Burying Old Ideas


I have an assignment for you good (and bad) people. I wish I could make it manditory, but I can’t. I know it is a pain to click on links and listen to podcasts, but you will not regret taking the time to listen to these two from Freakonomics:

How Many Doctors Does It Take To Start A Revolution (As a teaser, it partly discusses the fact that patients are less likely to die when cardiologists are away at a conference….)

How Do We Really Know What Works In Healthcare? (They share some startling information about the economics of healthcare utilization and reform…)

I am going to leave this up over the weekend and would love, love, love to have a discussion here in the comments for anyone who is interested.

(This was the final day of the Black and White Five Day Challenge, thanks to Cordelia’s Mom, Still. I have to say it was more exhausting trying to figure out who I could pass it on to than actually doing the photos! As for the last nominee, heck… I am gonna tag Gibber.)


80 thoughts on “Burying Old Ideas

  1. Well I listened to the first one about studying outpatient programs to decrease ER visits and hospitalizations. I think they are on the right track. But guess what, this is not new. Because this is what I did as a Visiting Nurse about 25 years ago. Yes we prevented hospitalizations, made sure patients understood their diagnosis, treatments and medications, arranged for dieticians and social services and others to support people in the community. We saved lives. So along came managed care which is private HMOs and guess what, their genius bean counters decided it was too expensive to pay for so many Nursing Home Health visits. I always thought this would lead to more hospitalizations, wound infections, post-op complications, etc. But they were looking at the bottom line. Many insurance companies do have Complex Case Managers. These are usually RN Case Managers assigned to follow a case load of medically complex, multiple diagnoses, chronically ill patients in the community. Many times it is over the phone. Medicare was tracking our outcomes with the Oasis data. I thought we were discharging our patients too soon, in Home Health after the trend for decreased visits, to get an accurate picture of the effectiveness of Home Healthcare visits on outcomes.

    Liked by 1 person

      • Ok I listened to the second one. I am not sure I got the study results clearly. If this was a one time study or were the results repeatable? Also, there are many factors going into the condition of each patient. Were all their conditions identical? There are protocols set up in all hospitals for caring for patients with CHF, MI or Cardiac Arrest. I don’t know about hospitals back East but I think Kaiser here uses evidence based treatments and I would think that all the major medical centers do, like UCSF, UCLA, USC, Cedars, and Childrens among others. Out here you can’t get admitted to hospital that easily and you get discharged pretty fast IMO. Sometimes I think people should be admitted and not discharged so quickly. Insurance companies take a hard look at admissions and length of stay. Medicare is not happy if patients are readmitted within a short time period. Again, readmissions can be prevented and patient education is improved with F/U Home Health visits.


      • Wondering if the studies could be reproduced and get the same data. But there are many variables about the patients. What medications were they taking. Did they have other diagnoses. I think you have to take a group of people with the same diagnoses, same meds, same health status and then treat one group with heart caths and have a control group that is not treated and see what happens. But I think you are risking people’s lives unless you have strong evidence that treatment /tests would cause more harm. My understanding is that medicine is very conservative and they don’t jump to new ideas until there have been several studies.

        Liked by 1 person

      • You are wrong about jumping to new ideas. Medicine jumps quickly to things that will make more money. Not so much to things that don’t. For instance, the Da Vinci robot. Thousands of dollars more expensive per surgery, but patient outcomes? Not really better. People have a desire to believe in the altruism of medicine but in the US at least, that is not the case. I am not talking about nurses or physicians being evil per se. I am talking about the corporatizing of medicine, the MBAs and CEOs…. At any rate, the cardiology study looked at data during two major cardiology conferences over a ten year period. Specifically looking at heart caths they found that there were fewer procedures but the mortality rate was unchanged. This mirrors the results of a study a few years ago that showed that medical management was just as good as angioplasty in patients with stable cardiovascular disease. In this study they examined all sorts of variables including the type of hospital at play. What types of meds they were on does not really matter in this context because if someone is not having a procedure, they will be treated “medically” with drugs. The same drugs that would be used during nonconference times. The overall point here is that we rush to be aggressive when that is not always the right choice. “Do everything!” Sometimes we do that because it is what patients expect. Sometimes there are “other” reasons. We really need to take a step back.

