Wednesday, December 28, 2011
Here is a sneak preview of a few topics that I plan to write about after the New Year:
1) Costs and charges of health care - As you may know if you have been reading this blog from the beginning, the hospital bill for my second child (a normal spontaneous vaginal delivery) was $8,569.27, a staggering sum of money that the hospital couldn't begin to explain in an itemized bill, and of which our then-health insurance company ultimately wrote off more than 40 percent and we paid $100. Now that my wife is covered by health insurance with a 20 percent deductible on all medical services other than preventive care (alas, though the Institute of Medicine has decreed that pregnancy prevention counts as preventive care, bringing a new life into the world does not), we're naturally very interested in what the bill for our soon-arriving third child might be. I'll detail our extensive efforts to pin down the same hospital on its usual maternity care charges, and explain why it's so hard in the current health financing environment for patients to get any straight answers about health care costs.
2) Dissecting American Health Care - I first met former Assistant Surgeon General and current RTI International Chief Scientist Doug Kamerow, MD while precepting Family Medicine residents at the Fort Lincoln Family Medicine Center seven years ago, and since then he's written dozens of short essays for National Public Radio and BMJ on a variety of health care-related topics, now collected into a terrific book that was recently reviewed by patient advocate Jessie Gruman at the Prepared Patient Forum. I'll review highlights from my favorite Kamerow commentaries and explain how his perspectives point the way toward future reforms of our broken health system.
3) Cancer and the media - Building on a cancer screening talk that I gave to reporters at the National Press Foundation a few weeks ago, I will explore the pitfalls of reporting on cancer news and ways to improve communication about the latest research findings on screening tests and treatments to the public. Gary Schwitzer's recently renamed Health News Watchdog Blog has covered much of this territory already, but I hope to add some unique contributions to the dialogue from my experiences as a practicing family physician, teacher, researcher, and consumer health blogger.
My very best to you and yours for a happy and healthy 2012!
Kenny Lin, MD
Thursday, December 22, 2011
Wednesday, December 14, 2011
I have a BHAG (Big Hairy Audacious Goal).
I want people to hear "Family Medicine" and know that it refers to a medical specialty dedicated to providing relationship-based, patient-centered health care.
I want people to know that family docs take care of a lot of complicated, challenging diseases - and not usually in isolation. Our patients have high blood pressure, complications from type 2 diabetes, congestive heart failure, depression, chronic kidney disease, emphysema, anxiety, asthma, and coronary artery disease, to name a few; treating each of those conditions individually is nothing like treating them in relation to each other.
I want people to know that I trained for three years to become an expert in my specialty. During my Family Medicine residency, I learned about providing preventive care. I learned how to treat a multitude of acute problems - colds, fractures, lacerations, rashes, etc. I learned how to deliver babies, resuscitate victims of cardiac arrest, and drop a central line into a coding patient. I can take off your moles, skin tags, and warts. I can remove your ingrown toenail and treat your acne. I can obtain your pap smear, discuss your birth control options, and treat your STDs.
I want people to know that I can care for your kid and your grandparent. I routinely counsel teens about sex, drugs, and rock 'n' roll. I am comfortable in offices, hospitals, maternity wards, newborn nurseries, intensive care units, nursing homes, and even patients' homes.
I want people to know that Family Medicine residents learn about using the best medical evidence and the latest medical technology to guide decision-making conversations with patients. They can intelligently sift through the tremendous reams of medical studies that are published daily to pull out the information most relevant to their patients.
I want people to know that those residents learn how to work within a healthcare team. Nurses, medical assistants, pharmacists, care managers, social workers, administrative staff - it takes all of us to provide outstanding care. These incredibly important people are my hands, eyes, and ears into the thousands of little tasks that must get done every day in the office and at the hospital.
I want people to know that no medical specialty is as devoted to medical education as Family Medicine. The Society of Teachers of Family Medicine holds an annual meeting devoted solely to medical student education. We are one of only a handful of medical specialties with an entire fellowship (post-residency training) devoted to faculty development - training the next generation of academic Family Medicine teachers, researchers, and leaders.
Lastly, I want people to know that family docs do everything that they do in the context of our patients' belief systems, families, and communities. Our specialty is the only one that mandates dozens of hours of educational time during residency about the doctor-patient relationship. How to help folks quit smoking/over-eating/whatever, how to tell someone that the biopsy did show cancer, how to mediate family disagreements about end-of-life wishes - this behavioral instruction is just as important to a Family Medicine resident as the pathophysiology, treatment, and prevention of disease.
