Saturday, August 17, 2013
We nurses all have stories — if we're lucky, it's just one — about the time we failed a patient. It's usually a problem of being too busy: too many cases, too many procedures to keep track of until one critical step, just one, slips through our frenetic fingers and someone gets hurt.
I saw it happen the first time while in nursing school. A patient needed an escalating dose of pain medicine. Her pain eased, but her breathing slowed and her oxygen level dropped. I told her nurse that the patient might need narcan, a reversing agent for opioids.
"Narcan?" The nurse didn't have time for that. Caring for eight patients on a busy medical-surgery floor meant that getting through the day's tasks took up all her time. Half an hour later, though, the patient needed an emergency team to revive her. I held her hand while an anesthesiologist stuck a tube down her throat. She ended up in intensive care.
It would be easy to blame the nurse. How could she be too busy? But she was a good nurse, smart and committed. She simply had too much to do, too many acute needs to address. And then one, just one, got out of control.
Bedside nurses are the hospital's front line, but we can't do the first-alert part of our jobs if there aren't enough of us on the floor. More demands for paperwork, along with increasing complexity of care, means the amount of time any one nurse has for all her patients is diminishing. And as hospitals face increasing financial pressure, nurse staffing often takes a hit, because nurses make up the biggest portion of any hospital's labor costs.
For patients, though, the moral calculus of the nurses-for-money exchange doesn't add up. Pioneering work done by Linda H. Aiken at the University of Pennsylvania in 2002 showed that each extra patient a nurse had above an established nurse-patient ratio made it 7 percent more likely that one of the patients would die. She found that 20,000 people died a year because they were in hospitals with overworked nurses.
Research also shows that when floors are adequately staffed with bedside nurses, the number of patients injured by falls declines. Staff increases lead to decreases in hospital-acquired infections, which kill 100,000 patients every year.
The importance of sufficient nurse staffing is becoming irrefutable, so much so that the Registered Nurse Safe-Staffing Act of 2013 was recently introduced by Representatives Lois Capps, a Democrat from California and a nurse, and David Joyce, a Republican from Ohio.
Among other things, the act would require that hospitals include their nurse staffing levels on Medicare's Hospital Compare Web site and post their staffing levels in a visible place in every hospital.
Concerns over money will determine whether this bill has even a chance at passing. It is collecting co-sponsors, but similar legislation has never gotten very far because hospital administrators view such mandates as too costly.
It's hard to do a definitive cost-benefit analysis of a variable as complicated as nurse staffing because health care accounting systems are often byzantine. But data suggest that sufficient staffing can significantly reduce hospital costs.
Medicare won't reimburse a hospital if a patient is readmitted before 30 days, and a full nursing staff is one way to reduce readmissions. Having enough nurses increases patient-satisfaction scores, which also helps maintain Medicare reimbursement levels. Understaffing leads to burnout and nurses' quitting their jobs, both of which cost money in terms of absenteeism and training new staff. Finally, falls and infections have associated costs.
What this discussion of finances misses, though, is that having enough nurses is not just about dollars and cents. It's about limiting the suffering of human beings. When hospitals have insufficient nursing staffs, patients who would have gotten better can get hurt, or worse.
Several months ago I started a new job, and a few weeks in I heard my name being called. A patient getting a drug that can cause dangerous reactions was struggling to breathe. I hurried to her room, only to discover that I wasn't needed. The other nurses from the floor were already there, stopping the infusion, checking the patient's oxygen and drawing up the rescue medication.
The patient was rattled, but there were enough nurses to respond, and in the end she was completely fine.
Now picture the same events in a different hospital, one that doesn't adequately staff, and this time the patient is you. As the drug drips in, you feel a malaise. You breathe deeply but can't quite get enough air. Your thinking becomes confused, your heart races. Terrified, you press the call light, you yell for help, but the too few nurses on the floor are spread thin and no one comes to help in time. A routine infusion ends with a call to a rapid-response team, a stay in intensive care, intubation, ventilation, death.
This kind of breakdown is not the nurses' fault, but the system's. We are not an elastic resource. We can be where we are needed, but only if there are enough of us.