        Liked by 2 people

      • Well it is very hard to have a control group. How can someone withhold treatment to see if the patient can survive without it. I thought the patient is hospitalized because of unstable angina. But am I wrong in thinking that people usually have a stress test before angiogram if they come in with chest pain. I think a lot of stuff is bought because of good sales pitches. Do you have those machine BP monitors. They used to be only used in surgery and L & D and now all the MD offices have the horrid things. I wonder how much those cost for every exam room. They squeeze my arm so tight it is painful and I keep telling them that is what is making my BP go up. I keep reminding myself to ask them to check my BP with the old fashioned manual cuff.


      • You will be happy to hear that we only do manual BPs in my office. 🙂 people go to the hospital with chest pain. It may or may not be angina. In this study the control would be patients who present during nonconference times. Life randomizes so we don’t have to.

        Liked by 1 person

      • I am glad you are using manual only. Your patients are lucky 🙂 Yes I realized about the control in this study. But there was one cardiologist that said you really need to pull apart all the data and compare all the factors to be sure that having a heart cath or other treatment is the only factor. I still can’t be so cynical though to think that heart caths are done to make money. I know they are done to prevent a further or worse heart attack. I think that radio show was mixing up many issues. There are so many “studies” and we need to be able to look at them closely before we automatically accept the results.


  2. Anyone who has been paying attention to healthcare knows that something has gone awfully wrong over the years. My immediate friends and family invest heavily in their own health through diet and exercise and do their utmost to stay away from doctors and hospitals unless it really is an emergency. As a cancer survivor I owe my life to modern medicine but I also know that doctors are the third leading cause of death in the U.S. killing 225,000 patients a year through iatrogenic causes. What’s to be done? Let the discussion begin.

    Liked by 3 people

  3. One reason is that, as a result of a historical accident, healthcare in the U.S. has been provided primarily by corporations offering health insurance as an employee benefit. This results in over-utilization and means that employees cannot apply the same skills they exercise in buying a house or a car, to the purchase of their health plan. If they could health plans would be designed much more carefully to meet the needs of their customers.

    Liked by 3 people

    • The God’s honest truth is I know woefully little about all of this. I know medicine. I can help you with your diabetes or high blood pressure but when it comes to the politics and economics and such, my eyes glaze over and I find it hard to focus. This is true for the majority of physicians which ultimately is going to bring down the profession. I work for one of those big healthcare delivery corporations. They want to get bigger. Much bigger. They are counting on the hundreds of physicians in their employ NOT caring or being too busy to dig deeper. In the end, the patients suffer and they die. I have to change how I am in all of this if I ever want to make a difference because what I see going on around me is wrong. I have to wonder, though, if it will make a difference.

      Liked by 1 person

      • I think you are unusual in admitting your ignorance of these subjects. Unfortunately healthcare is like education, not just because everyone has an opinion about them, but also because most people believe these services should not be subject to the discipline of the market, because they are qualitatively different from other services. However, we all know why we hate going into our local post office and why the service is so bad there. Consequently we don’t need to understand the intricacies of economics and politics to understand why most public schools suck. Similarly, healthcare is one of the most heavily regulated of industries so it shouldn’t take a genius to work out that government is a big part of the problem rather than the solution.

        Liked by 1 person

  4. Too many middlemen and big corporate healthcare is always my complaint. Where I live it used to be just patients and doctors. We didn’t have to worry about what insurance would allow or what hospital dictates demanded. People actually mattered because that is who you were serving.

    Liked by 1 person

  5. If I have to choose between a going to the doctor and a healthy meal I prefer a healthy meal.

    Thing is my hay fever and dust allergies sometimes surpass the symptoms of a mild asthma. I am privileged to live in the Netherlands.

    Yet I am already preparing to stock up on medicine when things turn for the worse. Even in the “quiet” Netherlands certain developments are taking place…