If you're not a family doc, I bet you didn't know all of those things. And the blame for that truth lies squarely with us as family docs. Frankly, other specialties have been better than us at promoting themselves. You all likely know what a dermatologist or a cardiologist is, even if you're not working in the medical field. Family docs can learn a lot from how other specialties have advanced the interests of their patients by advancing their specialty's cause; it's something we have failed to recognize the importance of until now.
Because of that failure, Family Medicine is not understood - and thus not valued - by the public, by politicians, by health plan administrators, and by too many of the other people who make decisions about health care in this country.
We need to show them what Family Medicine is all about.
My BHAG is to share Family Medicine with the people who don't know about us yet. I hope that this blog does that in some small way; certainly, many of the Family Medicine bloggers and tweeters out there are doing it in a bigger way.
But, I don't think that's enough. We need more. We need an #FMRevolution. I have to believe that there's something even bigger, hairier, and more audacious that we could do. I wish that I knew just what that that big, hairy, audacious thing was. Fortunately, though, I am but one of many.
It will take all of us to get the chorus of Family Medicine to echo across our nation.
Thursday, December 8, 2011
Cynicism grips Washington. It grips Washington far too much, far too much for a place that could instead remind us continually of the grandeur of democracy. ... Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels” – the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas.
The truth, of course, is that there are no “death panels” here, and there never have been. The truth is that, as our society has aged and as we have learned to care well for the chronically ill, many of us face years in the twilight our lives when our health fades and our need for help grows and changes. Luckily, palliative care – care that brings comfort, company, and spiritual and emotional support to people with advanced illness and their families – has grown at its best into a fine art and a better science. The principle is simple: that we can and should offer people the very best of care at all stages of their lives, including the twilight.
The truth is, furthermore, that patient-centered care demands that the ways in which a person is cared for ought always to be under his or her control. The patient is the boss; we are the servants. They, not others, should direct their own care, and the doctors, nurses, and hospitals should know and honor what the patient wants. ... It is one of the great and needless tragedies of this stormy time in health care that the “death panel” rhetoric has denied patients the care that they want, denied caregivers the information they need to give that care, and denied our nation access to a mature, open, informed, and balanced discussion of the challenge of advanced illness and the commitment to individual dignity. It is a travesty.
If you really want to talk about “death panels,” let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say a senior citizen of marginal income, “I am sorry you cannot afford your medicines, but you are on your own?” What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins?
Maybe a real death panel is a group of people who tell health care insurers that it is okay to take insurance away from people because they are sick or are at risk for becoming sick. Enough of “death panels”! How about all of us – all of us in America – becoming a life panel, unwilling to rest easy, in what is still the wealthiest nation on earth, while a single person within our borders lacks access to the health care they need as a basic human right? Now, that is a conversation worth having.
And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.
The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.
When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of Seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.
Wednesday, December 7, 2011
Thursday, December 1, 2011
Typically, experts present a “clean” version of their findings without any narrative about how they made sense of the data. This fulfills the scientific virtues of objectivity, coherence, and synthesis. When the USPSTF released its report on screening mammography to much controversy, it included no narrative about the process. Only later was the story of the task force deliberations revealed. This narrative, with multiple characters operating within the context of historical precedents, timing mandates, and a messy political milieu, created a substantially more compelling perspective. But the account came too late to engage a confused and angry public with the task force's conclusions.
Guideline developers could include as part of their reports the narrative of their internal workings: We started with what we knew, we looked at the evidence, we revisited our hypotheses, we argued about the findings, and ultimately we acted here and now because it was prudent, but there are more data to come, and here is what we plan to do as we learn more. Such stories could increase trust and therefore improve the translation of evidence for individual use and public policies.
Consequently, I couldn't agree more with the elegantly stated conclusion of JAMA commentators Drs. Zachary Meisel and Jason Karlawish:
Tuesday, November 29, 2011
Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak, please e-mail me at email@example.com or KWL4@georgetown.edu.
