This is the stunning conclusion to last article’s gripping overview of why the Affordable Health Care Act is so darn screwed up here in the US. In part 2, I’ll cover the largely-snuck-by 21st Century Cures Act as well as put forth MY ideas to fix this mess of health care.
And, depending upon how open your mind is, you might not like my solutions.
21st Century Cures Debacle
While you have undoubtedly heard about Obama Care Insurance, it seems like passage of the 21st Century Cures Act after Thanksgiving of 2016 pretty much flew under the radar.
Considering that the law is 90 pages LONGER than the Obama Health Care law, this seems a little of a shocker to me. As expected with a bill this long, it does many things. Few of them good.
As an example, in 2017 and 2018, $500 million would be placed in a fund to help states combat the opioid epidemic (more on this later). Over a 10-year period, $2.8 billion and $430 million would be placed in funds to support NIH research and FDA innovation, respectively. Most of this NIH funding would come from cuts to the Prevention and Public Health Fund.
Great, more drugs hitting the market faster while less money is devoted to prevention.
Beyond all of this, the law allows the FDA to fast track approvals for drugs based on surrogate end markers. Surrogate end markers (like cholesterol) are used in research instead of real outcomes (like heart attacks) so that drug companies don’t have to spend years trying to see if their drug really does what it is supposed to.
Two great examples:
- Lipitor was originally approved based on the surrogate end marker, cholesterol, to lower heart attack rates. It wasn’t until almost a decade later that the studies were finally published looking at whether this cholesterol lowering medication actually stopped heart attacks. Turns out, while it was great at lowering cholesterol, it pretty much sucked at stopping heart attacks.
- 18 cancer drugs were approved by the FDA from 2008-2012. These were approved based on their ability to extend cancer free progression. ALL of these drugs, however, were not shown in post market studies to significantly prolong overall survival (although it DID take longer for cancer to show back up with the drugs, no one lived longer). So, all side effects and cost, no benefit.
From an emotional standpoint, measures like this sound great. This way the politics associated with all that tedious stuff like safety and outcomes can be biased in exchange for speed.
But I can guarantee that this is never a good thing. It’s bad enough that a large chunk of drugs that do go through the lengthy process of approval through the FDA are later pulled from the market or given black box warnings when information comes in from post-market surveillance.
Just in case you think this is hogwash, in 1992 the Prescription Drug User Fee Act (PDUFA) was passed that basically forced the FDA to speed up the approval process. (It’s actually a bit worse—drug companies could pay money to get fast-tracked approvals) This is much like what is done with the 21st Century Cures Act.
We are apparently slow learners. Under PDUFA, drugs approved with this process were 35% more likely to be pulled from the market or given a black box label.
Don’t expect anything better from the 21st Century Cures Act. Just in case the Affordable Health Care Act didn’t create enough problems with increased access to drugs that have side effects and little benefit, the 21st Century Cures Act will just make the entire “drug culture” that we live in more of a problem.
Ideas of How to Fix Obama Health Care
Because my presidential bid didn’t get picked up by either of the political parties, I was not able to promote my ideas during the presidential debates. So you’re stuck getting my ideas here.
Before I solve this whole mess in a few thousand words (far shorter than the law itself), something needs to be said.
While you may certainly disagree with me, health care in the United States is NOT A RIGHT. Rights in the United States are defined by the Constitution and the subsequent amendments.
You could still argue that a country as wonderful as the United States should provide health care for its citizens. But, as I pointed out in the first part of this article (which can be read by clicking here in case you missed it), the need for health care is heavily dependent upon the choices of the individual.
Heart disease, obesity, diabetes and yes, even cancer are largely driven by lifestyle choices. Make more bad choices and you’ll need more health care. That’s a pretty well accepted equation.
It just doesn’t compute that people can make bad choices and he or she then has the “right” for society to pay for health care.
So what do I think we need to do to fix this mess?
Premium Adjustments in Obama Care Insurance
Almost since its inception, health insurance premiums were dependent upon the health of the individual. This is not about pre-existing (I covered my thoughts about this in part one of this article). But if you were overweight or had diabetes or high blood pressure, your health insurance was going to cost you more.
That is because you are going to be more expensive to cover. And the premiums you pay will NOT cover your health care expenditures. Not even close.
