The third reason for death in the U.S. is unintended outcomes of medical treatment. A study by Martin Makary, MD, then a professor of surgery at Johns Hopkins University School of Medicine, found that medical errors–comprise the third leading cause of death in the U.S.
“It boils down to people dying from the care that they receive rather than the disease for which they are seeking care,” Makary said to The Washington Post.
We know about some of these problems. When the specialists go on vacation the mortality drops. For the one out of 1,000 women saved by mammography, up to 10 healthy women will be treated needlessly. A third of FDA approved drugs have been found to later have safety issues.
However, in a comparison of age-adjusted deaths from all causes, the World Health
Organization ranks the United States last in similar countries. At the same time, Louisiana
ranks 50 of all the states.
For this report, we look at the barriers to providing prevention, rather than the expensive and dangerous treatments now provided by the medical and pharmaceutical industries.
Consider an example from mental health. Imagine that a patient with psychosis is given nutrients. She improves her quality of life to such a degree that she no longer needs yearly hospitalizations, which, along with other expenses, amounted to $500,000 of costs over a five-year period.
Dr. Bonnie Kaplan, Professor Emerita in the Cumming School of Medicine at the University of Calgary, in and expert in the field of nutritional mental health, thinks this type of prevention might save lives and money. Kaplan publishes widely on the biological basis of developmental
disorders and mental health – particularly, the contribution of nutrition to brain development and brain function.
In her “Hospitalization cost of conventional psychiatric care compared to broad-spectrum micronutrient treatment,” in International Journal of Mental Health Systems, Kaplan points to
dramatic savings for those patients that respond to nutritional interventions. Nutrition is one of the innovations in illness prevention that has been neglected for decades. Other basic approaches include behavioral and psychological treatments for lifestyle based illnesses, equally as costeffective.
“Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases,” said Hamilton Moses and co-authors in, “The Anatomy of Health Care in the United States,” in an article of the Journal of the American Medical Association.
While medical costs are driven by chronic disease, it is not due to an aging population, even though age is often cited as the cause. Moses shows that about 80 percent of the total health care cost is accounted for by those under 65, and relate to psychological, social and behavioral elements. The CDC estimates that three lifestyle factors––poor diet, inactivity, and smoking–– account for 80 percent of heart disease and stroke, 80 percent of type 2 diabetes, and 40 percent of cancer.
“Behavioral intervention is the foundation for lifestyle medicine,” writes Dr. John Caccavale, author of Medical Psychology Practice and Policy Perspectives. “Of the top four classes of medical problems in America – metabolic disorders, respiratory disease, cardiovascular disease, and mental disorders – physicians will have great difficulty demonstrating that they are improving patient health by utilizing medications as a first-line treatment for these classes of disorders,” writes Caccavale.
“I think wellness/prevention are areas where there is tremendous need in primary care,” said health psychologist Dr. Michelle Larzalere.
“For both physical and mental health, the need to work on active problems is often so high that wellness/prevention get shorted on attention,” Larzalere said.
“The health habits that most reduce the preventable component of the most prominent causes of morbidity and mortality in the US, –for example, refraining from smoking, eating a healthy diet, getting regular exercise, and limiting alcohol consumption– are behaviors that psychologists can really impact positively. Unfortunately, at least in my experience, other needs are so great that it is hard to make time for wellness/prevention initiatives unless there is a specific plan put in place.”
Author of Health Psychology, Dr. Linda Brannon said, “The division of health into mental and physical health is a false dichotomy that we need to get over. I think that many providers address the presenting problem to the extent that they do not look beyond it.”
For decades now, psychological scientists have known that behavior is the key to costs. Larzelere explained that psychological scientists have agreed that those using an integrated care model can expect a 30 to 60 percent reduction in medical use costs.
Quality care and cost savings dovetail at the primary care level. To put this in perspective, a 10 percent reduction in medical/surgery costs nationwide –by treating the mental or behavioral
component– would exceed the entire current national mental health budget, she explained.
She is correct. Prior to Covid, CMS and The National Health Expenditure Accounts reported that healthcare spending reached $3.5 trillion in both public and private sources. This is $10,739 per person. And accounts for 17.9 percent of the Gross Domestic Product.
A ten percent savings, as Larzelere suggests, is $350 billion. Estimating savings at 30 percent could mean a savings of $1 trillion dollars.
Is all this spending doing anyone any good?
A pattern of poor health outcomes and high costs reflects the country as a whole. The United States ranks 50th out of 55 industrialized countries in a measure of life expectancy and medical care spending, according to Bloomberg, who concluded the U.S. is the “least-efficient” health-care system in the world.
Louisiana is always at the bottom. In the most recent report from America’s Health Rankings, an annual analysis of the United Health Foundation, Louisiana ranks No. 50.
The state has its challenges. Nearly 21% of the population of the state is at the poverty level or below, when only 12 1/2% of the citizens nationwide fall at this level of economic status. Over 41% of the citizens a Louisiana fall at 200% of the poverty level or below. Compare this to 29.75 percent nationwide.
Health is woven into a complex set of social and psychological behaviors, not a single cause. “Socioeconomic status is one of the most powerful predictors of all cause mortality,” says Dr. Chris Leonhard, health psychologist and Professor at the Chicago Professional School at Xavier. “New Orleans is a startling example of this,” Leonhard said. “Life expectancy at birth in the Tremé where the average household income in 2010 was about $26,000 is 55 years, while in Lakeview, the average 2010 household income $75,000, and life expectancy at birth is 80 years.”
