Tuesday, June 16, 2009

Chronic Disease Costs Out of Control

We absolutely need health care reform and we need it now. A new study shows 3/4 ($1.7 trillion) of all U.S. health care spending in 2007 was related to treatment of the 7 most common chronic diseases. They are cancer, hypertension, mental disorders, heart disease, pulmonary conditions, diabetes, and stroke.

Forty five percent of Americans have at least one of these conditions and 26% have multiple conditions. These patients receive clinically recommended preventive care services only 56% of the time. Here is a jaw dropper...every thirty seconds a limb is amputated as the result of diabetes. That leaves a patient who is unable to work and is probably in an electric wheelchair and still has the other expensive health conditions that are associated with diabetes.

I see so many red flags here I just don't know where to begin. First of all...look at the list and then look at the rising incidence of childhood obesity. Unless we get a grip on this, those kids are going to have chronic problems by the time they are 30.

Why does anyone still smoke? Is there any value to tobacco farming (except for the farm cartel?) Cigarettes should cost $100.00/pack, since we live in the land of the free and don't want to ban them all together.

Why does Medicare pay lucrative rates to doctors who perform procedures (colonoscopy, stent placement, removing moles, passing scopes,) and doesn't even cover business cost for primary care physicians that take care of the people with multiple chronic conditions? The primary care "crisis" has been growing for the past 10 years and nothing has been done to change payments or to address the shortage.

Why is there a shortage of psychiatrists and why are mentally ill people living in homeless squalor? Our jails are filled with mentally ill people and we are happy with "out of sight, out of mind." The prison budget has bankrupted California.

There are solutions to these problems but our fragmented health delivery system will not work. The financial incentives to "pay more for doing more" episodic treatment is pushing us over the edge. We don't need one more dermatologist who does Botox, we need thousands more primary care physicians who work with care teams and are well paid to develop systems of interrelated care. Every time a patient has to go to an Emergency Department because they don't have a doctor or cannot see their doctor...we have failed.

Health care reform means "reform". The special interest groups (AMA is one of them) would like to see status quo for their interest.

The housing/banking crisis will look like a rainstorm, compared to the health care crisis flood that is looming with the baby boomers hitting Medicare age.


m.scott said...

Dr. Brayer:
Can you provide the source of your statistic on diabetic amputations? While I don't question that the problem of diabetes in the US is rampant, I do question whether there are really 1,051,200 amputations performed each year (1 every 30 seconds).

Toni Brayer MD said...

m. scott: Yes, the reference is as follows and it is global, not just U.S.:

Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The Global Burden of
Diabetic Foot Disease.The Lancet. November 12, 2005; 366 (9498): 1719–1724.

HugeMD said...

I agree. I am overwhelmed by the problem. The solution comes down to primary care docs. But, to do primary care well, it's a 24-hour-a-day job. And the pay for doing it is worse all the time. And you have to see patients faster and faster to make that lower salary. But yet you have more and more to accomplish in each visit, but with less help due to budget cuts.

I'm not a lazy person, but I gave up. I was sacrificing my own health. I do urgent care where I can do what I can to help but still have time to sleep and see my family and work on making myself healthier. I feel like I sold out in a way, but I couldn't find a place where I could be supported to do primary care in a the way I felt it needs to be done with time left over for my own health and sanity.

I don't know that our government is going to come up with the right solution to all this. I don't know that the right solution exists.

The one place I saw primary care work the best--a tiny rural clinic owned by a PA and where two of us docs each went once a week. The staff all knew all the patients well. They had automatic systems in place for everything. The billing folks kept track of all the little details of billing and coding that we couldn't.

I'm fairly pessimistic that our healthcare system can be fixed. I kind of think that as it gets worse, more and more docs will "opt out" and open their own little places like this, which I think may give better care in the end than the huge multispecialty groups that have so much bureaucracy.

Beastarzmom said...

with one caveat - I'm sure my psych sister would love to treat some of those patients who are sitting on curbs not being treated, but they are mentally ill and do not follow through with care. Not sure we can blame that one on our health care system.

m.scott said...

Thank you Dr. Brayer. I knew that you could back up the figures, but they are still astounding when you carry it out over a several year span.

Of course, this was not the real point of your article. As someone who is just a healthcare consumer, I am wondering what hope there is for those of us who do not live in the rural PA type clinic that HughMD cited. I am an independent consultant, and thus, must carry my own heath insurance. The only way to make this affordable is to choose between accepting a high deductible, or severely curtailing the services that my plan will cover. In either case, day to day health maintenance directed by my physician becomes less and less of an viable financial option.