Identifying and Using Good Practice Guidelines
36th Semi-Annual Family Practice Review Course
Temple University School of Medicine / Lancaster General Hospital
- March 12, 2012
Why You Should Stop Screening for Prostate Cancer
Journal Club, Preventive Medicine Residency
Uniformed Services University of the Health Sciences
- January 18, 2012
Cancer Screening: A Primer for Journalists
National Press Foundation
- December 14, 2011
Tuesday, November 22, 2011
1) In praise of individual health mandates (11/1/11)
2) Rethinking the war on drugs (11/8/11)
Friday, November 18, 2011
Monday, November 14, 2011
Tuesday, November 8, 2011
Friday, November 4, 2011
A prostate-specific antigen (PSA) test for prostate cancer. In 2008, the USPSTF found insufficient evidence that this test reduced mortality from prostate cancer, and 2 subsequent long-term studies of PSA screening published in March 2009 reported no mortality benefit and a very small survival benefit limited to men ages 55 to 69 years, respectively. (President Obama is 48 years old.)
A coronary calcium scan for coronary heart disease. In 2009, the USPSTF found insufficient evidence that patients who test positive and receive treatment for coronary artery blockages have fewer heart attacks compared to similar patients who don't have the test.
CT colonography ("virtual colonoscopy") for colorectal cancer. Most guidelines, including the USPSTF's, recommend that colorectal cancer screening start at age 50 in persons without a family history. However, in 2008 the USPSTF found insufficient evidence that CT colonography was as effective as older, established tests such as fecal occult blood testing and optical colonoscopy, exposed patients to higher doses of radiation, and commonly leads to unforeseen consequences of incidental scan findings in other parts of the abdomen. Based largely on these concerns, in 2009 the Centers for Medicare and Medicaid Services declined to extend Medicare coverage to CT colonography.
A colleague of mine argued that the Leader of the Free World might be subject to different standards than you and me, given the psychological impact it would have on the nation and the world were President Obama to be suddenly felled by a heart attack or belatedly diagnosed with metastatic prostate or colorectal cancer. But this argument cuts both ways. What if his PSA test (reportedly a normal 0.70) had been slightly high, leading to a prostate biopsy that showed a low-grade cancer? Or if the coronary calcium scan had suggested a non-critical blockage in a coronary artery? Or if CT colonography had picked up a suspicious mass on a kidney that couldn't be distinguished from cancer? All of these results would have potentially been false positives, but would have required additional invasive diagnostic tests and treatments with important adverse effects.
The experience of the late President Reagan, who underwent surgery during his Presidency to remove an apparently malignant colon tumor, reminds us that even the perception of poor Presidential health can dramatically affect the psyche of the nation. So regardless of your political persuasion, we should probably be happy that President Obama's physicians gave him a "clean bill of health" this time around. At any rate, I hope that they counseled him to stop smoking and offered medications to help him quit - a preventive service that the USPSTF reaffirmed in 2009 with an unequivocal "A" recommendation.
Tuesday, November 1, 2011
Wednesday, October 26, 2011
As H. Gilbert Welch and colleagues argue convincingly in their new book, ... much of the rise in cancer diagnoses over the past several decades has been the result of overdiagnosis: the detection (through screening or incidental finding on medical images obtained for other reasons) of cancers that would otherwise never have caused problems for patients. In the absence of screening, patients would not have developed symptoms because the "cancer" would not have progressed, or the patient was destined to die from some other cause (typically, heart disease). In the presence of screening, however, they suffer the psychological effects of knowing that they have cancer, the complications of diagnostic procedures, and the consequences of unnecessary treatments.
Seen in this light, the rise in cancer survivorship is not a modern medical success story. For millions of patients who received diagnoses that they didn't need and would do nothing to improve their health, it is a catastrophe.
Wednesday, October 19, 2011
As family physicians, we often face difficult decisions about ordering tests for the early diagnosis or prevention of disease in healthy-appearing persons. It is hard to convince many patients to think about prevention, and those who come in for health maintenance visits often expect to undergo tests that they have heard about from advertising on the Internet, radio, or television, or in popular magazines. For example, a colleague recently saw a healthy, asymptomatic woman who scheduled an appointment to receive the results of an ultrasound examination that had been ordered by another physician to screen for abdominal aortic aneurysm (AAA). The results were normal, but because the test was not indicated by generally accepted standards, our colleague was perplexed at what reassurance to provide the patient, if any.
Saturday, October 15, 2011
Now that the U.S. health reform bill is law, and over 95 percent of Americans (as opposed to today's 84 percent) are expected to have health insurance by 2014, many physicians may be tempted to think that they can ignore the costs associated with prevention, diagnosis, and management of patients' health conditions and just focus on doing what's "right" for the patient, since somebody else is footing the bill. But contrary to popular opinion, that "somebody else" isn't an insurance company or the government; ultimately, it's the patient, in the form of higher insurance premiums (or taxes) to pay for an ever-expanding range of tests or treatments of questionable or zero benefit.