But the idea of paying more based on your health status is something that the people WITH the health concerns don’t like. The people who take care of themselves think it’s a great idea.
Look at it this way—the people who have health concerns pay into the system way, way less than they receive in health care benefits. On the flip side, those who are healthy will pay more into the system than they will ever use.
Until we accept the fact that people with health conditions related to their lifestyles SHOULD pay more, we will never be able to iron this out and make everyone moderately happy.
This list could be short. Elevated waist-to-hip ratio. High blood pressure. Elevated HbA1c. Elevated cholesterol. Elevated trigylcerides.
These are all easily measured and objective. All of them are an indicator of underlying health concerns that are linked to almost EVERY chronic (read: expensive) disease.
And, they are all modifiable. If your markers are high and you’re paying more in your health insurance premium, than make the changes you need to make.
With today’s technology, it would be easy enough to give insureds REAL information about what lifestyle changes to make to bring these markers down. It’s a win-win. If you’re willing to make the changes you can lower your premiums. If not, you’ll be paying more.
But this alone won’t fix the problem.
Choosing Wisely to Fix Obama Care Insurance
This one is going to be the hardest to face.
Medicine has created its own demons. Make no mistake about it, if we are going to fix this healthcare debacle a lot of people involved in healthcare are going to lose their jobs. The list is long and starts from entry level admin to highly paid physicians.
And there are a lot of doctors who won’t go down without a fight. Do you think that hospitals that make hundreds of millions of dollars putting in cardiac stents would close up shop and fire the cardiologists?
Do you think the drug companies are going to go down without a fight? They have created a culture where society believes that we need its drugs for “health.” They have created a society where they can pretty much price their products that have NO relationship to the cost of producing the product, instead charging as much as the market will bear.
These companies make BILLIONS of dollars on lying, cheating and deceiving the public and doctors. The stories by which the drug companies maintain their dominance read like a Hollywood blockbuster movie script.
They will NOT give up without a major fight. And considering that they donate more money to political campaigns than any other group, politicians are going to be loath to make any changes that will affect the drug companies.
There is a long list of very expensive medications and procedures that we do every single day, day in and day out, in the guise of health that has very little value. And all cost.
To give a few examples:
- Statins, despite some $20 billion annually spent on one of the most expensive drug classes on the market (based on total cost), pretty much suck at preventing heart attacks and stroke.
- Blood pressure medications for stage 1 hypertension (systolic <160 and diastolic <100) do nothing to protect against heart attack, stroke or death. While they don’t save lives, blood pressure drugs do provide a long list of side effects that then cost even more. And while most blood pressure meds are not expensive, they are expensive because of the massive volume of prescriptions written.
- Cardiac angioplasty for non-emergency situations. This has been shown to do nothing other than help with chest pain. No lives saved, no lowered risk of cardiac bypass in the future. Very expensive and risky.
- Fancy new chemo drugs that do not extend lifespan (just so happens to be the last 18 drugs approved by the FDA for cancer-free-progression mentioned earlier in this article).
- More aggressive spinal surgery procedures like fusion where simpler, less expensive and safer procedures have the same (or better) outcomes.
- Spinal imaging (X-rays, MRIs and CT scans) done for uncomplicated conditions that have not yet undergone conservative treatment. It has been shown that early imaging drives additional procedures like epidurals and spinal surgery.
- Spinal steroid injections (epidurals) for local low back pain. There is no evidence that supports the use of epidurals for local back pain. Now, if you have true sciatic pain that runs down the leg all the way to your foot, it’s more likely to provide some benefit.
- Opioids. Just opioids. Where do we start on this one? Even despite the widespread knowledge that opioid addiction and overdose deaths have been increasing over the years, the tide is not turning. While these drugs do have a place in medicine, it’s not in acute or chronic musculoskeletal pain. These drugs, more than any other class of drugs in history, have created more problems for the people to whom they are prescribed.
- Arthroscopic knee surgery for “clean outs” and degenerative meniscal tears. Both of these conditions have evidence that they do nothing for the patients. And the cost of these procedures, collectively, is massive.
If I had some more time to think about it, I’m sure I could come up with lots more, but you get the idea. Even from this short list we could save billions of dollars per year, and with no loss in health outcomes to the patient.