    Liked by 1 person

  6. Pingback: My Article Read (4-9-3015) (4-10-2015) | My Daily Musing

  7. I listened to the first one and as I tried to get my head around the stats I kept coming back to two things. Firstly I don’t live in your world so far be it from me to make a comment. BUT secondly here comes a comment. It’s sort of a segue into my experience. I live in a reasonable sized city (100,000) in Victoria Australia. We have a very efficient medical system and I am not sure if we lack anything much. A few years ago I complained to my GP about a pain in my chest. I’m 72 and both my father and his brother died of heart attacks and my brother has had a stint inserted on the day he nearly dropped of the coil.
    (This may take a while so go and make a coffee)
    My GP sent me to a cardiologist and he subjected me to a stress test. I worked my guts out. I used to be a rower and I don’t give up quickly. He showed me the read-out with red ink circles on particular ares that he found interesting.
    Then he booked me in for an angiogram. I had to have it done in Melbourne 100 kms away. He said that the place in Melbourne was the best. Who was I to argue. I would not be in a condition to drive home so my wife and daughter should book in to a motel. He recommended one within walking distance from the hospital.
    Although most of the costs were covered by Medicare there were gaps to be filled and as I had retired it was a bit of a struggle.
    They found nothing to concern them.
    The pains in my chest continued and my GP suggested a gastroscopy. (I think that’s it) In the end they found a hiatus hernia and my heart problems just went away.
    Now that sounds like a good outcome and you know that diagnosis isn’t always simple.
    However I was a little disturbed when I learned that the private hospital in Melbourne was owned in partnership by my local Cardiologist. AND he also was a partner in the motel I was directed to.
    I would have saved me a lot of money if he had been on a conference in outer Mongolia.

    Liked by 2 people

  8. I read both transcripts (think you should reverse their order, BTW, as I was a bit confused by their reversed chronology–but I am easily confused : ).

    Enjoyed the ticking off discussion of the possible reasons for the heart patients’ improved outcomes. Found it interesting that once the team settled on reason “x” being most likely, they never looked back. Careful there, scientists…

    I’m happy to agree with that too-quick-to-prod reason, though. As you’ll read in one of my own “future” posts (which will actually be a repost of a lupus post written online in 2006 in an early Yahoo website I had.)

    I had not known about the super-consumers of services. Yikes.

    Re: the possible coming revolution Brenner (was that his name?) predicts, hard to say. He may be speaking more from frustration and wishful thinking. Most of us feel so hopeless now to effect change anywhere in corporate-run America.

    However, our nation is now becoming a majority Latino–Mexican. I think the “swing vote” may come from this quarter. Will familias put up with their mamas and tias wasting away in hospital? That has not been my experience, from the few families I’ve seen. I don’t know what the larger experience shows or longer time will indicate. How are cancer diagnoses accepted by Latino men? Is there a difference from non-Latino? Do they undergo treatment, or go home to die, fatalistic with God’s will? Too, all are aware that, regarding any drain of out of pocket costs, an entire easier set of economics awaits south of the border: Medicine, nursing care, etc.

    Not only Latino, but our immigrant population in general, with their knowledge of how things work elsewhere–and how respect for end of life should go–may make a difference.

    What do you think, Victo? Will these things have an effect?

    Liked by 1 person

    • Nope. They won’t. You have generalized in the wrong direction, I think. My experience would be very different. I do agree that it is wishful thinking on this fellow’s part. I doubt that he will affect real change. I also hope, but feel powerless to do much of anything about it… partly out of ignorance, partly because I am not a very good politician.

      Liked by 1 person

      • For me I can justify taking 10 minutes or so to read and comment on a blog post at work, but I can’t multi-task with the listening and working. But these are issues I have thought a lot about and I think I have some decent contributions with my experience auditing clinics, hospitals, and hospital systems. I’m excited to listen to these ideas and talk with people on the front lines (i.e. you and some other commenters) to see what we can come up with; so I WILL come back with comments eventually.

        Next step – how do we go about influencing public policy and the healthcare marketplace as a whole? If only we could, right?

        Liked by 1 person

  9. I misunderstood the instructions. I listened to both podcasts but I thought you were going to have a seperate post and discussion about it on Monday. I don’t know why I thought this. It clearly says something very different in this post. Sigh. I apologize for not paying better attention.