In response to Dr. Howard Brody's challenge to the medical profession to identify lists of unnecessary tests and treatments, physicians have suggested antibiotics for colds, coronary calcium scans, PSA and thyroid tests in well patients, drugs for high blood pressure that are more expensive and offer fewer benefits than older drugs, MRIs and spinal fusions for low back pain. And if reform is to have any hope of slowing the extraordinary growth in the cost of health care in the U.S., doctors can't keep looking to patients, hospitals, pharmaceutical and medical device companies, and insurers for solutions. In an editorial in the New England Journal of Medicine, Dr. Molly Cooke argues convincingly that cost-consciousness must be systematically incorporated into medical and continuing education:
First, we should be honest about the choices that we make every day and stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit. Second, we must prepare every physician to assess not only the benefit or effectiveness of diagnostic tests, treatments, and strategies but also their value. Value can be increased through cost-conscious diagnostic and management strategies and by the engineering of better and less wasteful processes of care.
"Value" isn't about saving money, but means getting the maximum health benefit for our enormous investments in health care. This wake-up call needs to be delivered and reinforced to students, residents, and health professionals at every level - starting today.
Thursday, October 13, 2011
The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information—“best” implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and “available” implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.
Monday, October 10, 2011
The extraordinary, albeit sometimes idiosyncratic, approach to medicine practiced by solo FPs today is often overlooked. Nimble (no bureaucracy to consult when changing policies), in touch (no one knows the local population better), and increasingly likely to use EHRs and health information exchanges (like physicians in larger groups), these doctors are paving the way to a brighter future. Whether they’re focusing on lean design, integrating concepts of public health, or creating environments that foster holistic healing, I see a lot of innovation and passion among solo practitioners who aren’t afraid to take risks or fight for their patients. Moreover, practices with only one or two physicians are frequently on the cutting edge of change and leaders in providing quality health care. What’s more American than that?
Thursday, October 6, 2011
Wednesday, October 5, 2011
Tuesday, October 4, 2011
Thursday, September 29, 2011
Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak about any of these topics, please e-mail me at firstname.lastname@example.org or KWL4@georgetown.edu.
What to Do When Screening Guidelines Conflict: HIV and Mammography
- Grand Rounds, Georgetown University Department of Family Medicine
November 4, 2011
Overdiagnosed and Over-Prevented: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health
October 28, 2011
For Geeks and Geezers: With Social Media Skills You Can Change the World: Blogs, YouTube, Facebook, Twitter, BlogTalk Radio – and the list goes on!
- Family Medicine Education Consortium Northeast Region Meeting
October 22, 2011
Screening for Diabetes: What Does the Evidence Say?
- Spanish Catholic Center of Catholic Charities of Washington, DC
October 5, 2011
Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians
Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Librarians Association
Medical Blogging and Other Professional Uses of Social Media
- Virginia Commonwealth University Medical Center
Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine
Health Promotion and Disease Prevention in Clinical and Community Settings
- Uniformed Services University of the Health Sciences
The Value of Preventive Health Services
- Employees of MetLife
COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians
Wednesday, September 28, 2011
1) Actual causes of death in the U.S.: not what you think (8/26/11)
3) Care transitions: 4 key questions to ask your doctor (8/11/11)
Friday, September 23, 2011
Tuesday, September 20, 2011
Friday, September 16, 2011
For much of 2007 I combed the medical literature for every study I could find on the benefits and harms of prostate cancer screening. In November of that year I presented my findings to the USPSTF, a widely respected, independent panel of primary care experts. They discussed and debated what the evidence showed and then voted unanimously to draft new recommendations. I didn't get to vote, but it has been my job in 2008 to shepherd the draft statement and literature review through an intensive vetting process and to finalize both.
As August 5 approaches, my colleagues in public relations warn me that the last time the USPSTF said anything about prostate cancer screening, the phones started ringing off the hook. I'm not so secretly hoping that the same will happen this time.
And I'm not disappointed! After we release the statement, my normally placid government agency buzzes with excitement. In addition to sparking front-page stories in major national newspapers, the story brings our PR office "hits" from television, internet and radio outlets all over the country. With the volume of requests far exceeding what the Task Force's press-liaison person can handle, I offer to pitch in. I give two newspaper interviews and debate a respected urologist on a live radio call-in show. My colleagues cheer me on. I forward the radio clip to my friends and family.
