walkitout (walkitout) wrote,

health care musings

I'm in a bad way here: I'm halfway through two books and I just opened a third. This tends to happen when something about a book is bugging me, and I can't figure out what it is, so I put it down and read something else. In this case, since I stayed on topic, something (maybe the same thing) bugged me about that, so I put it down and picked up a third book. There _will_ be real reviews posted later on for the first two of these (the third is a reread), but in the meantime, I'm going to try to explain what's bothering me.

The first book (the what-was for nursing and home care) I stopped shortly after reading the wind up of visiting nursing with Metropolitan Life Insurance ending its visiting nurse benefit. MetLife (this was _life_ insurance, not _health_ insurance) justified its benefit on the basis that the visiting nurses could take a _healthy worker_ (this was their weekly-premium product aimed at industrial workers) who had suffered an acute health problem (accident or illness) but who would be helped by nursing to return (quickly) to productive labor -- and therefore continued premium payment and NOT a death payout. Their statistical evidence in support of the benefits of this service were, er, suspect, but it definitely helped their PR (which really needed it, because they were being investigated for some fraud, abusive marketing, etc. when they originally set it up), supported sales of their industrial worker product and was a nice thing to do all 'round.

They discovered what, as near as I can tell, _everyone_ discovers who collects health care statistics over time.

(1) A small amount of care for pregnant women/new mothers is really worth while, but more is not better, and certain particular scenarios create black holes for money. In particular, for them, midwifery services that did a lot of visits for blurred vision tended to consume large amounts of resources without much benefit to show for it. Think HELLP -- it was a problem then; it's a problem now; we still have no mortal clue what to do about it.

(2) A small number of visits for acute health problems (accident or illness) can have benefit. Again, more is not better.

(3) Chronic illness (diabetes, for example) is something you really want to unload as a problem on to Someone Else.

While I was digesting this, here's what started to bother me. Whether it's a home-care visiting nurse thing, or office visits through national health care, or a skilled nursing facility or whatever, whenever you have a patchwork of services with a variety of payers and rules and what-have-you, everyone will expend a certain amount of additional energy attempting to (a) get more for themselves and (b) unload the cost onto someone else. Kind of inefficient.

I picked up _Clinical Decision Making_ by Eddy, because this was clearly his deal, and I'm halfway through it and within the context in which he is writing, what he says makes sense. Here's my problem: the context is way, way, way past insane. (If you are a friend of this man or, please no, the man himself: I'm _not_ slamming you! You are Teh Awesome! Everyone Should Read Your Book! Etc.! Really! Back to the insanity...)

Several of Eddy's chapters are essays originally published elsewhere; they explain how to create and communicate practice guidelines/standards. He uses a particular pair of "treatments", where treatment is interpreted loosely enough to include screening, to explain basic ideas involving calculating effectiveness with or without dollar costs (benefit vs. harm in terms of morbidity/mortality and/or translated into cost of services/value of life, etc.). The pair of treatments are high-dose chemotherapy with bone marrow transplants for women with metastatic breast cancer vs. pap smears for cervical cancer screening.

There are a couple of twiddly problems here. Screening someone for cancer does _not_ cure them of cancer, so you can't compare a screen cost to a treatment cost on that level; you'd also need to factor in the treatment cost. I _don't_ think it would impact the end result (way more worthwhile to do pap smears that high dost chemo!), but it bothered me that I don't see any recognition of the idea that screening people doesn't cure them. When put that way, it sounds pedantic and loony, but it is a fairly common bit of confusion. There's also the issue of how the metastic breast cancer was diagnosed -- there are a lot of costs before that point. I'd feel better about this comparison if it were "lifecycle" or at least "disease cycle" analysis.

Here's another way of thinking about it. Is it more cost-effective to fill a cavity or to give someone antibiotics for pneumonia? Those are much more likely to be "standalone" treatments: someone walks in with a problem that is identified in a single visit, fixable with a "single" treatment (scrip for antibiotics or drilling and filling -- altho it's worth noting that the antibiotics would have to be taken orally over a period of days in all likelihood).

The other thing that bothers me is that as clear cut as pap smear testing at some interval (probably 2 years, maybe 3) for women within a certain age range who have at some point been sexually active is, there are still a surprising number of problems with pap smear testing, particular once you've had one non-squammous blah blah blah result but no cancer upon further testing. (Go read Welch's excellent _Should I Be Tested for Cancer?_ for all the gory details.) While I still think pap smears are worthwhile (and, for the most part, so does Welch), when you get into some other kinds of testing that seem clear cut and obvious (mammograms for women in their 40s, for example), this kind of problem gets worse, and when you get to PSAs, you are definitely in a Very Bad Place.