Friday, August 16, 2013
The howler was a patient in his 30s who earned his nickname for his nightly bouts of yelling. This was in the early 1990s, during the peak of the AIDS epidemic. I was a second-year medical resident at Bellevue Hospital, in charge of the sprawling AIDS ward that night. Admissions were rolling in, one after another, each more feverish and emaciated than the previous.
This patient was already receiving hefty doses of pain medication, yet he kept screaming to the nurses about his pain. This went on, night after night, despite extensive medical evaluations to see if there were any missed explanations for his pain.
Nothing seemed to help, and the nightly yowling was agitating the other patients and driving the nursing staff to distraction. The head nurse paged me at 3 a.m. "You have to do something," she said.
I went to the patient's room. It was my fourth visit of the night, and the patient and I were both pretty exasperated with each other. He was sullen and cranky; I was exhausted and at my wits' end.
I pulled out a syringe and carefully drew up one c.c. of plain saline. "You know about Tylenol," I said, showing him the liquid-filled syringe. "You've heard of Tylenol #3. There's even a Tylenol #4. This" — and here I paused for dramatic effect— "this is Tylenol #5."
The patient stopped howling and gave me an interested look. Then he lowered his pajamas and allowed me to inject his gluteus maximus. Afterward, I pulled up a chair to his bedside and we waited together, allowing the minutes to tick unhurriedly by.
After what seemed like a mutually agreeable time, I stood up and bid him goodnight. The patient put his head to the pillow and promptly fell asleep. The ward was silent for the rest of the night.
I felt terribly guilty that I had committed an outright deception with this patient — something that is a true no-no. But on the other hand, it was the first night he got a full night of sleep, to say nothing of all the other patients on the ward and the rest of the staff.
When I related this story to Dr. Ted J. Kaptchuk, director of the program in placebo studies at Harvard, he gave a sigh of recognition. "We all have our moments of desperation," he said. "Usually around midnight."
Dr. Kaptchuk does not condone deception, but his research bears out that how caregivers present and administer treatments has a powerful effect on clinical outcomes.
Patients, for example, who received pain medicine directly from a doctor achieved better pain relief than patients who unknowingly received the same medicine, even at higher doses, automatically in their IVs. The rituals the doctor performs — drawing up the medication, visibly injecting it into the IV, discussing expected benefits — not to mention the attention and caring that comes with the presence of an actual human being — effected as much pain relief as doubling the dose of the medicine.
Placebos used to be thought of as psychological mumbo-jumbo more akin to hypnotism than real medicine. The biological breakthrough came in 1978, when researchers showed that not only was the placebo effect real, but that it could be reversed by administering naloxone — the chemical that blocks our endorphins, our natural painkillers.
Suddenly there was a plausible pharmacological mechanism for how placebos work and research in the field flowered. In June, Harvard Medical School and the Robert Wood Johnson Foundation held an international medical conference devoted entirely to placebo science.
Dr. Kaptchuk describes placebos as not just the traditional sugar pill, but also "everything that surrounds a medical treatment": how caregivers describe the medication, how they administer it, the expectations they have for the medicine, their tone of voice, their strength of eye contact. In short, everything that doctors and nurses do in an interaction with a patient.
This is not especially surprising. Healers and shamans have known intuitively about the importance of this interaction since the dawn of time. Before we had developed treatments that could significantly impact the pathology of disease — antibiotics, chemotherapy, stents, organ transplants, transfusions — the "everything else" was the mainstay of medical care.
Doctors and nurses always feel a bit uneasy when it comes to placebos. Somehow it seems wrong, unethical, deceptive. But patients, it turns out, seem to be more flexible in their thinking. Studies have shown symptom relief even when patients are told they are getting a placebo; many patients are quite amenable to such "open-label" placebos. "If it gets rid of the pain," a patient once told me, "I don't care if it's a dill pickle!"
The ethics are evolving, but the general consensus is that transparency is the bottom line. What I did as a young — and desperate — resident wouldn't pass muster, because I deceived my patient about the medication. But if I'd told him that it was inert saline and if he was amenable to trying it, it could have been a reasonable treatment option. And it still might have helped him, especially if we had been able to have a detailed and compassionate conversation about his pain.
