August, 2015
Doctoring the Numbers
By Michael J. Katin, MD
The headline of the July 29, 2015, issue of USA Today said it all: "WHAT COULD BE WORSE THAN LAGUARDIA." And right next to it: " Drastic drop in Medicare deaths, costs."
The initial impression was there had been a decrease in deaths due to Medicare, but the article actually referred to a publication from the day before in the Journal of the American Medical Association regarding "Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013." The most prominent observation was the dramatic variation in capitalization protocol for various publications, but the newspaper article was a condensation of a very detailed report by Harlan M. Krumholz, Sudhakar V. Nuti, Nicholas S. Downing, Sharon-Lise T. Normand, and Yun Wang tracking multiple parameters of the Medicare population over a 14-year period.
The lead author Dr. Kruholz, has a resume that makes one realize how little one has accomplished in comparison. In addition to being the Harold H. Hines, Jr., Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation, he is also one of the directors of the Robert Wood Johnson Foundation Clinical Scholars Program and is on the Board of Trustees of the American College of Cardiology and Board of Directors of the American Board of Internal Medicine. In 2014 he was the recipient of the Friendship Award of the People's Republic of China. Of even further interest, he has a blog on Forbes.com and has authored "The Expert Guide to Beating Heart Disease ."
With all this going on, Dr. Krumholz was still able to make time to be interviewed by USA Today about the JAMA article, stating 'It's a jaw-dropping finding. We didn't expect to see such a remarkable improvement over time."
Indeed, the findings are remarkable, in terms of being to generate remarks. The obvious conclusion that a reader of USA Today would make would be that the Medicare program, or at least our system of medical care in general, has resulted in an improvement in survival with less money spent to achieve this! That's absolutely fantastic!!! Jaw-dropping would be appropriate in that case, but the question remains as to whether there are other reasons and also how this impacts on popular opinion (and, therefore, legislative interest) on the importance of supporting medical research and treatment of cancer.
It is somewhat worrisome to note that after World War I, when the United States had mobilized itself into a major world power, the Army and Navy were significantly downgraded and, in fact, in 1939 there were only 187,893 on active duty in the U.S. Army, fewer than in the army of Portugal that year. In addition, rapid demobilization also caused a recession in the U.S. economy due to the sudden loss of jobs (and, to be fair, things to be blown up). Winston Churchill guided the United Kingdom through World War II and, in gratitude, his party was voted out of office in May, 1945. Charles Dillon ("Casey") Stengel managed the New York Yankees to ten American League pennants and seven World's Championships between 1949 and 1960 and was let go as manager at the end of the 1960 season (he said he was going to be fired because he was "too old," and he was "never going to make the mistake of being 70 again "). Does it therefore make sense that if the medical profession is successful in making people live longer and spending less money doing it, that it should be penalized for that accomplishment? This is being done by the constant mantra about excessive spending for health care and the role of fraud, waste, and abuse (which, of course, occur only in the medical field) and the necessity for physicians to be paid less and have more bureaucratic responsibilities to be entitled to that reduced income. not to complain, of course. The medical profession has been fulfilling to millions of us but it would be nice to not have to worry about increasing pressures turning our future neurosurgeons to become hedge fund managers instead.
The truth is that advances in medical care and hospital and outpatient management probably have nothing at all to do with decreasing costs and lowering mortality of Medicare clients. Interestingly, the USA Today article mentioned that the 1999 report of the Institute of Medicine estimated that 98,000 people per year were killed by hospital errors and that attention to this might be responsible for a decrease in mortality rates. In fact, in 2014 the House Subcommittee on Primary Health and Aging heard testimony that 400,000 people per year are done in by preventable medical errors. It is remarkable that the very same issue of JAMA in which Dr. Krumholz' article appears has a report by Ravi Rajaram et al. that the hospitals that were penalized more frequently in the Hospital Acquired Condition (HAC ) Reduction Program of CMS turned out to be the ones with more quality accreditations, which had more advanced services, were major teaching institutions, and had better performance scores on other process and outcome measures. The most amazing observation was that hospitals with the highest quality score of 8 were penalized significantly more frequently than were hospitals that scored 0. The conclusion may not be to encourage your friends and relatives to go to hospitals with the lowest ratings, but that attempts to manage the system with quality and outcome scales are not necessarily guaranteed to be successful, just as complicated, detailed efforts to manage economies and deal with natural disasters often can have poor results.