Pre-Covid, Louisiana paid $10.7 billion on behalf of about 1.9 million Medicaid recipients, averaging about $5,694 per recipient, according to the Louisiana Department of Health.
During the fiscal year 2017–2018, about 39.6 percent of Louisiana’s population were enrolled in the Medicaid program and payments were made on behalf of 1,876,908 recipients.
However, according to an analysis by Blake Kruger and Jeremiah Brown, Louisiana spends the most on Medicare beneficiaries per capita than any other state. At the same time, we reports greater disparities in health status and death rates than other states.
Kruger and Brown investigated the associations between healthcare intensity, healthcare spending, and mortality in Louisianan Medicare beneficiaries. They defined healthcare intensity to be synonymous with the hospital care intensity index, a combination of inpatient days and physicians’ services.
The researchers found no association between healthcare intensity and spending. Nor did they find any association between spending and mortality, noting, “We also observed no association between health-care spending and age, sex, and race-adjusted mortality.” And, when they compared healthcare intensity to age, sex, and race-adjusted mortality, they could find no meaningful associations. Nor did they find than more spending made any difference in survival when adjust for smoking, inactivity, or obesity.
They concluded, “We found that no associations exist between healthcare intensity and spending, spending and mortality, as well as healthcare intensity and mortality. The lack of an
association between healthcare intensity and spending may indicate that outpatient care in Louisiana is becoming more highly utilized and thus our measure of inpatient care intensity
is becoming less sensitive. These findings may also reflect that spending more on healthcare in Louisiana may not improve rates of survival and should prompt reflection as to the role social programs play in producing more auspicious health outcomes for Louisianans.”
Healthcare is Designed by Special Interests
The sheer size and complexity of the healthcare industry would suggest that innovations would be challenging, but change may be even more unlikely because of the political power yielded by the industry. Over the last years the pharmaceutical industry, Blue Cross/Blue Shield, the American Hospital Association, and the American Medical Association were the some of the highest contributors to Congress.
Psychology and other groups have not been able to garner a place at the medical table. California Attorney David Ries of Human Capital Specialists tried to persuade federal Rule makers to include psychologists in the bonus plan for Accountable Care Organizations (ACOs) but failed. He told the Times that the final Rules were very disappointing, and said, “The broad recognition of the importance of behavioral health to overall wellness indicates that ACOs are unlikely to achieve their treatment objectives …”.
These special interests exert themselves not only through direct lobbying, but the medical-pharmaceutical-hospitalinsurance industrial complex has a firm hold on the prices and services through the “CPT Codes” and the “Relative Value Scale Update Committee” or RUC. These special interest groups decide what services are allowed and how much they are reimbursed.
The CPT codes, short for Current Procedural Terminology, control what services are allowed and reimbursed. The codes are created by three hundred “Advisors and Experts,” primarily from the American Medical Association’s House of Delegates, representing medical specialties, who attempt to influence an “Editorial Panel,” composed of representatives from medical societies, insurance companies and the government. This panel conducts secret meetings and decides on what healthcare services are paid for, and which are not.
Dr. Tony Puente, Past-President of APA, was one of the two outsiders allowed to participate in the CPT process. “Essentially,” he said, “the CPT tries to divvy it up in a way that is theoretically and empirically, and diplomatically and politically, correct.” Participants must sign a strict AMA (American Medical Association) confidentiality agreement and declare, “I will not disclose, distribute or publish confidential Information to any party in any manner whatsoever.”
To decide on reimbursement, 28 voting members on RUC, representing medicine specialties such as anesthesiology, cardiology, neurology, neurosurgery, obstetrics, oncology, psychiatry, and so on, meet and decide how much each service is worth, and how much is to be paid.
The CPT system is dominated by organized medicine. “Every seat at the table has a vested interest, mostly not supporting your proposed code,” said Dr. Travis Thompson, professor, psychologist, and leader in the Association for Behavior Analysis International. He was speaking after it took him and colleagues three years to muscle through codes for the treatment of autism.
While the CPT approval is a first leg of a long journey, another element of this behind-the-scenes influence is the panel known as AMA/ Specialty Relative Value Scale Update Committee, or RUC. Since 1991 members of the RUC establish the value or price for the CPT codes. Somehow this is not considered price-fixing.
Control of the CPT and RUC have helped shaped health care toward high technology and high prices, less primary care, and no prevention.
A dramatic example of flawed decisions in the medical/pharma industrial complex is the opioid crisis. Twenty years after a marketing blitz aimed at convincing physicians that opioids were safe and effective, the overprescribing of this heroine-type drug has catapulted overdose deaths to the highest rate in modern times.
Despite the flood of legal opioids into the society, the CDC reported no change in pain that would meaningfully drive the prescribing: “…there had not been an overall change in the amount of pain that Americans reported.”
In contrast, the CDC did find that psychological and physical treatments for pain were beneficial (“CDC Guideline for Prescribing Opioids for Chronic Pain”). This despite the fact that these non-medical approaches are rarely integrated into
treatment programs.
And, they were often the more appropriate treatment. “It is now widely accepted that pain is a biopsychosocial phenomenon,” clinical health psychologist and Past-President of the Southern Pain Society, Dr. Geralyn Datz said, and that must be treated as such.
Conclusion
Dramatic changes are needed in the structure and function of the healthcare institutions currently used for the state and the nation. Individuals will need to be treated for root causes,
which will be more behavioral and psychological in nature than the current methods or models.
Louisiana may have the most to gain from prevention and innovations of any state in the nation. But there is a long way to go.
“A bright new future of understanding, preventing, and treating mental disorders awaits us,” writes Bonnie Kaplan.
But just how long is that wait going to be?