While good analysis (and the kind of analysis that Eddy is proposing is _excellent_) will catch this stuff, it can only do so if you go looking for the right stuff and/or notice it happening later. AND EDDY KNOWS THIS! He supplies a balance sheet as a way of presenting the tradeoffs, and his balance sheet for cancer screening _fails_ to include the possibility that catching cancer earlier has a downside -- in his sheet, it's only good. This is a hideous error, and I don't think he should have made it altho everyone else made it too, so DO NOT BLAME HIM. We knew then -- and we know now -- that people die of one thing while harboring other things and cancer is definitely in the other things category. Over time, screening for cancer has made increasingly obvious that if you get the interval and sensitivity down to the point where you will really and truly catch the horribly aggressive nasty cancer that will cut some poor 38 year old suburbanite down in their prime, you will _also_ be catching hundreds if not thousands of other early cancer that won't kill anyone EVER no matter how long they live with those cells -- and if you treat any interesting fraction of those people, you will have killed dozens of people to save the 38 year old. Assuming you _did_ save the 38 year old.

So that's a problem.

There's also a big problem in the how-do-you-convince-people discussion. Eddy consistently veers away from really trying to communicate effectiveness analysis (with or without cost information included). He figures that if you present the information and method consistently and clearly, time will fix the communication gap for you. He's just wrong here. I think he was hoping that as we all go to the wall and realize there really are resource limits, we'll pick fine-tuned limits -- like effectiveness analysis -- rather than blunt limits -- like pay for performance or limiting who has access or whatever. He's just wrong there, too.

Leaving alone, for the moment, the screening-for-cancer issues, I'll go back to the problem of high-dose chemo with bone marrow transplant for metastatic breast cancer. It has taken quite a long while, but we seem to finally have come around to the idea that This Shit Does Not Work. Oh, there are still people out there willing to offer the treatment, and thanks to a lot of pressure through legislatures and the media, insurance companies who will cover it, but this stuff just kills you quicker and more painfully and saves no one. Maybe net no one. Probably negative no one. It's quite possible that if you have metastatic breast cancer, your odds of full remission are much higher with no treatment at all than with this particular treatment strategy (altho people were, at least until recently, still gilding that turd in hopes of salvaging something from the decade or more of Teh Evil, a sunk costs error if there ever was one). Eddy's articles and book were written back when this debate was still quite lively. In fact, years after Oregon finally passed its "rationing" system, Oregon was pressured into _covering_ this treatment, which just goes to show that anyone who thinks they can fix this system is insane.

Which brings us back to the Insane Context issue. And the third book, which is Ivan Illich's _Limits to Medicine/Medical Nemesis: The Expropriation of Health_. I'm going to quote a bit from the Preface to the 1995 edition.

"I am not a nurse and, emphatically, I do not care about health. I teach about the history of friendship and the history of the art of suffering...You study the quality of healthcare. What is it you focus on: is it the delivery of services or of messages? I would like to distinguish between those among you who want more, better, cheaper and less degrading services for more people, and others who want to do research on pathogenic myths and certainties that result from financing and organizing health care rituals."


"With my description uncovering clinical, social and cultural iatrogenesis, namely, the production of multiple misery, I did not target the medical establishment for reform. I used medicine as a paradigm for any mega-technique that promises to transform the conditio humana. I examined it as a model for any enterprise claiming, in effect, to abolish the need for the art of suffering by a technically engineered pursuit of happiness...By reducing each person to 'a life', bioethics is helpless to prevent total management of the person, now transformed into a system."


"That is the reason why I am worried by the fact that most of the current sales of _Limits to Medicine...are bulk orders from medical schools...You can obliterate the experienced sensual body of the past by conceiving of yourself as a self-regulatory, self-constructing system in need of responsible management and, in spite of this disembodiment, claim that you stand within the tradition of the art of suffering and the art of dying."

The problem I was having with the excellent books I was reading was perfectly identified here, in a book I read the last time I was pregnant/had a newborn, but which I apparently still haven't fully understood. You know: all those things you have to learn like ten times before you see them coming instead of recognizing them after they've run you down? Again?

I hate that health care sucks. I want it to be better. I'm pretty analytical, and therefore very tempted by Eddy-style analyses. But I have some basic beliefs about medicine that are not compatible with thinking this can ever be "fixed". One of which is that there is no such thing as medicine with no bad effects. Because everything has bad effects (and you probably won't know what they are until too late), it's best to just muddle along without whenever possible. (That's not always possible!) And it's really not so bad having chronic health problems, in fact, it's a lot better to you find some way to live with whatever's bugging you, than spend all that time and trouble trying to fix it and just swapping symptoms around endlessly.

But whenever I try to _explain_ the Right Way to Live (do what your body tells you, kind of thing), I use the language that Illich decries -- that the body is a system, that you can be responsible about managing it, and that you can talk this way and think this way and still think you are somehow part of the living past. I hear these words come out of my mouth and go, no that's not what I meant to say. But the process of saying it in a way that I think other people can hear it changes its meaning and not in a subtle way. Instead of I am my body and I do stuff, I talk about having a body and taking care of "it". I don't _mean_ listen to your body. I _mean_ Do the Next Thing. But I don't think that latter one can be heard -- and usually it isn't heard the way I meant it anyway. Instead, I'm stuck with behave-your-way-to-whatever, which is not what I meant either, but might lead a person in the right direction -- and might just sent us all further into the morass.

Well, I suppose it's inevitable, and we can blame the theologians for confusing being a soul with having a soul, because everything that happened afterward was inevitable. I suppose I should be grateful we're not building pyramids. (But at least those people understood that if you really think you're going to live after you die, you'll need food and other goodies, too.)
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