The Money Traps in U.S. Health Care - NYTimes.com

Why does an appendectomy in Germany cost roughly a quarter what it costs in the United States? Or an M.R.I. scan cost less than a third as much, on average, in Canada?

Americans continue to spend more on health care than patients anywhere else. In 2009, we spent $7,960 per person, twice as much as France, which is known for providing very good health services. And for all that spending, we get very mixed results — some superb, some average, some inferior — compared with other advanced nations. Why this is true isn't easily answered.

Health reform is supposed to control costs, but there is no simple avenue of attack. Our aging population has played a role in driving up medical costs, but Germany, Italy and Japan have much bigger percentages of elderly people while spending much less per capita on health care.

The spread of health insurance, which shields patients from price sensitivity, has played a role in driving up our spending. But almost all other advanced industrial nations cover virtually everyone, while we leave 50 million uninsured.

Administrative costs are high here — no surprise given the hordes of clerks and accountants needed to deal with insurance paperwork. And technological advances, which are sometimes highly beneficial and sometimes not, often cost a lot more than standard treatments. (Surprisingly, American doctors lag far behind their counterparts abroad in using electronic health records, which can help avoid costly errors and duplications.) Insurance companies' profits and the high pay of their executives may account for some of the cost differences with other countries, but there is little good data on this.

A recent report from the Organization for Economic Cooperation and Development, a 34-member group that includes the most advanced industrial nations, concluded that spending is high here partly because the prices charged by American doctors and hospitals are higher than they are anywhere else.

The International Federation of Health Plans, in its 2010 comparative price report, documented just how large the price differential can be for a wide range of services. While it's difficult to get data that is truly comparable from one country to another, the trends show Americans paying a lot more than people in other countries for the same services.

Measuring how effectively we spend health care dollars is hugely complicated. But cross-national surveys offer some clues. We're good at giving patients what they want — if they ask for it. So Americans can see a specialist or get elective surgery a lot faster than patients in other countries, according to surveys by the Commonwealth Fund. The surveys also show that Americans are more likely than people in other advanced nations to experience medical errors or problems with uncoordinated care, and to forgo care because it's too expensive.

The O.E.C.D. report rates America at or near the top for survival rates in breast and colorectal cancer but slightly below average in cervical cancer. We rank in the middle of the pack in the percentage of heart attack patients who die in the hospital within 30 days of admission. And we have alarmingly high rates of hospital admissions for asthma and uncontrolled diabetes — an indicator that many patients don't have good primary care, which can prevent costly hospital stays.

Most other advanced countries hold down prices through government regulations. We set prices in Medicare and Medicaid programs. But in private markets, reform has to rely on other means, such as financial incentives for providers to curb costs by coordinating care and improving efficiency. One demonstration program significantly reduced spending by bundling payments to hospitals and doctors to cover all in-patient services connected with heart bypass surgeries.

The idea at the heart of the reform law is that such strategies, once proved effective, could be carried out on a large scale — and eventually bring total spending under control.

http://www.nytimes.com/2012/01/22/opinion/sunday/the-money-traps-in-us-health-care.html?

Doctor and Patient: Why Doctors Can't Predict Life Expectancy - NYTimes.com

Slender, in her 60s and possessing the stoicism of someone who had single-handedly raised children in the toughest section of the city, our patient faced a difficult challenge of the medical kind. She had diabetes and such severe peripheral vascular disease that even the strongest antibiotics could not heal a long-standing foot infection. She needed an operation.

This grandmother who regularly held court in her hospital room with her extended brood also suffered from high blood pressure and heart disease, and all of us on the surgical team knew that operating would be no easy feat. We could amputate her infected foot, a relatively quick operation that would carry few risks, but she would never walk again. Or we could do an arterial bypass, a more complex operation that would save her leg but that might disable or even kill her before her surgical scars ever healed.

The final decision hinged on our assessment of her likely course, or prognosis. If she was unlikely to live long, we would amputate, because it wouldn't make sense to put her at risk of other life-threatening complications just to save her leg. But to throw out some ballpark figure, an actual number of the weeks, months or years this woman we had grown to care about had left to live, meant shouldering the responsibility none of us were eager to be reminded of – that is, our potential role in hastening her death because of poor clinical decisions based on the wrong prognosis.

A week after her bypass operation, our patient died of a heart attack. The prognosis of her senior surgeon and our entire team — that she would tolerate the surgery and survive long enough to walk again — had been incorrect.

