2010 Potpourri XLII

One of the difficult problems around end-of-life care is the inability of many patients to make decisions for themselves.  Some have advance care directives, but even those often don’t address every situation.  Surrogate decision-makers, usually family, are often called upon to make decisions.  A commentary in the Journal of the American Medical Association describes a new model for helping these surrogates make their decisions.  The model focuses on having the surrogate use their knowledge of the patient’s values and beliefs to identify what the patient would likely have decided.  (JAMA Commentary)

A study published in the journal Demography finds that while Americans may be less healthy than similar people in England, we live as long or longer.  No causation is implied!  People aged 55-64 in the US have more chronic disease than people that age in England but similar mortality rates.  For people over age 65, Americans continue to be sicker but actually live longer.   The authors hypothesize that this is due to better health care in the US in terms of treating chronic disease and identifying it earlier.  The researchers also suggested that the relationship between poverty and health is not that being poor causes health to decline but that being in bad health means you earn less and accumulate less wealth.   (Demography Article)

The state of Illinois commissioned a study related to its physician workforce.  It found that half the doctors being educated in the state were choosing to practice elsewhere.  One of the primary factors was a perceived bad environment for malpractice in the state.  The Illinois Supreme Court recently ruled the malpractice caps that did exist to be unconstitutional, which has raised the likelihood of being sued and malpractice premiums.  Having fewer doctors available exacerbates access problems, particularly for poorer residents of the state.  Illinois, however, has undoubtedly made the tort lawyers happy, and provided them with more money to give to politicians.   (Ill. Study)

Rep. Paul Ryan and Alice Rivlin, a former Congressional Budget Office head, have combined on a proposal to radically change Medicare.  Starting in 2021, new Medicare eligibles would receive a voucher that they could use to purchase a private health insurance plan.  The age of eligibility would also be increased gradually.  Eventually, Medicare would become a fully voucherized plan.  The amounts of the voucher would be capped at near the rate of GDP growth.  Changes would also be made to out-of-pocket amounts.  The CBO estimates that the changes would reduce the deficit in the next ten years by $280 billion.  The reductions would probably be even greater after than.  The only problem with this proposal is that it isn’t implemented soon enough.  This is the kind of radical solution that is needed if we are really to tame government health spending.   (CBO Letter)

Mercer weighs in on its view of employer health plan costs.   According to its survey, costs per employee have risen 6.9% in 2010 and will rise around that much again in 2011.  The cost increase would be higher next year, but employers have lessened it by benefit design changes, which generally amount to more cost shifting to employees.  Mercer found that cost increases were actually higher among larger employers, which may be a result of generally richer benefits.  CDHP use continues to spread rapidly, as does use of wellness programs and incentives.  Retiree medical plans are vanishing.   (Mercer Survey)

The Minneapolis Star Tribune has an op-ed on the role of prices in the increase in health spending in the US.  Research decomposing the source of cost increases has consistently found that this is more of a unit price issue than one of utilization, back to seminal work by Uwe Reinhardt.  As the article points out, the new “reform” law does nothing to really address that issue and provider consolidation will likely make it worse.  Suggested remedies like a public option, however, won’t fix the problem, because these large provider organizations have such significant political power that they will be able to demand and receive ongoing price increases.   (Star Tribune Story)