Dr. Kaptchuk thinks of placebo effects as just one of the many things in the toolkit of medicine. It would never be a substitute for appropriate medical care, but it is something that can enhance medical care greatly. Wise doctors and nurses already do this. They've found, usually just by personal experience, that their "everything else" — respect, attention, comfort, empathy, touch — often does the lion's share of medical care, no deception required. Sometimes the prescription is just the afterthought.
Danielle Ofri's newest book is "What Doctors Feel: How Emotions Affect the Practice of Medicine." She is an associate professor of medicine at NYU School of Medicine and has cared for patients at Bellevue Hospital for more than 20 years. She is editor in chief of the Bellevue Literary Review.
The only reasonable explanation for drinking Budweiser is to get drunk. It's certainly not for the taste. So it makes sense that in a pilot study of ER patients who'd been consuming alcohol, conducted by Johns Hopkins Bloomberg School of Public Health, the number one brand they'd been guzzling was Budweiser,NBC News reports.
Budweiser holds 9.1 percent of the national beer market in the U.S., but 15 percent of the questionably desirable demographic of people who drink and then end up in the emergency room. Also a top contender in the ER market is Steel Reserve, which only holds 0.8 percent of the U.S. beer market, but a whopping 14.7 percent of alcohol-inclined ER patients.
Bud Light, Bud Ice malt liquor and Colt 45 malt liquor also made strong showings in the hospital circuit.
The study is limited, of course, to the one small Baltimore hospital where the 105 patient interviews took place. (Sidebar: the survey takers wore white coats, which made patients more willing to talk—remember kids, not everyone in a white coat is a doctor)
Still, about one third of all ER visits involve alcohol in some way, and beer and malt liquor dominated in this particular study, so to improve your chances, perhaps reach for a refreshing glass of wine instead.
Thursday, August 15, 2013
Tuesday, August 13, 2013
Monday, August 12, 2013
Thousands of foreign-trained immigrant physicians are living in the United States with lifesaving skills that are going unused because they stumbled over one of the many hurdles in the path toward becoming a licensed doctor here.
The involved testing process and often duplicative training these doctors must go through are intended to make sure they meet this country's high quality standards, which American medical industry groups say are unmatched elsewhere in the world. Some development experts are also loath to make it too easy for foreign doctors to practice here because of the risk of a "brain drain" abroad.
But many foreign physicians and their advocates argue that the process is unnecessarily restrictive and time-consuming, particularly since America's need for doctors will expand sharply in a few short months under President Obama's health care law. They point out that medical services cost far more in the United States than elsewhere in the world, in part because of such restrictions.
The United States already faces a shortage of physicians in many parts of the country, especially in specialties where foreign-trained physicians are most likely to practice, like primary care. And that shortage is going to get exponentially worse, studies predict, when the health care law insures millions more Americans starting in 2014.
The new health care law only modestly increases the supply of homegrown primary care doctors, not nearly enough to account for the shortfall, and even that tiny bump is still a few years away because it takes so long to train new doctors. Immigrant advocates and some economists point out that the medical labor force could grow much faster if the country tapped the underused skills of the foreign-trained physicians who are already here but are not allowed to practice. Canada, by contrast, has made efforts to recognize more high-quality training programs done abroad.
"It doesn't cost the taxpayers a penny because these doctors come fully trained," said Nyapati Raghu Rao, the Indian-born chairman of psychiatry at Nassau University Medical Center and a past chairman of the American Medical Association's international medical graduates governing council. "It is doubtful that the U.S. can respond to the massive shortages without the participation of international medical graduates. But we're basically ignoring them in this discussion and I don't know why that is."
Consider Sajith Abeyawickrama, 37, who was a celebrated anesthesiologist in his native Sri Lanka. But here in the United States, where he came in 2010 to marry, he cannot practice medicine.
Instead of working as a doctor himself, he has held a series of jobs in the medical industry, including an unpaid position where he entered patient data into a hospital's electronic medical records system, and, more recently, a paid position teaching a test prep course for students trying to become licensed doctors themselves.