But we all have to take a close look at our own fields and be willing to throw out that which doesn’t work (especially when the research shows that it doesn’t work!), even if it may mean that our own incomes could be drastically effected.
So how do we objectively determine what procedures and drugs to use?
I’m sure there are other ways, but Numbers Needed to Treat (NNT) is a great place to start. NNT refers to how many people have to be given a drug or procedure for a single person to benefit. What makes a good NNT is always up for debate. But it should be clear that statins, at a NNT of 100, would not be a good choice to pay for (yes—you have to treat 100 patients with statin drugs for a single person to benefit). If someone was convinced that statins were the Holy Grail of preventing heart attacks and they save lives left and right, this person could always pay cash.
And boy, would we see the free market at play in THAT scenario….
Probably the best resource for understanding and looking at NNT the www.theNNT.com. This website does an incredible job of laying out just how effective many of the approaches used in medicine are (or are not) while taken in the context of any harms that may occur.
The Sin Tax Idea
While I am generally a fan of government staying out of our lives, I have to admit that there is some merit to the sin tax idea.
Sin taxes are just that—higher taxes on items that are considered “sins.” Alcohol and cigarettes are the prime examples and ones that people have come to accept.
In general, the population does not like sin taxes. Mexico recently adopted a sin tax on soda. But this law was fought tooth and nail by pretty much everyone, from the general public to most politicians. It was only through the hard work and perseverance of literally a handful of people that this law got passed.
So. Sin taxes would be placed on soda. Foods containing artificial sweeteners. Fast food. Grain products containing enriched wheat flour. Items with artificial food colorings. Items containing hydrogenated oils. And on.
The extra money collected then gets put into the health insurance pool to help cover premiums. It would not solve the problem, but in this situation you are ultimately helping to pay for future health costs if you choose to make bad choices today.
But it would likely be no more popular than charging higher premiums for those with health conditions. For me, while I love this idea, it is more of a utopian view.
The Missing Link in Accountable Care Organizations
One thing that was set up under the Obama Care Insurance plan was Accountable Care Organizations, or ACOs. Under an ACO, the goal is for providers to pool together as a group in an effort to follow best practices and save money on insurance costs for a large pool of patients (minimum 5,000).
The providers, in turn, would be rewarded at the end of a period of time (generally 3 years) by getting a percentage of money saved as a bonus. Most of these plans were under CMS and Medicare, but they were also formed under standard insurance plans as well.
The premise is that if Primary Care Doctors pay attention to their patients’ needs; making sure diabetics are on all the right meds, blood pressure meds are taken and all those other things that mainstream medicine considers important.
So how is that working out?
As of November 2014, Medicare ACOs in both the Pioneer and MSSP initiatives have together generated $877 million in savings (for the math wizzes out there, annual Medicare expenditures are $597 billion, so this savings equals 0.15%). Only 22% of MSSP ACOs qualified for shared savings payments in year one of the program; in other words a majority of Medicare ACOs have either shared in losses or have neither shared in savings nor losses.
In other words, the cost savings really suck (unless anyone happens to think that a fraction of 1% cost savings is anything more than a math error).
It’s because the paradigm is broken.
The ACOs are doing business as usual, but are just trying to be more effective at getting their patients on the right medications and making sure they are doing the right screenings and getting the right vaccinations and coming in for their annual wellness visits.
I’ve pretty much established that these aren’t really good for REAL health.
So what’s missing?
Chiropractic as the Missing Link in Accountable Care Organizations
While I have a clear bias in this matter, I’ll prove to you beyond a doubt that the chiropractic profession could turn this health care mess around.
For ACOs to work they have to shift their paradigm. To just be more effective at things that have little true overall impact on making people healthier is not going to cut it. They have to think differently.
For most in mainstream medicine, this paradigm shift could occur, but it’s going to take time. A LONG time. But for chiropractors, we’re already there. It’s the model we live under every single day for the last 100+ years.
The skeptic (and trust me, most would probably fit this category…so far) would say that chiropractors only treat back pain.
OK. I’ll bite…
In a study looking at health care spending data from 1996 through 2013, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion in spending, including. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013 at $88.1 billion.
Third place? Low back and neck pain at $87.6 billion.
