Wednesday, February 04, 2004

Multi-function Post:

Irrational Exuberance
Sleep Disorder Research
A Political Survey, Part 4 - Health Care

1. Today I am going to break my tradition and post about several things.  The first is this, from Netscape Business news:
Business News
Wednesday, Feb. 4, 2004
Cisco Caution Punctures Tech Optimism

CHICAGO (Reuters) - Cisco Systems Inc.'s (CSCO.O) cautious comments regarding corporate spending on its Internet routing equipment punctured market optimism on Wednesday that technology spending was set for a rapid rise.

"This is a reality check," said Richard Steinberg, president of Steinberg Global Asset Management, a Florida asset management firm that sold half its Cisco holdings ahead of the earnings announcement on Tuesday due to its lofty valuation.

"It's not bursting a bubble, but maybe it's pricking a hole in the balloon a little bit to slowly let some of the air out," he added.

Why is this noteworthy?  Because this is good news, that is why.  Why is it good news? Because one big reason we have the economic mess we are in, what with jobless recovery, increasing wealth gap between rich and poor, and stagnant incomes for the middle class, can be summed up in two very famous words: irrational exuberance.  We really, really need these reminders, lest we forget the folly of irrational exuberance. 

2. This next piece is from the University of Michigan's Medical Center website, regarding a common problem: Sleep apnea.  As the article points out, this is a problem that affects millions of Americans.  It often is a problem that afflicts people for years before the diagnosis is established.  It has a serious negative impact on productivity, quality of life, and life span.  I have seen it in a number of persons with treatment-resistant depression, or persons with unstable bipolar disorder.

February 3, 2004

Does the sleeping brain ‘wake up’ – if only just a little – with every snore?

UMHS, Altarum study finds sleep apnea disrupts sleep throughout night

ANN ARBOR, MI -Patients who snore or have other symptoms of sleep apnea often undergo testing in a sleep laboratory to measure the number of breathing pauses and arousals that occur while they slumber. But doctors find these tests do not effectively predict daytime consequences suspected to arise from sleep apnea, such as sleepiness in adults or hyperactivity in children.
Ronald Chervin, M.D
Now, neurologists at the University of Michigan Health System and engineers at Altarum Institute in Ann Arbor, Mich., have discovered evidence that the disruption of sleep in sleep apnea may be much more frequent than the breathing pauses, or apneas, themselves.

In two research papers published in the February issue of the journal Sleep, the researchers describe for the first time evidence that on average, brain waves change with each breath, not just the short periods of the night when apneas occur. Although the data are preliminary, they suggest a whole new thinking in sleep research that eventually might help doctors predict who will suffer consequences of sleep apnea, and who will respond to treatment...

“Complicated studies that require time, money, and technical expertise are often performed in sleep laboratories,” says Ronald Chervin, M.D., director of the Sleep Disorders Center and Michael S. Aldrich Sleep Disorders Laboratory at UMHS. “The most common reason is to gauge the severity of sleep apnea. A frustrating problem has been that results of these studies have not predicted the behavioral outcomes of sleep apnea very well. That makes us think that maybe we don’t have the best laboratory measures; maybe we are not recording some of the most important features of sleep apnea.[emphasis mine]...

I mention this for three reasons.  The first is a public health message.  There are a lot of people out there who have sleep apnea (or restless leg syndrome, or narcolepsy) who don't know it.  Anyone who is excessively sleepy (distinguished from having low energy or fatigue) should think about having the problem evaluated medically.  It astonishes me to see people who have fallen asleep while driving, who have not thought to see their doctor about it.  See the sleep apnea link for information.

Second, this article illustrates one of my favorite medical concepts: All diseases ae more complicated than you think.  There are NO simple illnesses.  There is ALWAYS at least one more layer of complexity.  These studies indicate that sleep apnea is not just a matter of mechanical obstruction of the airway; the obstruction is only the most obvious aspect of the pathophysiology. 

Even though I am generally a pacifist, there is one case in which I do advocate violence against the self: anytime you find yourself thinking that you understand an illness, you should slap yourself on the head (preferably on the side of your non-dominant hemisphere.)

Third -- this is more of a pet peeve -- this article demonstrates the seductiveness of objective testing.  All too often, when doctors have an objective test that demonstrates some aspect of an illness, they focus all of their attention on the test.  Doctors should not treat test results; they should treat people.  As Dr. Chervin points out, the test results (of clinical polysomnography) actually do not correlate well with the behavioral outcome (the impact of the disease, or its treatment, on the patient's level of functioning.)  Doctors should never forget that their mission is to improve function, not to improve the results of the test. 