For years the United States has been training too few doctors to meet its own needs, in part because of industry-set limits on the number of medical school slots available. Today about one in four physicians practicing in the United States were trained abroad, a figure that includes a substantial number of American citizens who could not get into medical school at home and studied in places like the Caribbean.
But immigrant doctors, no matter how experienced and well trained, must run a long, costly and confusing gantlet before they can actually practice here.
The process usually starts with an application to a private nonprofit organization that verifies medical school transcripts and diplomas. Among other requirements, foreign doctors must prove theyspeak English; pass three separate steps of the United States Medical Licensing Examination; get American recommendation letters, usually obtained after volunteering or working in a hospital, clinic or research organization; and be permanent residents or receive a work visa (which often requires them to return to their home country after their training).
The biggest challenge is that an immigrant physician must win one of the coveted slots in America's medical residency system, the step that seems to be the tightest bottleneck.
That residency, which typically involves grueling 80-hour workweeks, is required even if a doctor previously did a residency in a country with an advanced medical system, like Britain or Japan. The only exception is for doctors who did their residencies in Canada.
The whole process can consume upward of a decade — for those lucky few who make it through.
"It took me double the time I thought, since I was still having to work while I was studying to pay for the visa, which was very expensive," said Alisson Sombredero, 33, an H.I.V. specialist who came to the United States from Colombia in 2005.
Dr. Sombredero spent three years studying for her American license exams, gathering recommendation letters and volunteering at a hospital in an unpaid position. She supported herself during that time by working as a nanny. That was followed by three years in a residency at Highland Hospital in Oakland, Calif., and one year in an H.I.V. fellowship at San Francisco General Hospital. She finally finished her training this summer, eight years after she arrived in the United States and 16 years after she first enrolled in medical school.
Dr. Sombredero was helped through the process by the Welcome Back Initiative, an organization started 12 years ago as a partnership between San Francisco State University and City College of San Francisco. The organization has worked with about 4,600 physicians in its centers around the country, according to its founder, José Ramón Fernández-Peña.
Only 118 of those doctors, he said, have successfully made it to residency.
"If I had to even think about going through residency now, I'd shoot myself," said Dr. Fernández-Peña, who came to the United States from Mexico in 1985 and chose not even to try treating patients once he learned what the licensing process requires. Today, in addition to running the Welcome Back Initiative, he is an associate professor of health education at San Francisco State.
The counterargument for making it easier for foreign physicians to practice in the United States — aside from concerns about quality controls — is that doing so will draw more physicians from poor countries. These places often have paid for their doctors' medical training with public funds, on the assumption that those doctors will stay.
"We need to wean ourselves from our extraordinary dependence on importing doctors from the developing world," said Fitzhugh Mullan, a professor of medicine and health policy at George Washington University in Washington. "We can't tell other countries to nail their doctors' feet to the ground at home. People will want to move and they should be able to. But we have created a huge, wide, open market by undertraining here, and the developing world responds."
About one in 10 doctors trained in India have left that country, he found in a 2005 study, and the figure is close to one in three for Ghana. (Many of those moved to Europe or other developed nations other than the United States.)
No one knows exactly how many immigrant doctors are in the United States and not practicing, but some other data points provide a clue. Each year the Educational Commission for Foreign Medical Graduates, a private nonprofit, clears about 8,000 immigrant doctors (not including the American citizens who go to medical school abroad) to apply for the national residency match system. Normally about 3,000 of them successfully match to a residency slot, mostly filling less desired residencies in community hospitals, unpopular locations and in less lucrative specialties like primary care.
Over the last five years, an average of 42.1 percent of foreign-trained immigrant physicians who applied for residencies through the national match system succeeded. That compares with an average match rate of 93.9 percent for seniors at America's mainstream medical schools.
Mr. Abeyawickrama, the Sri Lankan anesthesiologist, has failed to match for three years in a row; he blames low test scores. Most foreign doctors spend several years studying and taking their licensing exams, which American-trained doctors also take. He said he didn't know this, and misguidedly thought it would be more expeditious to take all three within seven months of his arrival.
"That was the most foolish thing I ever did in my life," he says. "I had the knowledge, but I did not know the art of the exams here."
