McCain’s Health Proposals Under the Microscope, Part V

Does he really have a way to control costs?

This is the fifth and final entry in a series examining John McCain’s health proposals and how they have been covered in the press. The previous entries can be found here: Part I, Part II, Part III, Part IV.

The New York Times has been running a fine series called the “Evidence Gap” that, at its core, reveals a key reason why health care in the U.S. costs so much, and why the nation’s medical bill of $2.7 trillion is higher than anywhere else in the world. We can’t say “no” to new technology. That’s partly because of our deeply held cultural belief that the medicine man sits at the right hand of God, and partly because so many players throughout the medical delivery system make a ton of money. The Times series, which has covered heart scanning machines, the cancer drug Avastin, and artificial joints, notes that even though these technologies may not work or deliver much benefit—and may even be harmful—they are still widely used. Someone pays for them, most likely employers, and the costs are eventually reflected in increasingly unaffordable insurance premiums.

John McCain’s health proposals ignore our national propensity to demand more of the three Ts—treatments, tests, and technology. Instead they nip around the edges of the country’s health care expenditures, which a lot of experts say will continue to soar into the stratosphere. “It would be a mistake to build false expectations about the amount of cost reduction that will take place,” says Frank McArdle, who manages the Washington research office for Hewitt Associates, a benefits consulting firm. “There’s probably very little if anything that will reduce current health care spending below current levels. At best, we’re looking at lowering the future rate of growth.”

The health care section of McCain’s Web site is peppered with all the latest buzz words. He calls for quality cheaper care for chronic disease, coordinated care, tort reform, greater use of information technology to reduce costs, smoking cessation programs, and allowing cheaper Canadian drugs into the country. While this might sound good to the public—and some things like better care coordination might actually benefit patients—there is no evidence that these reforms will lead to big savings. Writing about numbers is tricky. In today’s media climate, where reporters have less time to figure out complicated stuff, it’s not surprising the press might believe his claims about cost containment.

A few news outlets have looked at disease management, the current panacea, which runs the gamut from primary care truly integrated into managed care organizations like Kaiser Permanente to ad hoc programs sold to employers by profit-seeking vendors. These programs include patient education, patient self-management, phone calls from nurses, and mailings. Some outlets have examined disease management mostly through the lens of local businesses, and their stories seem more like puffery than objective analysis.

In late July, CNN ran a story profiling a Nebraska company that mandates quarterly check-ups and provides a variety of wellness programs for employees. “The return on investment is extraordinary,” says the company president. Or take the story published in June by the Peoria, Illinois Journal Star, featuring wellness programs at two Illinois medical centers. It quotes the executive director of Optimum Health Solutions, a company that sets up wellness programs, saying that, while it might take a number of years to see benefits, numerous studies show that a healthier workforce translates into savings, both for the individual and the company. What studies? What sources? The reporter apparently took Optimum’s word, even though plenty of studies, including one from the Congressional Budget Office, question whether disease management will actually result in savings.

Memo to the media: beware of pols pushing disease management as the new savior for health care costs. Their words should ring familiar to those who remember that managed care was supposed to do the same thing over a decade ago. Last year a researcher writing in the Annals of Family Medicine delivered an assessment which should find its way into any story on the subject:

There is no solid evidence yet that commercial for-profit disease management vendors will save money and improve care of chronic illness on a long-term basis. It is much more likely that the current enthusiasm among employers and insurers for outsourced disease management programs will end up as just one more policy failure, undermining primary care and delaying increasingly urgent health care reform.

Same story for information technology—another fuzzy concept touted as a cure-all for too-expensive medical care. Having all your medical records available electronically will let you see, graphically, whether you’re making progress lowering cholesterol; it can keep your doc from repeating diagnostic tests; it might help him or her spot potentially deadly drug combinations among the medications you are taking. But is it a panacea? It doesn’t seem so, at least not at the moment.

The Congressional Budget Office, a credible source, has also weighed in on this one. At a recent Washington health forum, CBO director Peter Orszag said that, while information technology could improve health care quality, it is not the cure-all solution for reducing health care costs. While savings are possible on a small scale, Orzag said that maximum savings and efficiency would require national adoption of health IT. It looks like the country has a long way to go before that will happen. The CBO report noted that, in 2006, only 12 percent of the nation’s doctors and 11 percent of hospitals had adopted health IT.

Health IT could also have detrimental effects for patients—effects that promoters don’t tout in press statements. On Monday, the Washington Post explored the dark side of all this free-floating health information. The Post offered a squirm-inducing angle on the topic: Big health information services companies like Milliman and Ingenix, a division of UnitedHealth Group (which owns mega insurance carrier UnitedHealth Care), are already collecting information from databases containing millions of Americans’ prescription drug records. Information companies use the data to create a sort of credit report for insurers and others who want to know how sick you are, what drugs you take, and so forth.

An entrepreneur who built one of the databases told the Post that an insurer “would be able to know that you have a high, near-intractable cholesterol problem” and could avoid a costly blood test. It also could mean that the insurer wouldn’t have to pay for the test. If the patient could avoid the test, that’s good—but what if the doctor ordered it anyway and the insurer refused to pay? Health IT has its pluses and minuses. Here’s pretty important minus: an insurer could also use the information to boot you out of the health plan. Here’s another: a drug company could try to switch you to a different medicine that helps build their market share. There are a lot of directions to go on stories about health IT, and journalists should look at the Post story as a good starting point.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.