Whose perspective?

After a long hiatus filled with travel, work and lack of inspiration to write anything, I have chosen this arguably hottest day of the year to venture forth again. But I will make this brief, as it seems that everything that needs to be thought and said has already been thought and said. Yet who is listening?

Anyhow, to suspend my natural cynicism, I want to talk about perspective. No, not the perspective that makes parallel lines converge in the distance, but the one that gets lost in many of our political, civic, business, and, yes, even scientific discussions. I am talking about my perspective, your perspective, societal perspective, etc. I was inspired to write this because of these tweets by Gary Schwitzer to Kaiser Health News about a story on their web site:

Linking out to the story, I learned that a consulting arm of Disney is teaching hospitals about hospitality. Since there is going to be a financial incentive for these hospitals to deliver good customer service, many are feeling that an investment in this type of training will help them maximize these new reimbursements. Hurrah and ta-da! 

Well, Gary likes to burst these one-sided bubbles, and so he rightfully asked about the costs. What was baffling to me was the response by the KHNews who did not seem to appreciate the importance of reporting the costs or the various perspectives that these costs represent. So, this seemed like a teachable moment, and here is the teaching.

In outcomes research, we are always interested in understanding the perspective for both the costs and the benefits of interventions. In health outcomes these perspectives are broadly represented by the patient, the provider, the hospital, the payer, the employer, the manufacturer, the society, to name a few. These are just some of the examples of the usual stakeholders involved in healthcare decisions. Because our healthcare is such a fragmented disaster, many of these perspectives find themselves at odds with one another. Just think of the patient who wants to get what she perceives as a life-saving treatment that in reality has a 1% chance of helping at a cost of $600,000 per treatment course. From her perspective, since she is insured, this investment is well worth the cost. For a payer, however, this means $600,000 (multiply this by 100 in order to determine the cost to save 1 life) that cannot be spent on something else that can help more people more predictably. And if this payer is the taxpayer, the societal perspective enters the picture, where we have to decide what amount of money is worth spending on possibly saving one life -- is $60 million reasonable? Perhaps. But these are not simple questions, and, as such, do not have simple answers. In addition, all conversations that we hear or engage in have multiple perspectives. This is why a black-and-white approach is so divisive: it generally emphasizes two diametrically opposed perspectives. 

So, next time you hear about death panels or Mickey Mouse teaching hospitals how to maximize their revenue, consider the broader implications from may different perspectives. Chances are you will find yourself agreeing with more than one point of view. And when this happens, you will know that you have learned an important lesson and can now start engaging in more nuanced and thus productive debates, many of which will shape our society's future.

h/t to @garyschwitzer for this KHN story      

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National Healthcare Expenditures, 2009 (In pictures)

Well, it's that time of the year again: CMS has given us the accounting of our National Healthcare Expenditures (NHE) in a paper published in Health Affairs. I am sure you have already heard that the spending only went up by 4% this year over last, an all-time low.

At the same time, we have achieved the highest ever NHE as a proportion of the GDP (17.6%) and as expenditures per capita ($8,086). But the GDP proportion is a somewhat deceptive number on the one hand, as the GDP has suffered a substantial drop from its 2008 value of $14.4 trillion to $14.1 trillion in 2009. On the other hand, this implies that healthcare is eating into the rest of our expenditures on life. At the same time the per capita expenditures have continued their relentless rise.

Let us look at the components of the NHE individually and see what they can tell us.

As usual, the bulk of the expenditures went to personal health care (85%). Public health got a measly 3% of the total NHE, and this continues to be one of our gravest misappropriations. You may recall that about a year ago I did a post where I cited some startling statistics about some broad categories of causes of premature death in the US. Access to medical care accounted for a measly 10% of those, and the rest were attributable to behavior, genetics, environment and social factors. So, while, by inference, fixing medicine may impact 10% of these premature deaths, in reality 97% of the entire NHE goes to medicine rather than to potentially more impactful public health interventions. And the real travesty is that, despite these astronomical expenditures, we are still losing 1,000 lives per day to our broken healthcare system.

Looking a bit more closely at the "personal health" category, we see that, just as in years past, hospital costs and professional services comprise the bulk of this spending.

The "professional services" category, 81% of which is physician and other clinical services, is a bit murky. Yet, without too many leaps of faith we can say that if this expenditure buys us better preventive care, it may be a cost-effective area. At the same time we know that we can make this area a lot more efficient by streamlining and realigning incentives to promote better health rather than more care. Hospital expenditures, on the other hand, are a juggernaut that without a doubt requires containing. It is very likely that exchanging our inflated personal healthcare budgets for well placed public health funding along with reimbursement reform and improved end-of-life decisions, could substantially alter this category of spending.

One final data point that interested me was the breakdown of what are considered investments in the healthcare system. This broadly includes government-funded research and allocations for structures and equipment. Now, I am not sure what "structures and equipment" means, so, if any of my readers know, please, enlighten me. I do know what "research" means, however, and am rather disappointed about this breakdown. What I do not understand is, given that structures and equipment should have some kind of a half-life and not be replaced annually, how it is that this budget also grows consistently year-over-year at a steady rate? Would love to get more details on this.

To be sure, the total research expenditure of $45 billion is nothing to sneeze at. The big question is, however, are we spending it on the right research. I am not at all sure that the answer is yes, given that we still struggle with the same issues at the bedside that we have been struggling with for over a decade. But more on this later.  

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