Even with inadequate preparation, he passed, though earning scores too low to be considered by most residency programs. But as a testament to his talents, he was recently offered a two-year research fellowship at the prestigious Cleveland Clinic, starting in the fall. He is hoping this job will give residency programs reason to overlook his test scores next time he applies.
"Once I finish my fellowship in Cleveland, at one of the best hospitals in America, I hope there will be some doors opening for me," he said. "Maybe then they will look at my scores and realize they do not depict my true knowledge."
The residency match rate for immigrants is likely to fall even lower in coming years. That is because the number of accredited American medical schools, and therefore United States-trained medical students, has increased substantially in the last decade, while the number of residency slots (most of which are subsizided by Medicare) has barely budged since Congress effectively froze residency funding in 1997.
Experts say several things could be done to make it easier for foreign-trained doctors to practice here, including reciprocal licensing arrangements, more and perhaps accelerated American residencies, or recognition of postgraduate training from other advanced countries.
Canada provides the most telling comparison. Some Canadian provinces allow immigrant doctors to practice family medicine without doing a Canadian residency, typically if the doctor did similar postgraduate work in the United States, Australia, Britain or Ireland. There are also residency waivers for some specialists coming from select training programs abroad considered similar to Canadian ones.
As a result, many (some estimates suggest nearly half) foreign-trained physicians currently coming into Canada do not have to redo a residency, said Dr. Rocco Gerace, the president of the Federation of Medical Regulatory Authorities of Canada.
In the United States, some foreign doctors work as waiters or taxi drivers while they try to work through the licensing process. Others decide to apply their skills to becoming another kind of medical professional, like a nurse practitioner or physician assistant, adopting careers that require fewer years of training. But those paths present barriers as well.
The same is true for other highly skilled medical professionals.
Hemamani Karuppiaharjunan, 40, was a dentist in her native India, which she left in 2000 to join her husband in the United States. She decided that going back to dentistry school in the United States while having two young children would be prohibitively time-consuming and expensive. Instead, she enrolled in a two-year dental hygiene program at Bergen Community College in Paramus, N.J., which cost her $30,000 instead of the $150,000 she would have needed to attend dental school. She graduated in 2012 at the top of her class and earns $42 an hour now, about half what she might make as a dentist in her area.
The loss of status has been harder.
"I rarely talk about it with patients," she said. When she does mention her background, they usually express sympathy. "I'm glad my education is still respected in that sense, that people do recognize what I've done even though I can't practice dentistry."
Sunday, August 11, 2013
"I don't feel comfortable prescribing anything," he said. "Not with everything else you're on." He said it was probably safe to take Tylenol and politely but firmly indicated it was time for me to go. The next day my eardrum ruptured and I was left with minor but permanent hearing loss.
Another time I was lying on the examining table when a gastroenterologist I was seeing for the first time looked at my list of drugs and shook her finger in my face. "You better get yourself together psychologically," she said, "or your stomach is never going to get any better."
If you met me, you'd never know I was mentally ill. In fact, I've gone through most of my adult life without anyone ever knowing — except when I've had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my résumé, my education, my accomplishments, reduces me to a diagnosis.
I was surprised when, after one of these run-ins, my psychopharmacologist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medical care than "normal" people. Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions "a hidden human rights emergency."
I never knew it until I started poking around, but this particular kind of discriminatory doctoring has a name. It's called "diagnostic overshadowing."
According to a review of studies done by the Institute of Psychiatry at King's College, London, it happens a lot. As a result, people with a serious mental illness — including bipolar disorder, major depression, schizophrenia and schizoaffective disorder — end up with wrong diagnoses and are under-treated.
That is a problem, because if you are given one of these diagnoses you probably also suffer from one or more chronic physical conditions: though no one quite knows why, migraines, irritable bowel syndrome and mitral valve prolapse often go hand in hand with bipolar disorder.
Less mysterious is the weight gain associated with most of the drugs used to treat bipolar disorder and schizophrenia, which can easily snowball into diabetes, high blood pressure, high cholesterol and cardiovascular disease. The drugs can also sedate you into a state of zombiedom, which can make going to the gym — or even getting off your couch — virtually impossible.
