Rangel on Hilary

I have missed Rangel’s missives. This week he has dissected Hilary opus – Now Can We Talk About Health Care?. (note that I have made this a permanent link using two great web pages – New York Times Link Generator which makes NY Times articles “permanent” for bloggers and TinyURL.com which transforms the lengthy urls into very short urls).

Back to Rangel’s insights! Hillary Clinton takes on health care . . again – Part I of II and Hillary Clinton takes on health care – Part II.. Rangel makes a number of cogent points. I would like to focus and expand on only 2. Please read her political stuff and Rangel’s excellent posts.

My two points concern her misunderstanding of preventive medicine and her dislike of HSAs.

Preventive medicine, as Rangel clearly states, usually decreases the odds of one developing a disease. One should really distinguish preventive medicine from early detection medicine. Screening for breast cancer or prostate cancer represent early detection medicine.

What important diseases might we prevent (using the term prevention loosely to mean decrease the probability)? I offer some important diseases that fit this classification

• Colon cancer
• Coronary artery disease
• Congestive heart failure
• Chronic obstructive lung disease
• Type II diabetes mellitus

Colon cancer is a special case. Screening for colon cancer functions as both early detection and prevention. One hopes to find, and treat the precursor – colonic polyps. This prevents most colon cancer. However, one sometimes finds early colon cancer amenable to treatment.

The remaining diseases on my list (and one could expand the list) have a common set of risk factors:

• Heredity
• Cigarette smoking
• Hypertension
• Obesity
• Lack of exercise
• Dyslipidemia

Well, in 2004, we can do little about heredity (although we may have specific treatments in the future). Cigarette smoking remains our number candidate for prevention. So what are we as physicians to do? Most physicians that I know exert great effort towards smoking cessation. Our lack of success has nothing to do with money. Our problem comes from the addictive nature of nicotine. Smoking cessation challenges most patients. But nothing (that I am aware of) in our current health care system prevents our attempts.

Next comes hypertension. We do a reasonable job of treating hypertension. We have several drug classes, and generally can do a good job of control. Cost need not deter us here, and we have sufficient generics to achieve good control.

Obesity confounds most physicians and patients. We (physicians) express extreme frustration when trying to treat obesity. This is clearly not a money issue.

Lack of exercise plagues our society. The solutions must come from public health, not individual physicians. We encourage exercise, but rarely succeed.

We can treat hyperlipidemia, but my reading of the data makes the indications for treatment somewhat unclear. Less expensive statins would help here.

One could add other important prevention to the list, including vaccinations (no major problem here), wearing seat belts and avoiding excessive alcohol (although one could argue that moderate alcohol has preventive characteristics).

I could rant about prevention for hours, but I doubt that we have tremendous gains here.

Now I will switch to the power of HSAs (Health Savings Accounts). HSAs can improve health care in several ways. First, giving patients an incentive to understand health care costs (at least for “discretionary” costs) can lead to savings. Drug costs represent an excellent example.

A patient presents with heartburn. You explain the diagnosis, and suggest Aciphex (a relatively inexpensive PPI). The patient tells you that she wants Nexium. She has seen ads on TV and believes that it is a better drug. You try to persuade her, but she responds that her insurance covers Nexium and that is what she wants. I suspect that the conversation would run differently if she paid for her drugs out of a HSA.

Patients will rapidly start to understand outpatient costs. More practices would operate as cash only enterprises, markedly decreasing overhead. Patients would be able to buy the time that they need, not the time that the insurance company wants to buy. (Remember that as physicians our only commodity is time).

I have blogged on this subject repeatedly. As a believer in free markets, I find HSAs very intriguing, and do believe that they will work.

My ranting pales next to Rangel’s on this subject. Please go read him, and then feel free to comment.