While not all assessments of how long someone has to live result in life-or-death clinical decisions, addressing prognosis remains a challenge for most doctors. And after struggling for several years with determining their own patients' prognoses, a group of physicians at the University of California in San Francisco set out to collect and study all the research that had been done on so-called prognostic indexes, tools that help with determining general prognosis in older patients.

Given the growing use of age-based treatment and preventive care guidelines, the doctors assumed there would be plenty of data to help decide whether, for example, an 80-year-old patient might live long enough to benefit from a colonoscopy, a cancer screening procedure that can have its own set of complications.

But they found little.

Prognosis was rarely, if ever, alluded to in the most popular medical textbooks and on clinical Web sites used by practicing physicians. Even the widely used medical database PubMed, maintained by the National Library of Medicine, had no specific indexing category for prognosis, making finding any published study on the subject like searching for a book in a library before the Dewey Decimal System.

While the researchers were finally able to single out 16 indexes that hold promise in helping doctors predict how long a patient might live, there was"insufficient evidence at this time" to recommend any of them for widespread clinical use. None of the indexes had been tried with groups of individuals other than the initial test group to confirm reliability, and every single one had a potential source of bias. Some studies were never able to follow up on the final outcomes of a substantial subset of patients; others used researchers intimately involved with the development of the prognostic tool, and not impartial observers, to validate findings.

"There's a need for much more research in this area," said Dr. Eric W. Widera, one of the authors of the study, which appeared in The Journal of the American Medical Association. "Compared to diagnosis and treatment, prognosis is like the unloved stepchild of medicine."

A century ago, predicting a patient's life expectancy was an essential part of doctoring. Details relating to the art and science of "prognosticating" occupied a prominent position in textbooks, journals and conversations with patients. That emphasis began to shift as technology advanced, with doctors focusing more and more of their time on treatment and diagnosis.

Economic forces reinforced this new emphasis, as it became clear that while the ability to predict the timing of a patient's death was useful, the tools to treat and diagnose were profitable.

Perhaps even more important, prognosis has now become a potent symbol of the limits of medicine. With a growing array of successful treatments at hand, doctors often have the power to forestall death. But thinking about prognoses means recognizing not only fallibility but also possible culpability.

"Even in the privacy of their own minds, doctors don't like to think about prognosis," said Dr. Nicholas A. Christakis, a professor of medicine and medical sociology at Harvard Medical School and author of "Death Foretold"(University of Chicago Press, 2001), a book on the sociocultural issues of prognosis.

With so little research on how to predict how long a patient might live and few resources to turn to, physicians often end up relying on intuition. But studies have shown that these "guesstimates" can be wildly inaccurate, and that inaccuracy can adversely affect an older patient's quality of life and care. Doctors who are too optimistic may prescribe unnecessary and painful procedures and treatments; those who are too pessimistic may neglect to offer adequate care.

Most current clinical guidelines sidestep considerations about prognosis by relying on simple age-based cutoffs. The United States Preventive Services Task Force, for example, uses 75 as the age to stop routine colon cancer screening. "But age is an incredibly blunt tool," Dr. Widera noted. "We all know of 65-year-olds who are much sicker than some 95-year-olds."

While the authors of the study have created a Web site, www.eprognosis.org, to help physicians and patients access available prognostic tools, they are quick to acknowledge that this interactive tool is only a small part of what doctors and patients need. More work and resources must be devoted to creating accurate assessment tools, testing the reliability of those that exist and teaching doctors once again the art and science of determining, and talking about, prognoses.

"We actually have a moral responsibility to our patients to help provide them with the best prognostic information," said Dr. Alexander K. Smith, another of the study authors. "But somehow, we have lost sight of that responsibility as a profession."

http://well.blogs.nytimes.com/2012/01/19/why-doctors-cant-predict-how-long-a-patient-will-live/?

As Specialists Debate Autism, Some Parents Watch Closely - NYTimes.com

A debate among medical professionals over how to define autism has spilled over into the public domain, stirring anger and fear among many parents and advocates of those with the neurological disorder, even as some argue that the diagnosis has been too loosely applied.

A study reported on Thursday found that proposed revisions to the American Psychiatric Association's definition would exclude about three-quarters of those now diagnosed with milder forms of autism called Asperger syndrome or "pervasive developmental disorder, not otherwise specified," also known as P.D.D.-N.O.S. These are people who have difficulties with social interaction but do not share the most severe impairments of children with classic autism.