As a side note, from 1996 through 2013, spending on retail pharmaceuticals increased 5.6% annually, more than any other category with the exception of emergency care.
This means that, even if all chiropractors really did was address back pain (forget headaches, knee pain, shoulder pain and lifestyle changes) we are having an impact on the 3 highest spending category in medicine. Period.
Great. Billions of dollars spent on spinal pain. What does this have to do with chiropractic care?
Optum is a subsidiary of United Healthcare that manages the chiropractic benefit. In a massive study on the costs associated with 14.7 million courses of non-surgical spinal pain it was determined that, if a chiropractor was the first provider seen for these cases there would be a $1.3 BILLION savings in 2 years. No matter how they worked out the numbers, there was a massive cost savings, good outcomes and happy patients.
Where did this cost savings come in?
Cost Savings on Imaging
A study looking at claims from a single employer health plan that had employees who offered chiropractic care on-site. Researchers compared the 2 years’ worth of claims data.from the on-site clinic to how care was utilized outside in the community. The off-site group received more radiology services (55.5% vs 38.2%, including MRI, ultrasound, and X-rays) and had higher outpatient and ER visits.
A study on injured workers was done to see what affected the rates of a patient getting an MRI within the first 6 weeks (termed an early MRI). Overall, 20% of the injured patients received an early MRI. When a primary care doctor was the first provider seen, there was a 78% higher chance of an early MRI. When a chiropractor was the first provider seen? Forty-seven LOWER risk of an early MRI.
It is well established that early imaging increases the risk of getting epidurals and surgery and massively drives up costs.
Cost Savings on Surgery
In a study of injured workers to see if seeing a chiropractor first had an effect on surgery rates. Wow did it. In those who first saw a surgeon, 42.7% of the workers had surgery. But when a chiropractor was seen first? A respectable 1.5%.
Following the Best Available Guidelines
A rather large study looking at just under 15,000 injured workers over 8 years was designed to evaluate care patterns for low back pain. They identified 5 distinct patterns of care for the injured workers, of which chiropractic was one (11% of the workers). Information and Advice was the most common patter which included simple office visits, laboratory tests, emergency department or hospital visits, talk therapy, or visits involving imaging (x-ray, ultrasound, CT, or MRI) but no other procedures.
Complex Medical Management (the smallest group at 2% of injuries) is generally considered expensive and fragmented care and runs completely contrary to the way low back pain should be managed. Physical therapy and dabblers were the last two groups.
Researchers looked at 11 well accepted guidelines for the treatment of low back pain that is backed up by medical research. As would be expected, care to injured workers that was in line with 10 of 11 guidelines led to lower total costs.
Of the five patterns, chiropractic care had the highest adherence with accepted guidelines, lower total costs and the lowest prescription rates in all seven classes of drugs studied.
Chiropractic Users Spend Less
While this study was not specific to chiropractic care, chiropractic care accounted for 75% of CAM use. In the study, researchers looked at a group of just over 12,000 insured individuals with self-reported neck or low back pain.
The average annual spending for CAM users was $526 lower for spine-related costs. But, to add icing to the cake, annual costs for CAM users was $298 lower for TOTAL health costs, which mainly came from lower hospital inpatient costs. These numbers were calculated with adjustments for the chance that CAM users may be healthier overall (without this assumption, the dollar amounts saved is even greater).
The Real Icing on the Cake
The examples I’ve given are for direct cost savings. How much money was saved because chiropractic care is efficient and safe and patients are very happy with their outcomes.
The savings on imaging, pain management and drugs closer to indirect costs.
But the REAL savings comes from lower hospitalization costs and lower costs associated with the side effects of drugs. The secondary cost savings associated with drastically reduced spinal surgeries and the side effects from NSAIDs and opioids are massive.
This isn’t just about the direct cost for the surgeries and the drugs. It’s NOT having the costs of secondary infections and bad surgery outcomes. It’s NOT having the long-reaching side effects of NSAIDs like heart attacks, joint damage, liver damage and kidney damage. It’s NOT having the society costs and deaths associated with opioid abuse.
If we could somehow factor these in, we’re going to have a lot of jobs lost in healthcare.
