Medicare Waste--50%? (January 24, 2007)
Correspondent Paul M. raised the issue of waste in Medicare vs. waste in the Department of Defense. It's an important question, but rather than focus only on the waste which can be measured (over-billing, paperwork, fraudulent charges, etc.) I'm going to to take a "big picture" view and ask: how much of that $400 billion actually alleviates suffering, heals/cures the sick, and improves the health of elderly Americans? Could we do better for much less money?
The corollary question is: how much healthier would Americans be (of all ages) if we spent some of that $400 billion in other ways, say on prevention rather than after a person is already ill or disease-ridden?
Medicare program costs have risen from $70 billion in 1985 to $162 billion in 1994 to $390 billion in 2007 and are estimated to rise to $500 billion in 2011. Adjusted for inflation, that $70 billion 20 years ago should only be $130 billion now, not $390 billion. Are we three times healthier than in 1985? There's a variety of metrics we could use, but we shouldn't rely too heavily on longevity, in my view; "quality of life" (though harder to measure) is what counts to the patient and his/her family.
This is a long entry, but this is a program which will, in its current runaway form, bankrupt our nation. (thanks to correspondent John B. for this link): Bernanke Warns of Looming Deficit Crisis (MSNBC 1/18/07)
Let's start with the fraud and waste which can be measured: over-billing, etc. This has been documented for years:
Waste in Medicare, 1995
Here's a Washington Post series from 2005:
Bad Practices Net Hospitals More Money; High Quality Often Loses Out In the 40-Year-Old Program
Accreditors Blamed for Overlooking Problems
Once Health Regulators, Now Partners
All of this is IBD--Important But Dull. Let's face it--an astounding number of folks profit immensely from billing Medicare. It's the golden trough not just for large companies but small ones, too.
My thesis here is more radical than just "Medicare is riddled with waste, fraud and poor practices." I think a strong case can be made that 50% of Medicare funds are wasted in the sense they do not improve the quality of patients' life but often degrade it further:
patients are needlessly placed in harm's way by encouraging risky, useless or harmful procedures in hospitals teeming with incurable staph and other infectious agents,
patients are loaded up up with a dozen or more drugs which have never been tested in such an interactive stew of other pharmaceuticals, regardless of the relatively low value of the drugs as curative agents, or even outright negative affects of such drugs
and perhaps worst of all, funds which could have made a difference in preventative care earlier in the patients' lives are squandered on the patients' last few weeks or months, after they've contracted lifestyle diseases such as diabetes, lung cancer, liver diseases and heart disease.
Lest you think I exaggerate, here is Page One of yesterday's Wall Street Journal on the growing evidence that stents--one of the most common operations for heart-disease patients-- are not helpful but actually detrimental: (subscription required, or go to your library and read the print edition for free):
The Case Against Stents: New Studies Hint at Overuse
There is an alternative to useless, expensive (and immensely profitable) surgical procedures like inserting stents, which is called the
The Heart Healthy Lifestyle Program by Dean Ornish, MD.
What's the problem with the Ornish Plan, which has been clinically proven to reduce heart disease? You can't make any money off it! How the heck can I make billions off useless stents, useless drugs and dangerous operations with lifestyle changes which are controlled by--gasp--the patient? Well, you can't, and that's why Medicare is a largely worthless waste of $390 billion (soon to be $500 billion): it pays for operations, drugs, devices and "care" which rarely cure diseases or benefit the patients' quality of life. It does, however, create a vast trough of money which fattens companies and "healthcare" businesses with billions in profit.
Do you think I exaggerate? Take statins, drugs which are routinely prescribed to millions of Americans with high cholesterol. Well now it turns out--surprise!--these drugs have side effects which are long-term bad news, and even worse, lowering cholesterol doesn't seem to be the risk factor that the Medical Powers That Be assumed.
Here is the Center for Medical Consumers:
CHOLESTEROL SKEPTICS AND THE BAD NEWS ABOUT STATIN DRUGS
These cholesterol trials also looked at total mortality, that is, the deaths from all causes, and found little difference between the study participants who tried to lower their cholesterol and those who did not. In other words, some clinical trials showed that the heart disease death rates were, in fact, lower among men who had reduced their cholesterol levels. But this benefit was offset by a higher rate of deaths from other causes.And what happens if you question this stupendously profitable status quo? Your research funding gets cut off: Bad News About Statin Drugs
"Anyone who questions cholesterol usually finds his funding cut off," said Paul Rosch, MD, who started his talk with a reminder that half of all heart attacks occur in people with normal cholesterol levels. "Stress has more deleterious effects on the heart than cholesterol," said Dr. Rosch,In other words, statins may actually increase the risks of heart attack rather than lower them.