Educators and education policy wonks need to remember this too, but that's another story...)

3. This is a more about my response to Representative Nick Smith's survey of his constituents.   Today I will address the question on Health Care:

Health Care

Health care and health insurance costs continue to escalate. This is causing some employers to reduce or drop coverage for employees and retirees.

4. What should the government do on health care?
Nothing more. The government can't improve health care.
Make health care insurance deductible in order to reduce employees' dependence on employers.
Government health care for everyone based on the Canadian/European systems.
Pass laws to reduce lawsuits against doctors and healthcare providers.
Require all employers to provide health care for employees.
Price controls on medical services with some loss of new treatments and some providers refusing to provide services.

Again, I object to the the phrasing of the questions, but i will not belabor the methodological issues.  I covered that in the first part of this series. 

The first response I will dismiss as being incorrect.  The most efficient health care insurance program we have is Medicare.  According to Blumenthal, “Administrative Issues in Health Care Reform” (editorial), New England Journal of Medicine 329:428-429, Aug. 5, 1999,  for-profit hospitals and HMO's are both more expensive and provide lower quality care than not-for-profits.  See the review  at the Physicians for a National Health Care website.  In the USA, the administrative overhead in the USA accounts for 31% of health care expenditures.  It is only 1.3% for the national system in Canada. (NEJM Volume 349:768-775, August 21, 2003).  The overhead for Medicare in the USA is 3%, according to Dr. Angell  (Senior Lecturer, Department of Social Medicine, Harvard Medical School; Former Editor-in-Chief, New England Journal of Medicine)

There are many exceptions to what is commonly perceived as a general rule: that the Business Model always results in greater efficiency and lower costs.  This "rule" is not true in the case of necessary utilities, nor is it true in health care. 

This would suggest that a health-care system that is entirely government run would be best.  I am not sure that will be the case.  I think that there will always be a role for private health care in the USA, as there is in the UK; people are free to step outside of the system if they can afford it.  Yes, this does create a two-tier system.  But that is not necessarily a bad thing, if the first tier is adequately funded.

The common strategy of arguing against a single-payer system is to look at problems experienced in such systems in other countries.  This is not a valid line of argument: other countries all have different systems, in different social contexts, with different levels of funding.  It is more valid to compare the various systems of private insurance --here in the USA -- with Medicare.  That is more of an apples-to-apples comparison.  And with the exception of prescription drug coverage, Medicare is superior in most regards. 

As a physician, I would gladly trade the higher payments from some private insurance for the lower hassle of treating Medicare patients.  There are a number of reasons I don't do that, but all of those reasons would go away if we had a single-payer system. 

What many studies on this issue overlook is that a single-payer system would result in greater efficiency on the payer side AND on the provider side.  The inefficiency of having to deal with multiple payers, all with their own restrictions, preauthorization requirements, different forms, different addresses and phone numbers, etc., is getting worse for providers every year.  Please realize that, not only does each insurance company have its own policies, procedures, and restrictions, but each of them changes these things every year.  AND, they deliberately screw up any attempt to try to keep everything clear. 

Price controls , are, in fact, already in place.  Insurance companies effectively control prices already. 

Passing laws to reduce lawsuits always sounds attractive to potential defendants.  What I personally would like to see would be some kind of cap on legal fees, although, since most lawmakers are lawyers, that is unlikely to happen.  The problem is that if you make it illegal to take cases on contingency, then poor people will be locked out of the system.  Still, there should be some proportionality between what the lawyer gets paid and the actual cost of the legal process.  With the current contingency system, a lawyer can take 20 cases that he or she knows are lacking in merit, but one lucky break among those 20 cases can make the 19 losers worthwhile.  That leads to some attorneys to take on all kinds of cases that really never should get started.  The other reform could be to establish a rotating panel of expert witnesses, with fixed fees, for each specialty.  That would greatly reduce the cost of some of the trials. 

Forcing all employers to provide insurance would make many small businesses impossible to run. 

In summary, my answer is Government health care for everyone but not necessarily like the systems in Canada or Europe.  I would model it after Medicare, and add a real prescription drug benefit.  The drug benefit is the topic of the next question.