Monthly Archives: August 2011

Mortality amenable to health care

public health

“Mortality amenable to health care” is a statistical measure of the, well, mortality amenable to health care.  Briefly, it’s a measure of how many of a population’s deaths from certain causes could have been prevented by proper health care, or as the authors of a recent paper put it: “potentially preventable with timely and effective health care”.  It’s a statistic which in itself means nothing (it won’t tell you whether your grandmother’s death could have been prevented by timely and effective health care), but which can be used to compare different populations (like, people in different countries or (in the US) different states, and to track changes over time in the health care being provided to a population (if the MAHC is rising, then either the timeliness, quality, or amount of health care available to the populations is falling).

In a recent study reported by the Commonwealth fund (in the Journal of Public Health Policy, citation at the link), a group of three authors found significant differences between the various states in this measure, ranging from a low of 64 per 100,000 in Minnesota to a high of 142 in Mississippi (what a surprise) and a whopping 158 in the District of Columbia (bet it’s not among politicians, and also not a surprise).  Furthermore, they found that the US placed dead last in this measure among the 19 developed nations for which data was available from the OECD.  (The lowest?  France, at 65 per 100,000.  France, people.  Seriously, that sucks so much I can feel the interstellar vacuum getting harder).

Even better, the authors showed that there were some hard indicators of which regions or populations were going to have high MAHC, based on already measured public health indices.  Number of diabetics getting recommended preventive care, visits to emergency departments(1) by asthmatics, readmission to hospitals of recently discharged people, and admission to hospitals of long-term nursing home residents were all indicators of high MAHC.  These are the kinds of measures which doctors are railing against (well, to be fair, many doctors.  Other doctors, like me, are cheering the measures, and demanding they be used to provide the public some openly available information about the health care providers in their region).  Because many doctors feel both helpless to change those numbers, and trapped by a reimbursement system which, in effect, punishes them for making the numbers better.  This doesn’t work so much on an individual level: ask a specific physician whether they’d like to fix those numbers, and they’ll all tell you “Of course!”, but it works in subtle ways.  Fixing the numbers means working together with people who have traditionally been, not enemies, but rivals: hospital administrators, nursing home administrators, politicians in some cases.  And as you fix them, you watch your income figure drop, and suddenly there are just…other priorities.  Going to the meetings that keep the “fix the problem” process on track becomes less important.  Maybe you are frustrated with one of the other participants, and decide to say so to your colleagues, or the other members, or, heavens forfend, the media.  And suddenly the process is derailed; these things happen, couldn’t be helped, back to business as usual.  It’s never so open as “I decided to kill the process because it killed my income stream”, but that’s nevertheless what happened.

When it comes time to make the kinds of changes we need to make, I believe it’s crucial to 1) acknowledge the fact that income is a factor, and take steps to minimize and equalize the impact, and 2) see that the process keeps going, despite the lost income.  Maybe, after a while with the new system, new income streams will be found which encourage doing the right thing-that’s always been my thinking.  And one of my fondest hopes.

—

1) Never “Emergency Room”.  It’s the “Emergency Department”. That’s probably the only absolute in the Physician’s Pen style guide.

The problem is not the cost of health care

Politics, ,

In an interview with the Kaiser Family Foundation, former US Senator Jim Danforth spoke about the future of the upcoming “super committee” negotiations to reduce the deficit. Senator Danforth was a member of a similar committee constituted in the mid-90’s, also bipartisan, with the same partisan divide which now obtains. One of the things he is reported to have said is “the problem is the cost of health care”.

Well, I must respectfully disagree that *the* problem is the cost of healthcare. It’s *a* problem, to be sure; health care is expensive, and I recognize that a lot of both the national budget, and people’s personal budgets, are going toward health care expenses nowadays. But I think it’s overkill to call it THE problem, when there are, in fact, other problems which are making healthcare prices a larger issue than they deserve to be.

Let’s see. Jobs are the first problem to come directly to mind. In the US, a lot of health coverage flows from having a job, so if many people don’t, health care costs become magnified. Like many people, I was surprised when the administration decided to make health care the first big problem they tackled after the election. In my math, it came about third, after jobs and repairing/restructuring the banking sector. But those problems were, I suspect, both harder than health care. For government, the only way to make jobs quickly is to hire people, directly, or to fund a lot of work which causes businesses to hire people, indirectly. Another argument says that government can reduce regulation to stimulate job growth, such as by repealing environmental regulations or the minimum wage law. This has some merit, but it won’t make jobs *now*, and it has effects in the future which are unacceptable to many. (Repealing the minimum wage will make jobs which won’t pay family expenses nor, likely, provide health care. Repealing environmental laws will have health effects we will, eventually, have to pay for. Guess who will have to pay? If you guess “not the company which made the environmental mess”, take a gold star and feel good about yourself for the rest of the day).

Reforming the banking sector comes second in my personal list of things which needed doing. I’m not going to talk much about that, because others have done a better job, other than to note that until that Charlie Foxtrot is cleaned up to the satisfaction of more people, confidence in the stability of the market will continue to be poor, at best. The only people who are confident that there will not be further banking collapses are bankers, and they have not proven their trustworthiness in this matter.

So health care costs are not the most important thing. They’ve become the most important thing, because they’re getting all the attention, but health depends on more than just “medical care”. It depends on having a job, so you can stop worrying about making your mortgage payment and putting quality food on the table. It depends on having a society around you which is vibrant and self-assured, and which knows it can take care of itself regardless of the shifts of fortune. Because that society is much more likely to care for you when you need care than a society which is terrified of the next economic or natural disaster, knowing that we’ve only barely survived the last ones. And that society is much more likely to foster your continued good health, instead of making you sick enough to need health care.