It's little wonder that many people with a serious mental illness don't seek medical attention when they need it. As a result, many of us end up in emergency rooms — where doctors, confronted with an endless stream of drug addicts who come to their door looking for an easy fix — are often all too willing to equate mental illness with drug-seeking behavior and refuse to prescribe pain medication.
I should know: a few years ago I had a persistent migraine, and after weeks trying to get an appointment with any of the handful of headache specialists in New York City, I broke down and went to the E.R. My husband filled out paperwork and gave the nurse my list of drugs. The doctors finally agreed to give me something stronger than what my psychopharmacologist could prescribe for the pain and hooked me up to an IV.
I lay there for hours wearing sunglasses to block out the fluorescent light, waiting for the pain relievers to kick in. But the headache continued. "They gave you saline and electrolytes," my psychopharmacologist said later. "Welcome to being bipolar."
When I finally saw the specialist two weeks later (during which time my symptoms included numbness and muscle weakness), she accused me of being "a serious cocaine user" (I don't touch the stuff) and of displaying symptoms of "la belle indifference," a 19th-century term for a kind of hysteria in which the patient converts emotional symptoms into physical ones — i.e., it was all in my head.
Indeed, given my experience over the last two decades, I shouldn't have been surprised by the statistics I found in the exhaustive report "Morbidity and Mortality in People with Serious Mental Illness," a review of studies published in 2006 that provides an overview of recommendations and general call to arms by the National Association of State Mental Health Program Directors. The take-away: people who suffer from a serious mental illness and use the public health care system die 25 years earlier than those without one.
True, suicide is a big factor, accounting for 30 to 40 percent of early deaths. But 60 percent die of preventable or treatable conditions. First on the list is, unsurprisingly, cardiovascular disease. Two studies showed that patients with both a mental illness and a cardiovascular condition received about half the number of follow-up interventions, like bypass surgery or cardiac catheterization, after having a heart attack than did the "normal" cardiac patients.
The report also contains a list of policy recommendations, including designating patients with serious mental illnesses as a high-priority population; coordinating and integrating mental and physical health care for such people; education for health care workers and patients; and a quality-improvement process that supports increased access to physical health care and ensures appropriate prevention, screening and treatment services.
Such changes, if implemented, might make a real difference. And after seven years of no change, signs of movement are popping up, particularly among academic programs aimed at increasing awareness of mental health issues. Several major medical schools now have programs in the medical humanities, an emerging field that draws on diverse disciplines including the visual arts, humanities, music and science to make medical students think differently about their patients. And Johns Hopkins offers a doctor of public health with a specialization in mental health.
Perhaps the most notable of these efforts — and so far the only one of its kind — is the narrative medicine program at Columbia University Medical Center, which starts with the premise that there is a disconnect between health care and patients and that health care workers need to start listening to what their patients are telling them, and not just looking at what's written on their charts.
According to the program's mission statement, "The effective practice of health care requires the ability to recognize, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence is a model for humane and effective medical practice."
We can only hope that humanizing programs like this one become a requirement for all health care workers. Maybe then "first, do no harm" will apply to everyone, even the mentally ill.
By Juliann Garey, the author of the novel "Too Bright to Hear Too Loud to See" and a co-editor of "Voices of Bipolar Disorder: The Healing Companion."
We want patients to receive the best care available. We also want consumers to pay less. And we don't want to bankrupt the government or private insurers. Something must give.
The debate centers on how to make these trade-offs, and who gets to make them. The stakes are high, and the choices are at times unseemly. No matter how necessary, putting human suffering into dollars and cents is not attractive work. It's no surprise, then, that the conversation is so heated.
What is a surprise is that amid these complex issues, one policy sidesteps these trade-offs. A few drugs — such as beta-blockers, statins and glycogen control medications — have proved very effective at managing hypertension, heart disease, diabetes and strokes. Most insurance plans charge something for them. Why not make drugs like these free? Not for everyone, but just the groups for whom they are provably effective.
In traditional economics, such a policy creates waste. The basic principle is moral hazard: consumers overuse goods that are subsidized. This is why people fly in business class when they're on an expense account but in economy when it's on their own dime.