In fact, there are two elements that almost certainly explain why the Medicare population is generally healthier in 2013 than in 1999, neither of which are related to recent innovations in health management. First, the mean age of the Medicare clients went down from 75.3 years to 74.8 years. This may not seem like much, but the younger Medicare enrollees are self-absorbed Baby Boomers, aka the "Me Generation," who have tried harder to keep themselves in good condition than did previous generations. This means the mortality will probably start to increase again in several years, since despite their best efforts to remain perpetually young, apoptosis will eventually take its toll. This despite the fact that statistics have indicated a much larger than expected number of Social Security recipients over age 112. There would obviously be concern than if these "irregularities" were addressed and these persons were all listed as "deceased," the mortality rate would shoot up dramatically.
One additional factor can easily explain why Medicare expenditures per person and mortality rates have temporarily improved. Cigarette smoking has decreased dramatically over the past fifty years, and it has been estimated that more than 795,000 deaths from lung cancer were prevented between 1975 and 2000. This doesn't even begin to address savings in lives from heart disease, stroke, and other smoking-related cancers such as bladder, esophageal, and head and neck cancer. This one factor alone would easily account for the drop in mortality.
Dr. Krumholz includes this in one of four possible explanations for the findings in his publication: 1. the National effort to improve the care of all patients across the study period. 2. ...may have been, in part, a reflection of healthier behaviors 3. shifting lifetime exposures..because of improvements in public health and 4. at least in part, to technological advances. Decreases in mortality and morbidity due to cessation of cigarette smoking therefore fits in only in the "may have been" part of the second of his four possible explanations. He is being much too modest. In addition to the work of Surgeon General Luther Terry in 1964 with his declaration of the dangers of tobacco, and the ongoing efforts by Brian Williams, NBC News, there is also the major contribution by the co-author of "No If's, And's or Butts: The Smoker's Guide to Quitting": Harlan M. Krumholz....but then there wouldn't have been an article with speculative conclusions allowing generation of multiple additional articles. I would only hope he makes certain that fee schedules for oral and maxillofacial surgeons are adequately supported to allow intervention when jaws drop from these subsequent publications.
Emanuel Countdown: The Emanuel Countdown will be suspended for several months, to be replaced by a tribute to each of the 37 persons currently seeking the position of President of the United States. The Emanuel Countdown will resume after the nominees of both parties have been selected. The clock, however, will still be running.
Hillary Clinton (to the tune of Eleanor Rigby)
President Hillary Rodham Clinton
President Hillary Rodham Clinton
Hillary Clinton, looks at the White House
And sees where her family has been,
She's wanting back in.
Waited so long now, writing inaugural addresses
That no one has heard,
Checking each word.
Hillary Rodham Clinton,
We know your time has come
Hillary Rodham Clinton,
Why has it been so long?
Got past Benghazi, and Clinton
Foundation allegations are going nowhere
Nobody cares.
She's getting ready
Wiping the server she keeps in her house by the door
Very secure.
Hillary Rodham Clinton,
We know your time has come
Hillary Rodham Clinton,
Why has it been so long?
President Hillary Rodham Clinton
President Hillary Rodham Clinton
Barack Obama, got in the way
In 2008,
A strange twist of fate.
Martin O'Malley, Bernie and Biden
And others should learn
It's Hillary's turn.
Hillary Rodham Clinton,
We know your time has come
Hillary Rodham Clinton,
Why has it been so long?