The new recommendations surprise many people: They say that men age 75 and older should not be screened for prostate cancer.
Because there's no convincing proof that the prostate-specific antigen (PSA) blood test--the one used to detect early prostate cancer--actually saves lives. Most abnormal PSA tests do not actually indicate cancer, and up to half of true prostate cancers detected with the test would never have caused health problems if they'd gone undetected.
On the other hand, there's lots of evidence that the PSA test causes physical and psychological damage. Abnormal tests lead to prostate biopsies, operations and other treatments whose adverse effects range from anxiety to surgical complications to death. For younger men with decades of life remaining, these adverse effects may be worth the potential benefits; in men aged 75 and older, they almost certainly are not.
I soon learn that cancer recommendations, like cancer screening tests, come with their own adverse effects.
Comments pour into health blogs and the editorial pages of my favorite newspapers, accusing the Task Force, and me personally, of "ageism" and "taking the first step toward government-sponsored euthanasia." The systematic review I worked so hard on is trashed as a "shoddy meta-analysis" (although it's neither shoddy nor a meta-analysis), and many elderly men and their spouses lambaste us for being in league with heartless insurance companies.
I realize that this report has hit a nerve--the one that distrusts the healthcare system and that lacks faith in government. Cancer inspires more fear and anxiety than many other diseases. People worry about being denied access to cancer care--even care that hurts more than it helps.
I'm most wounded by one comment, which says that those responsible for developing the guideline can't possibly understand what it's like to have, or to care for someone with, prostate cancer.
This one really pains me because I do understand.
I remember only too well a 75-year-old patient--I'll call him Kendall--whom I met during my residency training in Lancaster, Pennsylvania, an area best known as Amish country. Kendall wasn't Amish, yet he hadn't seen a doctor in decades. Before I met Kendall, he'd been hospitalized with bone pain and a PSA of over 5000 (more than 4 is considered suspicious) and had been diagnosed with advanced, metastatic prostate cancer.
Kendall responded dramatically to a course of hormone-deprivation therapy and returned home. As I learned over the course of our outpatient visits, he was a man of few words but big gestures. At the end of our time together, he'd stand and clasp my right hand tightly in both of his, saying, "See you in a few months, doc."
Later, when the cancer and its awful pain returned, and Kendall became weaker, he was one of my favorite home-visit patients.
The end came surprisingly quickly. A hospice nurse paged me with the news that Kendall was in the ER, disoriented and combative. I rushed over and tried to soothe him as we ran tests, hoping in vain to find something we could fix. Soon afterwards, he was transferred to an inpatient hospice. He died a few days later.
Would PSA testing and earlier detection have spared or prolonged Kendall's life? Given the aggressiveness of his cancer, I doubt it, but it's hard to know for sure. And I admit that Kendall often came to mind as I was working on a recommendation to stop PSA testing at age 75. If he'd ever bothered to visit a doctor, maybe he would have been one of the few men helped by such testing, rather than one of the many harmed. I'll never know.
My colleagues and I labored for months to present a thorough and accurate review that would help the USPSTF make sensible recommendations aimed at doing the most good and the least harm. We performed our work without considering healthcare costs or political fallout.
I'd hoped that August 5 would free me from being labeled a faceless bureaucrat. Ironically, it ended up tarring me as a heartless one.
Prostate cancer causes a lot of suffering--I know. In the face of that, it's tempting to try and detect it early, to "do something." But for now, unfortunately, our best science tells us that doing something to a man older than 75 is likely to do more harm than good.
For Kendall's sake and for my own--for I hope to be 75 myself one day--I wish it weren't that way.
I wish that on August 5, 2008, I'd had better news to share.
And I wish that everyone had understood that.
Tuesday, September 13, 2011
One of the approaches some corporations are taking to hold down health care costs is to put more responsibility on their employees through high-deductible health insurance plans. It makes sense that they would try this. After all, this reflects the daily life of the business community as they compete for consumers of their goods and services. They make choices based on cost and features, so why shouldn’t their employees?
When it comes to readily accessible items such as anti-inflammatory pain relievers, of course the consumer can make rational choices between trade-offs: brand name drug or generic, acetaminophen or ibuprofen. But what about big ticket items in health care? In an article in the New England Journal of Medicine late last year, the limits of consumer choice in holding down costs were addressed. The authors looked at the hospital market, for which $700 billion was spent in 2008 (I would estimate this is over $800 billion now).