Let's not Sugarcoat it...

The Incentrive Structure of our Medical System is Making People Ill

In 2004, The New York Times covered a program called Pursuing Perfection which helped medical practitioners in Bellingham, Washington help patients with diabetes and chronic heart failure mitigate their symptoms, while preventing others from developing them altogether. They employed best practices for counselling patients, nutritionists, nurses, clinical specialists who knew their case and helped adjust their medications according to their needs. Not only did the program help many patients, but it saved Medicare and private insurers thousands of dollars per patient on treatment. Unfortunately, the program was, “killing the local hospital,” in the words of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, having cost it $7.7 million in lost revenue between 2001 and 2008 in payment from hospital visits.

I have been arguing that the incentive of our healthcare system is bound to ensure people get charged more and more for getting sicker and sicker. She seems to agree: “Doctors and hospitals don’t neglect to treat diabetics properly because they are lazy or incompetent or don’t care about their patients. They fail to do it in part because the payment system punishes them financially for doing so.”^[1]

“This is the sorry state of American health care,” Brownlee concludes, “Doing what’s best for patients is bad for business… The problem here is… the money flows through the system in the wrong way. Hospitals are paid for each episode of care, each hospitalization, and doctors are paid for each office visit, each procedure. They aren’t paid to coordinate the care of diabetics or heart failure patients, to hire nurses to track a patient’s weight or make sure his lungs aren’t filling up with fluid, or a nutritionist to help a diabetic understand what she can and cannot eat. In order for programs like Pursuing Perfection to succeed, hospitals must work will all local doctors, not just those who are willing to lose money in order to help their patients. The way to do that is to pay them as if they were a single, integrated group, hospitals and doctors working together. But that’s not how we do it. Instead, our insurers pay the hospital one fee and the individual contractors who work with in it-the doctors-another…”^[2]

It's worth closely studying successful diabetes-prevention programs like these because type 2 diabetes is usually earned. What’s more, sufferers are more susceptible to just about everything else.

In the Netherlands Dr. Sijbrands, a diabetes specialist at Erasmus DC, one of the largest hospitals in Europe, was concerned about how he could serve his patients better. Many of the inhabitants of the city were immigrants, and it was hard to consult with them because 70% of diabetes outpatients didn’t even speak Dutch. With the support of the hospital, he was able to invent “diabetes stations” nearer patient’s houses where they could administer tests on themselves. Personal guidance and instructions were given in their own language by a computer. They were able to see for themselves what progress was being made. Any worrying results were flagged up quickly with their doctors. As a result of a test there was a 70% reduction in those patients visiting the hospital. As it turned out a lot of people much preferred visiting the machines over going to see a doctor.^[3]

In the 1990s the Diabetes Prevention Program Research Group ran a study on over three thousand people judged to be at a high risk of developing diabetes. One group received standard lifestyle recommendations plus metformin (a blood-sugar lowering med), another received standard lifestyle recommendations plus a placebo, and a third received intense counseling about healthy diet, exercise and behavior modification plus a placebo. At the end of the three years, the people assigned to the intensive-lifestyle-modification group lost an average of twelve pounds and took significantly more exercise than the others. The usual objection people have to these kinds of programs it “they’re expensive!” The cost for each healthy year of life gained was put at only $1,100.[4] Usually, the expense of adding a year of life to a chronically sick person runs up to $150,000 a year!

The cynical mantra that “people just aren’t willing to change” might well be true in a society where people are just fobbed off by their doctor with glib instructions to“drink less, stop smoking and cut down on the calories,” but so long as our medical institutions are costing us an arm and a leg we should be demanding more from them. Two randomized studies to test of the effectiveness of counselling people at higher risk of developing diabetes showed overweight patients randomly assigned to receive exercise and weight-loss counselling were 50% less likely to develop diabetes then the people who were randomized to receive no counselling.^[5] Some people may indeed not be willing to change, but there are those who clearly would given the right support. In the system of the future healthchare must become a social affair.

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[1] Brownlee, S. (2008), p279

[2] Brownlee, S. (2008), p279-280

[3] Bartholomew, J. (2016) “The Welfare of Nations” Cato Institute, p50-51

[4] (2002) “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin,” New England Journal of Medicine 346, no. 6

[5] J. Tuomilehto, J Lindstrom, J G Erisson, et al. (2001) “Prevention of Type 2 Diabetes Mellitus by Changes in Lifestyle Among Subjects with Impaired Glucose Tolerance,” JAMA  344:1343-1359