    Liked by 1 person

      • Well. I think at some point the industry of medicine is going to become so expensive due to technology and specialization it will be unsustainable. Prevention is a simple remedy but politically such a hot potato that I don’t know if it will ever be an option. How would incentives work? Would there be penalties for engaging in acts (or inaction) that could be implimented? In Canada, we have universal health care but it costa us about 40% of each provincial budget. It gets more expensive each year. But no one ever talks seriously about prevention. I mean cigarettes are still sold and at $15 dollars a pack the government is making massive amounts of money off something that will kill people.
        I aslo found it astounding that the overall concencus was that most doctors are unable to critically think. But this would explain how for instance that my wifes breast cancer symptoms were dismissed as menopause (she was 46). She was patted on the head and told not to worry. Of course my wife immidiately talked to her sister who is an oncologist and Karen told Maureen she had breast cancer. Appointments for mamograms, ultrasounds, and biopsies, were set up. Karen took over Maureen’s treatment and the her GP is basically a thing to write her prescriptions. I get the sense that the GP has a chart with symptoms and corresponding medications, and anything outside that would require critical thinking skills that they do not have. Of course they aren’t all like that, but most Dr.’s I’ve had dealings are like this. I keep myself very healthy because of this.


      • There are already penalties on Heath insurance in the US for smokers, the obese, people with elevated blood sugar and blood pressure. And you are right about medicine being reduced to a bunch of protocols, eliminating critical thinking.

        Liked by 1 person

  10. I read the transcript of the second link. Forgive me, but what they are discussing here is Social Services, of which some components are Medical Services (and good ones I might add). It was a bit startling to read of economists looking for ‘randomized controlled trials’; although they did get a good stab at that with the Oregon Medicare expansion lottery. It will be interesting to see what the long term data shows there, and if anyone goes back to study it. What no one touches on is WHY people needed a Medicare expansion – medical costs continue to ratchet stratospherically while the average person’s paycheck remains flat. This impacts employers too.

    (drags out soapbox) The entirety of health care is corporatized, something unheard of until really the HMO Medusa appeared. What does it say about us when we have economists, think on that, studying and looking out treatment/patient outcomes? Poor health is draining all economies near abouts; bundling it with Social Services places an overwhelming financial burden on all systems. Can we blend the funding for both within our already over-extended, trillion dollar government debt? It is fantastic that the follow on in-home care dropped costs; but the ones profiting from this miasmic thing currently labeled ‘health care’ really don’t care about cost-savings or better patient outcomes. They care about their continuing revenue streams, regardless of the private or public pockets from which it leaches its lucre.
    (soapbox away)

    That said, it was extremely interesting about what was admitted about not knowing what works. What was saddening was the lack of self-involvement in care that was represented in the one home care example. Why do we hand over our bodies so easily? Where is our own responsibility? Where is the food manufacturer’s responsibility? It seems a Sisyphean task to try and fix one part of a multi-part, multi-responsibility failing system (personal health of citizens, regardless of country) while so many opposing interests are at the table!

    Glad you promo’d this Victo. Interesting read.

    Liked by 1 person

    • I highly recommend you scroll through the other transcript, too! The Medicaid thing in Oregon proved something that physicians have been saying for some time. How do you balance helping the lowest income people without bankrupting the system from unnecessary utilization? That is the real puzzle. We know the problem, now let’s find a solution! It will take someone smarter than me to figure it out, though, I am afraid.

      Liked by 1 person

      • I wonder if anyone has looked at those statistics (super-utilizers) when it comes to a baseline of insured average people. I know tons of people that go to the doctor far more than I do, and use tons of services. I don’t think super-utilizers are limited to one socio-economic group personally. I’m one of those healthy people paying premiums to cover the cost of the sicker ones 🙂

        I think it is like water availability, for an analogy. When water is always available, people use it with impunity. When it becomes scarce, usage often changes even without enforce watering rules.

        If the poor have been without services due to lack of affordable care, do they bunch up on a lot of things once they have care? I know non-poor people that jumped into the fray quickly once they had affordable care (mostly self-employed people). They caught up on things they would have done had they not been so costly. So I wonder if the data will continue to play out over time once the availability is constant. Just a thought. It is a business constant too – 20% of your customers will take up 80% of your time/resources.

        I’m reading the second one now, when I should be unpacking more stuff 🙂

        Liked by 1 person

      • When people are responsible for a higher portion of the bill (higher copay for ER services vs out patient treatment) they pick the cheaper. When either service is free or equal charge for the consumer then they will pick whatever. I am not sure why they picked ER over outpatient as in theory the amount of time in ER would be significantly more than an outpatient. I don’t know if there is a perception that the care is better somehow? The catch up you allude to does happen but I have had Medicaid patients demand that I order a CT scan for benign abdominal pain simply because they would not have to pay for it. Asking low income to pay a portion for it? If so, how much? It is right to ask the lowest income citizens to that? No. So how do you influence choices?