So why doesn't the FDA announce that statins are dangerous and not helpful? Because the pharmaceutical industry would freak out that their billion-dollar gravy train would end. Take a look at this story for more: (thanks to correspondent U. Doran for this link)
Cholesterol, Lipitor, and Big Government
Meanwhile, thanks again to U. Doran, we have this New York Times story reporting that plain old vitamin B, Niacin, is effective in lowering cholesterol and safer than the statins: An Old Cholesterol Remedy Is New Again
If you believe that statins and stents are rarities, then you need to check all the meds your elders are taking and delve deeply into their safety and efficacy trials. You will find most meds help only a subpopulation of potential patients, and the side-effects can be serious. Say a drug seems to do some good in 20% of the trial patients, and doesn't seem to do too much harm to the other 80%--it will be approved. But what if side-effects take longer than the trial length to appear? What if the drug is overprescribed because "we have to do something to help the patient"? What if it interacts negatively with other medications? None of this comes out until the damage is already done.
And if you're skeptical that lifestyle changes actually work, (stop eating junk food, start eating real food, pursue modest regular exercise--you know the drill) then read this U.K. study in which people ate a "primitive" human diet:
eating a primitive diet lowers weight, cholesterol, blood pressure.
The participants' health magically improved in just a few weeks: lower weight, more energy, lower cholesterol, lower blood pressure--what's not to like? If there was a drug which did all this without side-effects, it would sell in the tens of billions. But there is no such drug, nor will there ever be such a drug. "Health" is not a single metric but a systemic condition of healthy food intake, healthy mind (i.e. not depressed or stressed out) and a lifestyle which includes regular exercise.
There's nothing mysterious about the process of healing and getting healthy. But it does take jettisoning the entire American diet of French fries, high-fat, high-salt high-fructose packaged food. My own observation is that American packaged food (canned goods, frozen meals, etc.) are much saltier and sweeter than they used to be a few decades ago. On the rare occasion I eat a canned soup (a can someone gave us, since I never buy any packaged food), I am astonished at the high fat content, the high salt and/or the high sugar content. Read this for more: (thanks to correspondent U. Doran for this link)
Does High-Fructose Corn Syrup Have to Be in Everything?
We all know fast food is basically garbage--high fat, no anti-oxidants, low fiber, high-fat salad dressings for the "healthy salad" made with junk oils, etc. etc.--but basically the rest of the American diet--all packaged food, baked goods, soda, etc. etc.--is also not healthy. If you travel abroad a bit, you discover that other cultures still eat "real food"--actual vegetables and grains and meat which is purchased and prepared at either home or a restaurant. Yes, American fast food has made enroads elsewhere, and thus nations which had few obese young people are now seeing a rising number of unhealthy fat kids.
Recall that "lifestyle" diseases like diabetes have shot up from near-zero a few decades ago to epidemic levels. Pima Indians who live in the U.S. have horrendous rates of diabetes, while their next-of-kin (same genes) across the border in Mexico have none. What else do you need to know about the causes of diabetes? Here's more on research on the Pima tribe:
Obesity and Diabetes
My own observation is that exercise is more important than generally credited. People in northern Europe eat a lot of meat, white bread and cheeses--food which by "health nut" standards should have put them in an early grave-- and yet their lifestyle of eating modest portions and walking (i.e. "French women don't get fat") make them just about as healthy (in terms of longevity and quality of life) as the Japanese and Okinawans who eat a diet low in red meat and dairy products.
Various cancers have been linked to high-fat, high-protein diets, as has arthritis. I don't have the time to list all the links--do your own research. It's all there at your fingertips.
Then there's my own personal experience of the elderly people I have known. My uncle seemed a bit frail, but stable, but he went in for some operation which was supposed to fix something. He died in the hospital. Our old friend Joe was told he had an aneurysm in his chest, and the doctors decided to "fix" it. He died in the hospital. I could go on, but you have your own stories, no doubt. I can honestly say that I do not know one elderly person who entered the U.S. Medicare/"healthcare" system with a health issue (or a supposed health issue) other than an infectious disease which could be knocked down with antibiotics or a parts replacement (inter-ocular lens, hip, etc.) and emerged "healed," "cured," or alive and well. Is this just bad luck on my part, or the reality nobody wants to talk about?