My only hope is to contract some catastrophic illness or injury and then, while hospitalized, finagle some routine medical care.

Sad that we consumers have to scramble to find financial viable healthcare solutions, while at the same time, trying to find a financially strapped physician who is available to treat us.

Funny thing though, we just don't seem to hear about the insurance companies needing any bailouts. Guess they're doing just fine in this difficult economy.

KM said...

m.scott: AIG Insurance needed a BIG bail out.

Cecilia said...

I agree with this post wholeheartedly, Dr. Brayer, but I kind of resent your comment about the farm cartel. Here's why: I went to school in Wisconsin, in a small town that consisted mainly of family farms. These farmers' primary crops are corn, alfalfa, and soy, but I knew more than one family that simply could not keep their farm in the black without growing some tobacco. Tobacco is a "cash crop," in the worst sense. The tobacco harvest is dirty, hot and difficult work (I say this as someone who has participated), but the money is so good that farmers still do it. They literally can't afford not to. Now, I realize that the primary tobacco growers in this country are not family farmers. The family farm is on its deathbed, and I lament this fact. But it seems to me that if family farmers were able to make the kind of money on soy and corn that they make on just a little bit of tobacco, the problem would be ameliorated. I'm not sure jacking up the price of cigarettes would solve this problem for farmers. Might actually make it worse, if tobacco becomes concomitantly more valuable. I think policy surrounding agriculture in this country needs to change on a large scale. If that kind of change happens, if growing tobacco is no longer so much more profitable than growing food that small farmers see it as necessary for survival, it seems to me that we will have solved several problems at once. Just my two cents on an issue that's close to my heart!

Raymond Bouchayer said...

I do not think that politicians will want to loose making all the money they have ...health care reform ?
Under Senate ethics rules, Coburn can't accept money from his patients.

-- Gregg, R-N.H., disclosed $250,001 to $500,000 in drug maker Bristol-Myers Squibb Co. stock and $1,000 to $15,000 each in stock in pharmaceutical companies Merck & Co. and Pfizer, the Johnson & Johnson health care products company and Agilent Technologies, which is involved in the biomedical industry.

-- Kyl, R-Ariz., the Senate minority whip, reported $15,001 to $50,000 in stock in Amgen Inc., which develops medical therapeutics. Kyl's retirement account held stakes in several health care businesses, including the Wyeth, Bristol-Myers Squibb, GlaxoSmithKline, Pfizer and AstraZeneca pharmaceutical companies; medical provider Tenet Healthcare Corp.; CVS Caremark prescription and health services company; Genentech, a biotherapeutics manufacturer; and insurer MetLife Inc.

-- Harkin, D-Iowa, has a joint ownership stake in health-related stocks. Harkin and his wife, Ruth Raduenz, own shares of drug makers Amgen and Genentech, Inc., each stake valued at $1,001 to $15,000; Their largest health care holding, Johnson & Johnson, was valued at $50,001 to $100,000.

-- Hatch, R-Utah, a member of the Finance and Health committees, reported owning between $1,001 and $15,000 worth of stock in drug maker Pfizer Inc. He spoke to two pharmaceutical industry conferences last year. Sponsors of the conferences donated $3,500 to charities instead of speaking fees, as required by Senate rules.

tracy said...

Thank you, Dr. Brayer. This was, as always, excellent.

i believe few physicans go in to psychiatry because the only ones that do mostly become "pill pushers", do Meds Management, 15 min or less appointments, because, of course, they want to make as much money as other physicans. It is a very fortuate person who actually finds a good psychiatrist who does therapy....for a reasonable price...because he does not take insurance and does not have to bother with the hassle of a secretary, etc...

tracy said...

i'm sorry..i should have said, as much money as other "Specialists".

tracy said...

Ha, ha...i'm waiting for Dr. H.... to post and say "...most, if not all of these conditions can be prevented or controlled by lifestyle changes."

Rich said...

How many of the prisoners in Ca are Illegal Immigrants?

Toni Brayer MD said...

Rich: you gotta' get over this obsession with illegals.

CountryMidwife said...

Oh, dear. How to not get mired in anger and hence, eventual apathy about the lameness of the American system? It's so bad. We are so pathetic. :::pounding head against wall::: Advice????

Generic Viagra said...

This is really interesting because I think could be a cure for those diseases, I mean if cancer, hypertension, mental disorders, heart disease, pulmonary conditions, diabetes are the most common scientists must create a cure now because we have spent long time looking for the cure.