Health for life

When pundits claim that health care spending is out of control, what do they mean?

Does it mean that Massachusetts outlawing of hospitals excessive price increases is a good thing? That rolling back the Affordable Care Act will automatically usher in a new round of price gouging? That when the DMCB generates another medical co-pay, the DMCB spouse is right to wave a copy of the bill around and demand that the DMCB do something now to orm the U.S. health care system?

As the Disease Management Care Blog understands it, what the pundits, Massachusetts legislators, patient advocates and the DMCB spouse mean is that more and more of our nations gross domestic product (GDP) is being spent on health care services.

That assumes wed all be better off if the U.S. were spending its national treasure on stuff like manufacturing, technology, education and innovation. So, instead of committing just under 18% of our output on hospital care, physician services, nursing homes, medical devices and drugs, wed all be better off if we spent it on the production of solar panels, Facebook, public school vouchers and iPhone apps.

That way we wouldnt be struggling with the prospect of another 1% gain on GDP (to 19%) and the looming possibility that well soon be spending a whopping fifth of our economy on health care.

But is the spending on health care really that bad?  As noted here, the DMCB pointed out that non-government-insured health care costs have been moderating for years.  Whats more, recent year-to-year increases in health care spending in the U.S. are actually lower than much of the developed world.

And now theres one more reason to doubt the prevailing wisdom about rising health care costs. Charles Roehrig, Ani Turner, Paul Hughes-Cromwick and George Miller of the curiously name Altarum Institute point out that the normally rising and falling GDP associated with routine economic cycles can make steady health care costs look relatively worse or better than they appear.

To dampen the impact of a cyclic economy on the assessment of health care spending, the authors compared health spending to U.S. "potential GDP." Apparently, this obscure economic metric has been used by economists to portray what GDP would be if the economy were operating at full employment of the current population and without any idle production capacity.  This metric has the advantage of "smoothing out" many of the peaks and valleys of the normally measured GDP.

Using potential GDP as the comparative baseline, the authors found that health care spending growth gained less than 1% of the economy starting in July of 2005, well before the onset of the Great Recession of 2008. In other words, during that time, the health care industry grew pretty much at the same rate as the "potential" GDP. 

Whats more, in June of 2009, health care cost growth gained an additional 1% of potential GDP, only to fall back below 1% again in May of 2011.  Most of the increases seemed to be accounted for by Medicare Part D spending; if that particular cost is backed out, excess growth would have been 1% or less throughout the measurement period.

The authors can only hypothesize on why health care costs didnt outstrip the U.S. economy. While it could be partially accounted for by the rising numbers of uninsured (who would have avoided going to hospitals or seeing doctors), the authors point out that other trends could have played a role: changing physician practice standards, increasing numbers of salaried physicians, market pressures pushing down on fee schedules, increases in patients out-of-pocket expenses making them less likely to access the care system, new care models (including disease management?), the increasing use of generics, previously expensive drugs going off patent and the drop-off in the number of "blockbuster" pharmaceuticals.

This means when the economy bounces back and/or Obamacare results in more insured Americans, there is no guarantee that underlying health care inflation will return.

The risks associated with hypertension, high blood pressure (BP) as its commonly called, may be different for very old compared to younger adults. Paula Span, who writes the New Old Age Blog at the New York Times discussed this in her post:

For the Very Old, a Surprise in Blood Pressure Readings, New York Times, 8 August 2012

Span writes:

"I was startled to learn that in the very elderly - those over 85, say - high blood pressure may indicate better health while lower numbers could mean trouble ahead."

Span had been reading a study and an accompanying editorial published in the Archives of Internal Medicine last year:

Rethinking the Association of High Blood Pressure With Mortality in Elderly Adults, JAMA Internal Medicine, August 2012
Comment on “Rethinking the Association of High Blood Pressure With Mortality in Elderly Adults," Goodwin JS, JAMA Internal Medicine, August 2012

In his editorial, Goodwin offered some background:

"In 1988, Matilla et al reported that, among the very old, elevated systolic and diastolic blood pressure (BP) were associated with longer survival. The differences were not subtle. The 5-year survival of those with systolic BPs greater than 200 mm Hg were almost twice as high as those with levels of 120 to 140 mm Hg. Over the ensuing 25 years, a substantial number of population-based studies have reported the same findings: in those older than 85 years (or older than 80 years in some studies), high BP is an excellent prognostic sign.

Perhaps the most rigorous assessment came from the Framingham Study, which reported that the strong positive association of BP with cardiovascular mortality was reversed between the ages of 75 and 85. Importantly, no population-based study has found the opposite, that high BP is a marker for bad outcomes in octogenarians. Conversely, “normal” BP is bad. Perhaps the worst sign is falling BP."