        Liked by 1 person

      • Is is possible ER use is chosen because of work/life balance? My working children will take an ER visit because they can go after work, over trying to schedule a peds visit, particularly in an acute situation. But their children are sick more often than they themselves were, an have a lot of unusual stuff occur that I never dealt with when raising them. I think that is one aspect that might be looked at – ER is there 24/7.

        Ordering/requesting unneeded services because they are ‘free’ to the recipient is on the line with people suing after car accidents on the advice of a lawyer, imho. No one seems to put two and two together that EVERYONE pays more when the system is manipulated like that. Free is never actually free; someone, somewhere is absorbing that cost. No one thinks like that. Never mind that doctors lack critical thinking skills, it is darn near impossible to find within the general population, too.

        We as a society now feel like we have a ‘right’ to so much, with a huge lack in the responsibility realm. And insurance companies drive that I feel. My GP gives me no grief on what I decide I want as preventative care, and actually agrees I don’t need most of what is offered as ‘free’ services. But my insurance company penalizes me for not doing them. I realize that you and I may have a wide variance of opinion on this, so I’ll tread lightly. Every service, even if included (their verbiage) in ‘preventative’ isn’t called for within every person’s risk pattern. And I take responsibility for what I leave on the table for others; it is my choice, my body.

        So while I think everyone should have affordable access to ‘care’, my opinion on what constitutes care varies wildly from what our health consumer market leads us to believe is our ‘right’.

        As to influencing choices? Turn off the television for one, lol! People want to be led, so they can blame someone else. I’m sorry, I don’t feel it is my responsibility as a taxpayer to pay for someone to sit on the couch and scarf two boxes of Twinkies and a 2-litre soda and surprise! you’ve got diabetes. It is such a huge power pyramid though, from advertising (food), to food (how it is made and delivered), to our lifestyles..gyahh. You wanted to fix which portion again? 😀

        Education would help, but everyone is too busy to even read their child “Goodnight Moon”, are they going to teach them that the food pyramid is wrong and we can’t always have four candy bars and a soda to wash them down with? That we should run and play and get a little sunshine on our bodies instead of sitting hunched over in front of X-Boxes and computers (guilty!)? Parents don’t even know what is right, wrong, healthy, bad anymore. We’re decades into packaged foods, how to make more with less (unless it’s GMO corn, that’s everywhere). It’s not simply health care that is broken, it is health itself.

        Ooops, I think I ranted…LOL!

        Liked by 1 person

      • Convenience is not such an issue I would think. I have worked some nontraditional hours to accommodate that sort of thing. So do my partners. Acute care facilities are all over the place, though none seem to take Medicare (the government has made it too burdensome). I wonder if that is the case for Medicaid? I will have to check on that. 6hrs in an ER vs 45 min in an outpatient setting? Meh. As for preventive care? I am going to do a flu vaccine post soon. That ones makes me kind of angry. PAPs are every 3-5 years by current guidelines and stop after hysterectomy or age 65. Mammo’s start at age 50 and are every two years by USPSTF guidelines. Many physicians have their income tied to having their patients do these things, so they can be very pushy. For years I was told that I had to prescribe aspirin to all of my diabetics over the age of forty despite evidence saying that was too young. It counted against me each year, refusing to follow my employer’s set guidelines. That is just plain stupid.

        Liked by 1 person

      • Wow, that was an eye-opener! Do you think there will be a hit squad for him, or some type of reputation smear? How wonderful to hear yet another within the system point out what some of us outside know. But fear-mongering is constant within the insurance industry, and supported by the pharmaceutical industry, and so on and so forth.

        I have such respect for scientists, doctors, researchers who are willing to take a stand. If he wasn’t in Jersey, I’d volunteer for his Coalition when I retired 😀

        Liked by 1 person

  11. My biggest surprise were about the lack Evidence Based Medicine and critical thinking – that was the opposite of what I would have expected.

    On the same subject, I thought Jeffrey Brenner’s remarks on med school incomplete. Not that I disagree with him, but, by ignoring the need for a minimum of science to get into med school and also ignoring residency, he reduces the education of a doctor to two years of memorization and yes-manning. On second thought, maybe I do disagree with him – critical thinking is a skill that should be taught to everyone pre-university.

    Liked by 1 person

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