A National Disgrace

This is a bit off-topic for the environmental health blog, but I really should get something posted while I struggle to complete the next installment of “Cancer, Animals and Man” (I picked a really hard chemical to review, and there’s lots of other things going on at the same time right now . . . ). According to the WaPo yesterday, health care now consumes about 16 percent of the nation’s economic output. And, this is buried in a report noting that the growth in health care spending is decreasing over time, something I suppose should be treated as good news. The actual paper is behind a subscription firewall at Health Affairs. The abstract notes the 16 percent figure is nearly the same as in 2003, which makes me wonder what the WaPo means by “record” spending. Doesn’t matter – at least they published it.

Other trends noted here are the concerns that health care costs were increasing faster than wages or inflation, that they threaten to financially swamp many employers, and that there are still substantial ethnic and racial disparities in the level of care.

What leads me to title this a disgrace is this report in today’s NYTimes, which notes that several diabetes centers opened by hospitals in New York City and oriented towards prevention have now closed because they were money-losers:

At four hospitals across the city, they set up centers that featured a new model of treatment. They would be boot camps for diabetics, who struggle daily to reduce the sugar levels in their blood. The centers would teach them to check those levels, count calories and exercise with discipline, while undergoing prolonged monitoring by teams of specialists.

Sounds good, so far, but:

But seven years later, even as the number of New Yorkers with Type 2 diabetes has nearly doubled, three of the four centers, including Beth Israel's, have closed.

They did not shut down because they had failed their patients. They closed because they had failed to make money. They were victims of the byzantine world of American health care, in which the real profit is made not by controlling chronic diseases like diabetes but by treating their many complications.

Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000.

Patients have trouble securing a reimbursement for a $75 visit to the nutritionist who counsels them on controlling their diabetes. Insurers do not balk, however, at paying $315 for a single session of dialysis, which treats one of the disease's serious complications.

Not surprising, as the epidemic of Type 2 diabetes has grown, more than 100 dialysis centers have opened in the city.

An operator of one of the failed centers is quoted, "[i]t's almost as though the system encourages people to get sick and then people get paid to treat them".

But, life expectancy is rising in this country, which is good news, right? However, the real question should be, “are the added years quality ones”? And, does it have to cost so much?

The Times article goes on to note:

. . . the lone hope on the horizon is a restructured reimbursement system that puts the business of chronic care on a more competitive footing with acute care. Experts say this restructuring could start if government insurance programs like Medicaid began paying more for preventive efforts like education, a move that the private sector would be likely to follow.

You can’t blame the hospitals and insurers entirely (considerably, but not entirely). The Times article closes with a pathetic story of a diabetic, a client of the now-closed center, slipping back into her old high-risk habits and opining, “I needed reminding”. You mean needed reminding not to suffer needlessly and die early? This should be a wakeup call for all of us to reclaim our human dignity and stop acting like we’re simply a market segment for the healthcare industry.

Making chronic care cost-competitive. What a concept. From a good governance perspective, it makes sense. However, perhaps viewing peoples’ ill-health as assets to be strip-mined makes more sense from a business perspective.