Why does high BP appear to be a good sign in an older population? Goodwin explains that the old are a mixture of frail and more robust individuals.  High BP does not connote the same level of health in both groups.  Referring to Diehr et al. he said:

"[The very old] showed a steady decrease in BP in the 3 years before death. ... High BP is only a good sign in very old age because many of those with “normal” BP have it for bad reasons."

When is it advantageous to treat high blood pressure in an older person? Goodwin says:

"Many robust, very old individuals have hypertension. Antihypertensive treatment in those individuals is beneficial. Frail older individuals are less likely to have hypertension, and treating those who do may produce bad outcomes."

How do you measure robustness? One good test is walking speed.

In the study at the top of this post, those with hypertension who could walk a 20-foot corridor at an average pace of 1.8 mph or better had about the same risk of dying as younger adults. Those with high BP who walked slower did not have an increased risk. And those with high BP who couldnt complete the walk had a 60% lower risk of death:

"Higher systolic BP was associated with an increased risk of mortality only among elderly adults who had a medium to fast walking pace. In contrast, among slower-walking older adults, there was not an association between elevated systolic or diastolic BP and mortality. Strikingly, we found elevated systolic and diastolic BP was strongly and independently associated with a lower mortality risk in participants who did not complete the walk test."

The lead author of the study, Dr. Michelle Odden, said:

"The paradigm in medicine is, high blood pressure is bad, treating it is good. We’re saying, maybe we need to look more closely at the guidelines and tailor them more to older adults."

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In 2011, the Oregon legislature approved the creation of Medicaid "coordinated care organizations" (CCOs). Once the initiative was granted waiver status by CMS, the "Oregon Health Plan" was launched. Its regulated and funded by the "Oregon Health Authority," which also oversees the health insurance for Oregons public health employees. When it became clear that contracting for the states public employee business was tied to the CCO participation, most of the larger health systems in Oregon responded by signing up to be CCOs.

According to Eric Stecker writing in the Feb 13 the New England Journal of Medicine, "there is a distinct possibility it could fail."

Yikes.

The planning for CCOs was ultimately based on the assumption that its capitation-based payment methodology would achieve a 2% reduction in costs versus a 5.4% trend. That assumption, in turn, enabled Washington DCs waiver that included $1.9 billion in funding. Unfortunately, that money was tied to penalties if the savings are not achieved.

CCOs signed up with primary care medical homes, promises of clinical integration and a commitment to greater coordination of care. Yet, when Dr. Stecker reviews the Oregon health care landscape, he sees little proof that medical homes are achieving large savings, that the arms race of local competition has moderated or that the movement of patients across care settings is seamless and efficient. Whats more, local health providers within the CCOs are largely autonomous and fee-for-service remains the dominant payment methodology for these health systems other lucrative payers. The likelihood that theyre going to change their culture or their clinical work flows to serve the CCO segment of their business is remote.

Dr. Stecker correctly identifies the unproven assumptions that underlie the belief that physician-hospital organizations can cut out the middleman insurers and manage global risk contracts with the pixie dust of medical homes and care coordination.  While those ingredients are necessary, the Disease Management Care Blog agrees that the likelihood of CCOs ending the year with a 2% reduction in claims expense is a stretch. 

The DMCB will stay tuned.

Even on the 100th anniversary of RMS Titanics sinking, the Disease Management Care Blog cant make it through a single sitting of either A Night to Remember or James Camerons Titanic.  It only cares to watch the films last half hour.

That doesnt mean that the DMCB cant use the tragedy as a Medicare metaphor. 

To wit:

1.  We still believe the guarantee that Medicare is unsinkably going to meet its obligations.

2.  The threat is a huge fiscal iceberg that we know exists. It will not be seen until it is too late.

3.  Medicares design experts were likewise stunningly wrong.

4  The regulations, made years if not decades ago, remain hopelessly obsolete.

5. The twin unpredictable Black Swan mirages and tides of a) "savings" and b) technology can only be recognized in retrospect.  And there are other "unknowns" out there.

6.  Those presently in charge can be wrong about remaining calm: if the ship is listing, its time to panic and run for the lifeboats.

7. Once disaster strikes, ill-conceived actions can make things worse.

8.  Whether its news or movie media, much of what we think we know is a littered with historical inaccuracies.

9.  If the ship goes down, the lowest socioeconomic classes will suffer the most.

10. When we deal honestly with the lessons of a disaster, we can eventually build a better and safer system.