The closest that anyone has come to this was the AMI group out of Illinois. This group partnered with Blue Cross / Blue Shield of Illinois to allow insureds to choose a chiropractor as their PCP.
These chiropractors went through some additional training to bring them up to speed on some additional guidelines and referral pathways they may have been rusty on. But overall, it was still the attitude of chiropractic (as a profession, NOT a procedure) that was on trial here.
In looking at 21,743 member months over a 4-year period those plan participants who chose a chiropractor as their PCP had 43.0% lower hospital admissions, 58.4% lower hospital days, 43.2% lower outpatient surgeries and procedures and 51.8% lower pharmaceutical costs.
THAT, ladies and gentlemen, is enough to solve the Obama Care Insurance debacle we have set up in this country.
Aggressively Against Chiropractic as the Solution?
I’m sure there are some out there outraged at this solution. Feel free to counteract my arguments in the comments section, but it better be a damn good argument without reference to personal bad experiences. Had a bad experience with a chiropractor? Great, I’ll line up just as many people who had a bad experience with a surgeon, epidural, primary care doctor or had a nasty life-threatening side effect from a drug.
Get over it. I’m sick of hearing it. Every profession has its bad apples and anecdotal stories of bad experiences.
These studies I’ve presented are with the AVERAGE chiropractor doing the AVERAGE thing a chiropractor does. That would take into account the chiropractors who can get their patients better lightning fast as well as the chiropractors who saw their patients 45 times for an uncomplicated case of low back pain.
For those primary care doctors who are in an Accountable Care Organization and would rather have a colonoscopy without sedation from a gastroenterologist with Parkinson’s, macular degeneration and support staff having a bad day than partner with chiropractors, would you still feel this way if you did the numbers?
If you get bonused on cost savings, how big would your bonus check be if your ACO posted a FIFTY PERCENT cost savings??
Almost enough to retire on, I’d imagine. And all because the patients in your ACO were managed more conservatively.
Final Thoughts on Fixing Obama Care Insurance
While I’ve bitched and whined over the costs of the Affordable Health Care Insurance Act, this is the first time I’ve put what I consider solutions down in an orderly fashion.
If I must say so myself (and since I’m pretty much the only one around as I type this), I’m pretty proud of this package.
None of these ideas should be implemented in a vacuum. Portions or ideas from each would need to be implemented for the full fix. And IT’S GOING TO HURT. Many in health care will lose their jobs, from the top down. But our system is bloated and wasteful, feeding on itself by the mistakes and harms that we continually make as part of the everyday process.
This has to change.
We can’t just juggle with who is making the payments or spreading out the cost. We don’t need health INSURANCE reform, we need health CARE reform. Our paradigm in this country is not working. And our model has been taken up by other parts of the world, and countries that have adopted more Westernized lifestyles and medicines are started to see the same problems we have.
I do firmly believe that chiropractors can potentially play a strong role in this re-thinking process, but we’ve got to grow up as a profession as well. It is likely, however, that if we got paid what we are WORTH, rather than what insurance companies think they can get away with paying us, the charlatans and marketing-based decisions will right themselves.
Mainstream medicine is going to have to change as well. They are going to have to come to grips with the idea that mainstream treatments are not always the best option. They need to stop poo-pooing the thought that chiropractic care is a scam and stop throwing epidurals and opioids at the problem first.
Health care in the United States has some of the best options available on the planet. We rock when it comes to innovation and new treatments, but we absolutely suck when it comes to conservatively managing chronic conditions and keeping people healthy.
Last note—for those of you who think that Universal Health Care is the future. Universal Health Care is a very bad idea. The discussions on Universal Health Care are all about who is going to pay for what and not about how to deliver more efficient care or make patients healthier.
And I can guarantee one thing under Universal Health Care. Chiropractic care will be a big loser. We already are severely stunted under Medicare and Medicaid and it’s highly likely that any Universal Health Care would mimic aspects of these already-in-place Federal programs. For this reason I have grave concerns over anything resembling Universal Health Care.
So…these are my ideas on how to fix the Affordable Health Care Insurance mess we’ve created. If anyone happens to have Donald Trump or any other high-ranking members of congress on their personal email list, feel free to share.
Until then, I can only hope for real changes. If you’ve got better ideas, feel free to hop in on the comments…