Wednesday, June 24, 2020

Do We Need Less Health Care?

We have all heard the stories about people who have been deprived of health care because coronavirus patients have monopolized medical practices. Also, in a time of social distancing it becomes risky to see a doctor.

Dr. Sandeep Jauhar understands this problem well:

Admittedly, postponing health care had terrible health consequences for some patients with non-Covid-19 illnesses, such as those with newly diagnosed cancers that went untreated because outpatient visits were canceled, or because patients avoided going to the hospital out of fear of contracting the coronavirus. The spike in deaths in major cities like New York during the crisis almost certainly includes such patients.

And yet, Dr. Jauhar points out, less health care has not produced worse health for most people. Clearly, this is bad news for the bottom line.

For months now, routine care has been postponed. Elective procedures — big moneymakers — were halted so that hospitals could divert resources to treating Covid-19 patients. Routine clinic visits were canceled or replaced by online sessions. This has resulted in grievous financial losses for hospitals and clinics. Medical practices have closed. Hospitals have been forced to furlough employees or cut pay.

Most patients, on the other hand, at least those with stable chronic conditions, seem to have done OK. In a recent survey, only one in 10 respondents said their health or a family member’s health had worsened as a result of delayed care. Eighty-six percent said their health had stayed about the same.

10% of patients report that their health has suffered under the new rules. 90% report that they are doing just fine. Dr. Jauhar considers why this may be so:

Still, a vast majority of patients seem to have fared better than what most doctors expected. It will probably take years to understand why. Perhaps patients mitigated the harm of delayed care by adopting healthful behaviors, such as smoking less and exercising more. Perhaps the huge increases in stress were balanced out by other things, such as spending more time with loved ones.

Given these possibilities, another possible explanation pops into view. What if Americans overuse health care? What if they are abusing the system? Or better that the system is designed for such abuse?

However, there is a more troubling explanation to consider: Perhaps Americans don’t require the volume of care that their doctors are used to providing.

What kinds of care are considered wasteful? Some of it involves avoiding lawsuits. One notes in passing that getting lawyers out of the health care business would be the quickest and easiest way to improve the cost efficiency and the effectiveness of the health care system. Naturally, the lawyers in Congress are not proposing this reform. 

Wasteful care is driven by many forces: “defensive” medicine by doctors trying to avoid lawsuits; a reluctance on the part of doctors and patients to accept diagnostic uncertainty (which leads to more tests); the exorbitant prices that American doctors and hospitals charge, at least compared to what is charged in other countries; a lack of consensus about which treatments are effective; and the pervasive belief that newer, more expensive technology is always better.

And, strangely enough, some illnesses get better by themselves. 

Studies suggest that up to 20 percent of surgeries in some specialties are unnecessary. If your surgery was postponed because of the pandemic, it is worth having a conversation with your doctor about whether it is still needed. Despite the complexity of disease today, ailments sometimes do get better by themselves. And in some cases, scheduled surgeries weren’t necessary in the first place.

Heath care in America costs too much. Naturally, the Democratic approach is to nationalize it, to have the government pay for all of it. Republicans tend to prefer a free market approach, though they do not seem very clear about what that entails. No one seems to be thinking as Dr. Jauhar is: to the point that most of the health care people receive is either superfluous or overly defensive.

It's the economizing, stupid.


Anonymous said...

Look up the number of iatrogenic deaths in the US every year. This year that number will be much lower.

Stuart Schneiderman said...

For those who don't know, iatrogenic deaths are deaths produced by medical examination or treatment.

Paul said...

It would be interesting to see this broken out into men and women (and probably group children with women). Anecdotally, men need to be at death's door before we go to the doctor. Women (and especially mothers with their children) go much more. So if medical care is limited by the pandemic, you would expect the effect on male mortality to be much less changed.

David Foster said...

Not sure how much you can tell from less than a year's worth of data. Many medical conditions have a lag time before lack of treatment will show up in higher mortality rates.

You can get away for a long time without changing your car's engine oil, but sooner or later, the effects will show up.