Meanwhile, their last operation and intensive-care stay cost the taxpayers hundreds of thousands of dollars, and enriched the doctors, hospital, etc. Did the doctors feel they "had to do something" lest they be sued later? Very likely. Did the doctors feel they "had to do something" because their training stressed that over "first, do no harm"? Very likely. Did the soon-to-be dead patient willingly go in like a lamb because he trusted the doctors to make the right decision for him? Undoubtedly.
Instead of this insane system which waits until you have a life-threatening disease and then treats it with operations that don't work and drugs which actually do more harm than good, what if Medicare was operated for the health of the citizenry rather than for the profit of the "healthcare" industry?
Let's say $100 billion of the $400 billion was set aside for prevention. What if every American who turned 45 had to go in for a physical to qualify for future Medicare, and if they smoked, were obese, drank too much/were a druggie, had incipient heart disease from lack of exercise, etc., then they would be told, "We are partners in your health. We cannot fix illnesses like diabetes, alcoholism, lung cancer and heart disease later--we have to fix them now, and you have to do your part. And if you don't take any responsibility for your own health, well, the care choices under Medicare are limited. Frankly, the government isn't here to save you from your own unhealthy lifestyle."
A followup exam and lifestyle assessment would be required at 50, 55 and 60, making sure the future Medicare recipient was doing all that he/she could to maintain their own health. And if they continued to smoke and carry 50 extra pounds of weight, they would be warned that Medicare didn't cover "lifestyle-induced" illnesses like lung cancer and heart disease. In other words, if you're not partnering up and doing your part, the government isn't going to save you. Instead of sugar-coating reality (is that all that Americans can stand now, sugar-coated reality?), they would be told:"What you ruined--your health--cannot be repaired with any amount of money, and so we're not going to support the illusion that there's a miracle cure or surgery. We will keep you comfortable."
When did personal responsibility stop being part of healthcare? If you drink like a fish and get a DUI, your insurance skyrockets. If you continue to abuse alcohol and get another DUI, you're in big trouble. (In much of Europe, it's one strike and you're out: one DUI and you lose your license.) If you persist in destructive personal habits like drinking and driving, and you get nailed with a third DUI, you're out: your license is pulled and insurance--forget it.
My family has a history of alcoholism, so I'm not being cavalier here. Alcoholism is a serious condition which is very tough to manage. My siblings and I are able to drink responsibly, but I have friends from similar families who are teetotalers. Whatever works--the main thing is to take responsibility for your own health and risk factors.
Yet if you smoke, drink heavily, eat poorly, allow yourself to become obese and don't bother exercising, then there's no cost? The government is supposed to somehow "cure" you despite your abuse of your body and your forfeiture of any personal responsibility? Why? Why are you responsible for some things but not for your own health?
This lack of patient responsibility is built into the system. The system is set up to "process" lumps of passive clay: cut 'em open, give 'em meds, send 'em home. Here's just one example. My 80-year old father has osteoporosis. For this he has been given various puffers and pills to take. But no one in Medicare, or the entire vast system it feeds, has ever demanded that he do anything himself to improve his condition, though what this is--simple exercise--is well known: Bone density sharply enhanced by weight training, even in the elderly.
There is another fatal flaw in Medicare, and the entire U.S. "healthcare" industry: if you want to drive in a thumbtack, all you get is a sledgehammer. A close family friend was an internal medicine MD for decades in a busy urban hospital. He once told me that there was nothing wrong with half the people who came in to see him; they just wanted to talk. My own grandmother combatted loneliness and boredom with weekly visits to the doctor for vague ailments such as knee pain (Tylenol) and feeling low (anti-depressants, which never worked--why? Because she wasn't depressed). The doctor was pleased to bill Medicare for a 5-minute visit.
If you think this isn't common, you need to spend more time with elderly people. An elderly friend we keep an eye on (she has no surviving family) goes to Kaiser Hospital on a constant basis for basically the same reason: it gives her something to do. She recently insisted on an operation on her hand, and surprise, surprise: now her hand hurts more, and only closes halfway.