Paying the price

Politics

This may be a bit more personal than a lot of the content I have here.

From 1990-1995, I was a resident at what was then Boston City Hospital, and is now Boston Medical Center.  BCH sits in Boston’s South End, and is roughly at the intersection of South Boston, Roxbury, and Dorchester.  Roughly.  Then, as now, it is the City of Boston’s “Knife and Gun Club”.  Every major city has at least one-the hospital where the serious penetrating trauma mostly goes, usually because it’s in the part of town where most of the penetrating trauma happens.  Usually, it’s a poor part of town-the part where most of the people are people of color.  It’s where you end up if you’re out of work, out of cash, and out of hope.  And if you were unfortunate enough to have been born into that, you generally stay because it’s home and all your friends and family are there, or because you can’t get out-you don’t have the education or training for a better job, and you can’t get the education or training while still working the job, which in general doesn’t offer generous time off or tuition reimbursement.  Some folks manage it, through very hard work.  But it asks much of folks to be like superman just to get a little security, when many of the people making decisions had security handed to them on a plate (and to be clear, I am one of them).

Your population (which is medicalese for “the people you see”) are most often at the end of their resources.  They didn’t have many in the first place, and any illness uses them up.

And these, folks, are the people who are going to be the worst hit by program cuts now in progress at the federal level.  Not “fraud, waste and abuse”.  Not wastrels and do-nothings; most of these people work hard for their money.  Not a few of them take care of your elderly relatives, or clean your office building, or work on your car at the local Jiffy Lube.  Some are disabled from birth; they didn’t get much of a shot from the word “go”.  If you have Down’s syndrome, and can be productive but need a little help, tough.  If you have to care for an elderly relative, sucks to be you; if you’re hanging on to your job only because you get subsidized child care, or elder day care for your aged parent, get ready to cowboy up, because that stuff is going away.

Know what isn’t going away?  Subsidies for industries which can afford lobbyists.  Tax breaks for corporations.  (Gotta have someone creating those jobs-except the only industry which is creating jobs right now is health care (which is being cut, because when you look at it, most of those jobs are being paid for by tax dollars)).  Anything, in other words, which helps people who pretty much don’t need any help; they have a lot already.  That stuff is sacred, because those people have influence.  (which they’ve bought with the money they haven’t paid in taxes).  And the argument is always the same: if you cut that stuff, if you increase taxes on those people , you’ll stifle economic growth.  It’s the same, tired supply side argument which has failed over and over again, but which too many people unaccountably still believe.

(Hang in there; I’m getting around to a point).

And when the neighborhood I used to work in explodes once again in drug and gun violence, the people who don’t need the help are going to be surprised.  They are going to call for harsh suppressive measures for the violent elements.  They aren’t going to care that the people who are rioting, who are mostly shooting each other (with an occasional bullet for some rich kid (or rarely adult) who either strayed into the line of fire, or was slumming looking for cheaper drugs than he could get in the suburbs), do not, as my ex-father-in-law used to put it, have a pot to piss in.  The people who are both shooting and getting shot are (bluntly) poor.  They see people who are rich all around them.  And they know, they know, that the rich people want them to stay poor.  Because they know what’s going on at the top.  They know that tax breaks are for people who are not them, and that tax money goes to people who are not them, and that pretty much everyone has written them off.  They know that when the going gets tough, it’s not “everyone all together, E pluribus unum“. It’s “I got mine, and the devil take the hindmost”.

And I think that sucks, frankly.

If we’re going to pretend to be a nation composed of disparate parts, we need to act like one.  We need to see our neighbors as people.  All of them.  Including the ones who aren’t much like us, whether it’s because they’re brown, or gay, or Jewish.  Or poor.  And in my sole opinion, we need to do what we can to help people be stable in their lives.  Not meaning “keep anything from changing”, but definitely meaning “Keeping them from losing hope, keeping them trying to be better, stronger, more than they are now”.  Not just poor people; all people.  Enough of us have lost our way.  Enough have forgotten what it means to be part of something bigger than ourselves.  These people are on our crew, as Captain Malcolm Reynolds puts it in “Firefly”.  That doesn’t mean we have to like them, or let them get away with everything they’d like.  But it does mean that when they fall, as some inevitably will, that we will come back for them.  That we will pick them up, make them as whole as we can, and teach them not to fall again, if we can.  We can make people more resilient, and when we do, I think we’ll find that our entire society becomes more resilient.  When I was a resident, I always felt that a part of my job, when someone came to the Emergency Department, was not just to help them deal with what was going on now, but also to help them understand what had led to the emergency, so that in the future they could avoid it.  I’ve done my best to keep that up as I’ve practiced, and more than a few people have told me that “No one has ever explained [their health problem] to them like that before”.  Well, we have, as a nation, a fiscal problem.  And I honestly think that if you look, you’ll find that we’ve done all we can with cutting.  I’ve lived with a lot of people, friends and strangers, in combined households-I suspect most people have, at some point in their lives.  You live with a roommate, a housemate, a lifemate.  And I’ve had a household budget, in the same way we have a national budget.  We need to face the fact that a national budget (like a household budget) consists of both income and expense. If we have too many expenses, we can look to see what can be cut.  And if we, as a nation, decide to cut some I like, well, I don’t always get what I want.  Maybe we don’t need the deluxe cable, but we need the electricity. But if we decide to do nothing but cut, and don’t decide that maybe someone needs to contribute a little more of their surplus income to the household, we’re not going to last long as a household, because we’ve cut all the things which hold us together.