In health care, a doctor or patient might order an extra test casually, just because it's free. This is inefficiency at its worst: from money spent on costly procedures to tests and medicines that provide little medical benefit, some actions are undertaken only because someone else picks up the check. To discourage this waste, insurance plans charge co-payments. The logic is simple: if patients face costs, they will think more carefully about the benefits.
But people don't always follow a cost-benefit logic. Consider a patient recovering from a heart attack. A small cocktail of drugs may cost a trivial amount — say, $5 — yet it reduces the risk of subsequent heart disease mortality by as much as 80 percent. That's a good deal, but as many as 50 percent of people fail to take these medications regularly.
The problem is basic human psychology. Heart disease is silent, with few noticeable symptoms. You feel fine most of the time, so it's all too easy to justify skipping the statin.
The problem here is the exact opposite of moral hazard. People are not overusing ineffective drugs; they are underusing highly effective ones. This is a quandary that two colleagues — Katherine Baicker, a professor of health economics at Harvard, and Josh Schwartzstein, a professor of economics at Dartmouth — and I call "behavioral hazard."
We've found that co-payments do not resolve behavioral hazard. They make it worse. They reduce the use of a drug that is already underused.
A recent experiment by a team led by Niteesh Choudhry, a professor of medicine at Harvard, quantifies the problem. The experiment involved nearly 6,000 patients who had just suffered a heart attack, and were prescribed drugs known to reduce the chance of another one — statins, beta-blockers, angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers. Half had their co-pays for these drugs waived; the other half paid the usual fee.
As expected, more people in the zero co-pay group took the drugs, and their health improved. Those in the zero co-pay group were 31 percent less likely to have a stroke, 11 percent less likely to have another major "vascular episode" and 16 percent less likely to have a myocardial infarction or unstable angina. None of these benefits came at a net monetary cost. The insurers did not spend more in total. By some measures, they spent less.
Behavioral hazard affects all of the drugs listed above. They are all highly effective, and yet adherence to taking them is a problem. This is a major financial issue. The New England Healthcare Institute has estimated that solving non-adherence could save $290 billion a year, or 13 percent of total annual medical spending in the United States. A number this large is surely open to quibbling, but divide it by 10 and it is still a large figure.
I'm not proposing to make all health care free, or arguing for a return to so-called Cadillac health plans. Moral hazard is all too real for many treatments, and in some cases, behavioral hazard reinforces it. Just as people underrespond to inconspicuous symptoms, they can also overrespond to highly noticeable ones. People may seek too much care for back pain, for example, resorting to ineffective or possibly even harmful treatments. Behavioral hazard suggests that we need even larger co-payments for these overused drugs.
My proposal is targeted: Take drugs that are shown to be of very high benefit to some people, and make those drugs free for them.
It's a simple policy change, and it isn't meant as a complete solution.
First, researchers like A. Mark Fendrick, a professor of internal medicine at the University of Michigan, and Michael Chernew, now a professor of health care policy at Harvard, argue eloquently for what they call "value based" health insurance. All co-pays should depend on measured medical value; high co-pays should be reserved for drugs and medical services that have little proven value.
Second, some people will neglect to take their medications even if co-pays are zero. This proved true even in the Choudhry study.
Fully solving this problem requires more creativity. GlowCaps, for example, are high-tech tops for pill bottles. They beep and text you if you forget to take your medication. In another approach,Kevin Volpp, a professor of medicine and health care management at the University of Pennsylvania, and his colleagues use lotteries, giving people a chance to win only if they take their medications.
FINALLY, some will suggest that focusing on drug adherence is like closing the barn door. Why not focus instead on the behaviors — eating unhealthy foods or shunning exercise — that created the conditions we must now treat with drugs?
Each of these points has some merit. But they fail the "perfect as the enemy of the good" test. Sure, we should do more. But meanwhile, why continue to charge the same co-pay for statins and beta-blockers as we do for Viagra? At the very least, we need to experiment more with this policy.
Sendhil Mullainathan is a professor of economics at Harvard.
This isn't what it was like at all.