My father fell and fractured a bone last year, and so he spent a week in a rehab clinic. The gentleman with whom he shared the room had no real reason to be there; since we were with my Dad every day, we started talking to this gent. Turns out his daughter worked all day, and so he was lonely. Every few months he'd conjure up a reason to go into this rehab clinic (at hundreds of dollars a day) just for some human companionship and stimulation.
So what we have is lonely seniors, and what we offer is horrendously expensive medical "care" for their relief: a sledgehammer for a thumbtack. What depressed seniors need is a ride to the senior center, to join a depression management group, etc. This would be so much cheaper--and kinder, and more effective--than giving them a basically free visit with a doctor who then feels obligated to "do something" which ends up being costly, useless or even detrimental.
Personal responsibility seems to be a lost value in American life now. Hey, we all want to eat a quart of ice cream and gobble down chips and fries--they taste good, and in fact are engineered to taste good. (Have you ever noticed that the labeling on animal feed is more detailed than the information provided on human food?) But there's a cost to eating junk, so we can't indulge in irresponsible eating any more than we can indulge in irresponsible drinking. I like ice cream as much as the next sweet-tooth, but I eat it a couple times a year, at birthday parties. Do I miss it? Occasionally. Ditto the other things I no longer eat except on rare occasions--doughnuts, chips, fast-food burgers, etc. But is our life ruined by foregoing all this stuff? I think it's abundantly clear that it's ruined if we eat it as often as our taste buds (and emotional situations) desire.
What's sad (or ironic, if you're cynical) is that once you get overweight and contract diabetes--and yes, I do have friends with diabetes--then you can't eat that stuff anyway, but now you have to monitor your blood sugar and worry about losing years off your life.
Yes, many diseases are genetic and "not my fault;" I'm fair-skinned so I am at risk of skin cancer, even though I wear sunscreen and a hat every day. African-American men are at higher risk of prostate cancer, and so on. The lens in our eyes cloud up with age, and have to be replaced with a plastic lens. Fine; that's not too costly. Hips and knees give out earlier in some of us than others (not always from carrying around an extra 50 pounds, but that certainly doesn't help.) Fine. It's straightforward to diagnose, the cost is standardized and the pay-off is immense. We all have medical conditions which may rise up into crisis even if we have led a healthy lifestyle. Yes, Medicare should pay for the treatment of these diseases and body-part replacements. But how much of the $400 billion is actually spent on this type of care, and how much of it is actually effective? How much is worthless MRI tests so the clinic won't be sued later for "not doing everything possible"?
So here we are: as a nation, we spend 16% of our $13 trillion GDP on "healthcare," and will very shortly be paying more for Medicare than the entire Military and V.A., yet it is clear we are an unhealthy nation: poor child mortality rates, high obesity rates (either 40% or 60% of the adult population is overweight, depending on your metric) and so on. There have been public health victories: smoking has receded, greatly improving the lives and longevity of those who quit and those who live with them. Some genetically caused cancers, such as aggressive breast cancer, have improved drug treatments. Yes, some pharmaceutical research does result in drugs which improve the patient's life--but not as many as you might think.
A close friend's wife just went through surgery for colon cancer. My friend is a physicist by training so he did voluminous, painstaking research on the pros and cons of chemotherapy. He concluded that the difference in the 5-year and 10-year survival rates for those who endured chemo and those who did not were statistically insignificant. In other words, a horrendously difficult and expensive treatment which is recommended without hesitation by the "establishment" has very little chance of prolonging the patient's life, though it puts the patient through six months of Hell.
This is not some outlier; this is common. The conclusion: we pay trillions for medical care which doesn't work or actually makes us sicker, more at risk of illness or just flat-out kills us. Medicare is an insane system in which the government does virtually nothing to educate (or cajole) people into improving their life through preventative lifestyle improvements, but waits until the person is old and ill, and then it expends hundreds of thousands of dollars on the person's last days, wasting the money on illusory "solutions" and robbing the patient of their dignity and the opportunity to die in hospice or at home.
If we set out to design a more wasteful, destructive, useless system, I don't think we could do better than the current Medicare system. My own personal experience suggests that we'd actually be better off if Medicare simply went away and was replaced with a preventative-care system which sought to identify risks in middle age (or even sooner) and enrolled the patient in a partnership of health.
Thank you, Paul, for raising the issue of waste in the Department of Defense and Medicare. I hope I have found some links which have added to readers' knowledge.
For more on this subject and a wide array of other topics, please visit my weblog.
copyright © 2007 Charles Hugh Smith. All rights reserved in all media.
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