the will to do so. My impression is that problems like homelessness and obesity are very challenging, and we will need to sift through many potential solutions. Finding something that works and is widely applicable may not happen for many years, if ever.
Given the rampant practice of denying food and water to elderly patients in the United States, I find it hard to credit that end of life care is more expensive than it ought to be. There is very little statistical evidence available, probably for a reason, so anecdotal evidence is the best that I have, but the industry’s adoption of terms like “artificial nutrition and hydration” suggests that they really need fancy vocabulary to pretend that they are not in the business of killing people by starvation and thirst. It is not a pretty way to go and probably the biggest cost is keeping the victims sedated.
And contrary to the assertion that new treatments are high cost, low value, peer reviewed publications show a good return on improvements in care. See for example:
https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.1688
The notion that the USA underperforms other countries in health care is ludicrous. The US has the best cancer survival rates in the world. Mark Perry has blogged on this extensively. He writes:
“2. The bottom chart displays five-year age-adjusted cancer survival rates for the U.S. and selected European countries, showing that the U.S. has the best record for five-year survival rates for six different cancers. In some cases the differences are huge: 81.2% in the U.S. for prostate cancer vs. 41% in Denmark and 47.4% in Italy; 61.7% in the U.S. for colon cancer vs. 39.2% in Denmark; 12% in the U.S. for lung cancer vs. 5.6% in Denmark.
Also interesting is the fact that there is often a significant difference between white and black cancer survival rates in the U.S., e.g. prostate cancer – 82.7% for whites vs. 69.2% for blacks (see red circled data in bottom chart). But even in that case, the five-year survival rate for blacks (69.2%) is still higher than for all European countries except Switzerland.”
and the incidence ofr blindness is lower in the US than elsewhere, mostly due to availability of cataract surgery.
Many, many people reach a stage in where they are no longer able to swallow, and have no prospect for recovering. For example, this is an end-stage symptom of Alzheimer’s, which 6 million + Americans have.
A significant number of these people have end of life directives. I think you know that “artificial nutrition and hydration” means intravenous feeding.
These patients are not “denied” food and water. If they, or their health proxy, have not explicitly indicated they don’t want intravenous feeding, they get it.
Edgar,
I can’t say such things aren’t practiced without the consent of the patients, either verbally or by advanced directive, but I find it difficult to believe such coerced practices are widespread. My anecdotal evidence is that it is the patients that reach a point when they refuse to eat and drink. Both of my maternal grandparents and my father did this. I don’t know the status of my grandparents’ advanced directives, but I know we couldn’t get them to eat or drink by cajoling them. Both were terminally ill with cancer and congestive heart failure. My father had an advanced directive and was not yet actually terminal, but he had lost the ability to walk and simply stopped eating and drinking one day. My mother and I debated for a couple of days what to do, but we also knew that putting him in the hospital with intravenous fluids and a feeding tube would require the application of restraints because he was so adamant about dying. So we opted for in-home palliative care and he died 2 weeks later. It was an ugly death, and I wish we had had better options, but it was his choice. I suspect that if such things are common, it is probably not something forced on the patients, but is, instead their own choice in one manner or another.
On the killing issue, it is my suspicion, based on nothing more than anecdote, that there are more than a few people at this moment who are capably sentient and capable of eating and drinking on their own who are being either chemically or physically restrained from doing so in situations in which they did not knowingly give consent and who, if asked, would prefer to be able to help themselves to a glass of water than lick their dry lips in an induced vegetative state. It is very difficult if not impossible to write a good advanced directive that accurately anticipates how you would want to be treated in a variety of difficult circumstances. As far as I can google scholar, not much effort has gone into testing how accurately the advance directives commonly used accurately reflect their makers’ intentions. The courts are of little use as there really is no money to be transferred to lawyers in these situations. Economists, as we all know, live in mortal dread that the little people might be having it too good, and therefore are of little assistance in offering insight into these situations. I have deep sympathy for what many family members have to go through in these situations and know how difficult it is. Nevertheless, however difficult it might be the little people have to take control of their situation. There is no expertise to bow to here. The woman in front of you in line at the supermarket is as much an expert as anyone else in the country. All this talk about aggregate end of life care expenses is rubbish and those who would pretend to know what is the right amount to spend upon any health care procedure should be ruthlessly mocked. People pay for their health insurance and should get the full value of what they have purchased if they so choose rather than have some disinterested third party with no skin in the game making decisions for them.
“All this talk about aggregate end of life care expenses is rubbish and those who would pretend to know what is the right amount to spend upon any health care procedure should be ruthlessly mocked. ”
How infantile. You do know that those health care procedures actually have to be paid for, don’t you?
If we just had true free market insurance, most Americans that needed significant end of life care couldn’t afford it. We enforce access through regulation and socialized Medicare, and that means public decisions. There is no system where most elderly end of life patients pay their own way.
If you have a better idea, please tell us what your “suspicions” are. You seem to have quite a bit of confidence in those.
“Think of urban sanitation, reduced pollution, healthier and safer working conditions, and reduced smoking. To me, that argues for taking dollars away from subsidizing demand for medical treatment and trying to apply some those dollars to efforts to improve public health.”
So its settled. Let’s beef up the EPA, and get off fossil fuels as soon as possible!
What exactly would that do to improve health outcomes? In fact, it’d probably induce people to buy more cheap (and unhealthy) food due to the decline in income.
If you haven’t, RCA’s exposition on the determinants of health spending in the US is a must read:
https://randomcriticalanalysis.com/2018/11/19/why-everything-you-know-about-healthcare-is-wrong-in-one-million-charts-a-response-to-noah-smith/
He’s pretty convincing that we spend more in the US because we’re richer and more consumptive of everything.
Wow. That was a lot to wade through. But it is an interesting (if not exactly original) thesis. Its a good argument. I have noted in the past some relatives consume healthcare like they consume other luxury goods.
Anecdotally I would tend to agree. Half of all health care spending is wasted. But just try to be the one to tell Tricare to stop paying for $14,000 salve for “veterans.” Or be the one to note the vast majority of spinal surgeries are useless, and so taxpayers will no longer be footing the bill.
In LA the medical industry is expanding into housing.
They have a proposal to house poor patients and reduce the constant transport costs. There is a fixed point aggregation that is happening, take your moderately sick and fly them too LA. The UCLA Medical Center handles the rest, and will fly them back with a couple of years, healthy and knew.
Those are the word on the referendum, I think. The California legislature says they have a signed agreement fro the kids at Google to pay the whole bill. So, great news for the rest of the world, just keep a handy airplane ticket to LA, no need for local medicine except emergencies.