"He was right on the border, they told me when he got the diagnosis; that's what scares me," said Amanda Forman of Flourtown, Pa., whose 5-year-old son was diagnosed two years ago with P.D.D.-N.O.S. After receiving play therapy, occupational therapy and 17 hours a week of behavioral therapy, the boy, who was once unresponsive to other children and engaged in self-destructive behavior, may enter a mainstream kindergarten class next year, his mother said. "What if he has to be re-evaluated? If the criteria were stricter, he might not get these services that have been helping him so much."

The proposed revisions, which would take effect in 2013, are likely to have practical implications for those who would once have qualified for services that experts say can improve an individual's abilities to socialize, learn and ultimately live independently. But they have also ignited a broad discussion over the value of a diagnosis for behavior differences, and how to fairly apportion services at a time when resources are shrinking.

The Diagnostic and Statistical Manual, now under revision, is the standard reference for mental disorders, driving research, treatment and insurance decisions. Since 1994, when recognition of Asperger syndrome was first included as an autism-spectrum disorder, diagnosis of the condition has surged.

Over the last decade, the number of 6- to 21-year-olds with autism in public schools has quadrupled, according to the Department of Education. Such students may get private school placement, a classroom aide or curriculum adaptations. In recent years, 29 states have passed laws requiring insurance companies to provide behavioral therapies and other forms of care to people with an autism diagnosis.

"We have to make sure not everybody who is a little odd gets a diagnosis of autism or Asperger disorder," said Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force making the revisions, which are still subject to change. "It involves a use of treatment resources. It becomes a cost issue."

But some autism advocates argue that acknowledging the neurological basis for socially odd behaviors has benefits beyond eligibility for services, promoting cultural tolerance and a degree of self-understanding that may be lost without it.

"Having a diagnosis helps people understand why we process thoughts and emotions differently and make positive changes," said Michael John Carley, director of the Global and Regional Asperger Syndrome Partnership, which urged members to call the psychiatric association to complain. "Sadly, we may be heading back to the days when our differences are seen through the lens of character deficits rather than in the context of brain wiring."

Even within the medical community, the number of people who would not be eligible for an autism diagnosis under the new criteria is a matter of dispute. Some may fall under a new category, "social and communication disorder," though it is not clear what kind of aid, if any, they would be eligible for as a result.

Catherine Lord, the director of the Institute for Brain Development at NewYork-Presbyterian Hospital, and a member of the committee overseeing the revisions, said that the goal was to ensure that autism was not used as a "fallback diagnosis" for children whose primary trait might be, for instance, an intellectual disability or aggression.

She said the committee's own data shows that very few who currently have a diagnosis would be dropped. And another analysis of the effect of the proposed new definition, published this month in The Journal of the American Academy of Child and Adolescent Psychiatry, found that roughly 40 percent of individuals with Asperger syndrome would not be given a diagnosis under the new definition. That study suggested that altering the criteria slightly could recapture most of those who would otherwise be excluded.

Yet some parents of severely autistic children who are nonverbal, and may need constant care to avoid injuring themselves and others, say they would welcome a narrowing of the spectrum.

"Everyone on the spectrum benefits when money and services available are applied more specifically and appropriately to the individual needs of each person affected," said Mark L. Olson, of Henderson, Nev., whose daughter, 16, does not speak. Mr. Olson has argued on his blog that those with more severe needs have been overshadowed by people with the Asperger diagnosis, who have typical intelligence and language development.

Many comments, on the Web site of The New York Times and elsewhere, expressed the view that autism was overdiagnosed: "Come on, 1 in 100 children today?" one commenter wrote. "This pathology did not exist in the past because we did not label it."

And even some parents of autistic children noted in the debate this week that a diagnosis can be a double-edged sword.

"With it, a child gets needed services," wrote one Boston parent, whose son has a language impairment that makes socializing difficult. "The downside is that a child will be perceived by his peers as being abnormal and shunned socially. I noticed a huge change after my son was diagnosed. Once he got the autism label he rarely got birthday party invitations, for instance."

But like many parents, Ms. Forman, who requested that her maiden name be used to shield her son, said she sought the diagnosis only because her son so badly needed the services it would secure.

"I didn't know that feeling was so prevalent, that autism is so overdiagnosed," she said, having read many of the comments on Web sites. "I just know the amount of work I do for him, and that's not something I would do if I didn't have to do it.

"It's not the easy way out for anybody."

http://www.nytimes.com/2012/01/21/us/as-specialists-debate-autism-some-parents-watch-closely.html?_r=1&src=recg&pagewanted=print