In reality, medical care during pregnancy seemed to be one long list of rules. Being pregnant was a good deal like being a child again. There was always someone telling me what to do, but the recommendations from books and medical associations were vague and sometimes contradictory. It started right away. "You can only have two cups of coffee a day." I wondered why. What did the numbers say about how risky one, two or three cups were? This wasn't discussed anywhere.
Is drinking while pregnant really that bad? Economist Emily Oster talks with Wendy Bounds about the research behind the most common pregnancy taboos.
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The key to good decision making is evaluating the available information—the data—and combining it with your own estimates of pluses and minuses. As an economist, I do this every day. It turns out, however, that this kind of training isn't really done much in medical schools. Medical school tends to focus much more, appropriately, on the mechanics of being a doctor.
When I asked my doctor about drinking wine, she said that one or two glasses a week was "probably fine." But "probably fine" isn't a number. In search of real answers, I combed through hundreds of studies—the ones that the recommendations were based on—to get to the good data. This is where another part of my training as an economist came in: I knew enough to read the numbers correctly. What I found was surprising.
The key problem lies in separating correlation from causation. The claim that you should stop having coffee while pregnant, for instance, is based on causal reasoning: If you change nothing else, you'll be less likely to have a miscarriage if you drink less coffee. But what we see in the data is only a correlation—the women who drink coffee are more likely to miscarry. There are also many other differences between women who drink coffee and those who don't, differences that could themselves be responsible for the differences in miscarriage rates.
This problem is partially surmountable with better data, and I found that the best studies often painted a picture different from the official recommendations. Actually getting the numbers led me to a more relaxed place—a glass of wine every now and then, plenty of coffee, exercise when I wanted it. The economist's toolbox may not be known as a great stress reliever, but in this case it really was.
Consider weight gain. Almost every woman I have spoken to about pregnancy has a story about her doctor giving her a hard time about her weight. Later in my pregnancy it felt like all of my time with my doctor was focused on how fat I was getting—so fat! I was supposed to gain between 25 to 35 pounds. At one visit it seemed like I was on track for 36 pounds, and I got a serious scolding.
It's well known that frequent heavy drinking or binge drinking can cause fetal alcohol syndrome, with serious long-term consequences for your child. Yet the evidence shows that light drinking is fine.
What's the big deal? If you gain more weight during pregnancy, your baby will—on average—be larger. Babies who are very large are termed "large for gestational age." Babies who are very small are termed "small for gestational age." Babies in both categories are more likely to have complications.
Weight-gain guidelines are designed to maximize the chance that your baby is normal sized. If you gain less weight than recommended, you increase your chance of a small baby and decrease your chance of a large baby; vice versa if you gain more than recommended.
There is a nice logic to this, but I quickly realized that very small babies are associated with many more—and more serious—complications than very large babies. The main concern with a very large baby is difficulty in delivery. Very small babies have an increased risk of breathing problems and neurological complications.
The recommendations—which focus only on the probability of each thing happening and not on the magnitude of the problem—are incomplete. In the end, I concluded that I should be more worried about gaining too little weight than too much.
Pregnant women are also given a long list of off-limit foods: deli meats, soft cheeses, sushi. These are restricted because of the risk of various pathogens. The most serious by far is listeria bacteria, to which pregnant women are especially susceptible; it can cause late miscarriage and stillbirth.
I knew I didn't want to snack directly on listeria bacteria, but I wondered how much I could limit my risk by avoiding certain foods. What share of listeria infections was due to soft cheeses, for instance? It turns out that queso fresco, a Mexican soft cheese, has been implicated in about 20% of listeria outbreaks since 1998, and deli turkey in 10%. The rest of the recent outbreaks seemed random. One involved cantaloupe, another one, celery.
I concluded that avoiding queso fresco and deli turkey was a good idea, but in the end I didn't feel that it made sense even to exclude other deli meats. My best guess was that avoiding sliced ham would lower my risk of listeria from 1 in 8,333 to 1 in 8,255. I just didn't think it was worth it. It would have made more sense to avoid cantaloupe.
But food prohibitions are minor compared with the two items that women are most emphatically warned away from consuming during pregnancy: alcohol and coffee.