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All nations—rich a...
most important, although recent increases in obesity (Chapter 227) and
physician work force relative to their population, as well as a much highe...
The 2010 Patient Protection and Affordable Care Act (PPACA) contains
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Cap 5. socioeconomic issues in medicine


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Cap 5. socioeconomic issues in medicine

  1. 1. CHAPTER  5  SOCIOECONOMIC ISSUES IN MEDICINE 17 5  SOCIOECONOMIC ISSUES IN MEDICINE STEVEN A. SCHROEDER All nations—rich and poor—struggle with how to improve the health of the public, obtain the most value from medical services, and restrain rising health care expenditures. Many developed countries also wrestle with the paradox that their citizens have never been so healthy or so unhappy with their medical care. Despite the reality that only 10% of premature deaths result from inadequate medical care, the bulk of professional and political attention focuses on how to obtain and pay for state-of-the-art medical care. By com- parison, 40% of premature deaths stem from unhealthy behaviors—includ- ing smoking (about 44%; Chapter 31); excessive or unwise drinking (about 11%; Chapter 32), obesity and insufficient physical activity (about 15% but estimated to rise substantially in the years to come; Chapters 15 and 227), illicit drug use (about 2%; Chapter 33), and imprudent sexual behavior (about 3%; Chapter 293) (E-Fig. 5-1). Genetics (Chapter 39) account for an additional 30%; social factors—discussed next—account for 15%, and envi- ronmental factors (Chapter 18) account for 5%. Of the major behavioral causes of premature deaths (Fig. 5-1), tobacco use (Chapter 31) is by far the
  2. 2. CHAPTER  5  SOCIOECONOMIC ISSUES IN MEDICINE18 most important, although recent increases in obesity (Chapter 227) and physical inactivity (Chapter 15) are also alarming. SOCIAL STATUS INFLUENCES HEALTH Socioeconomic status, or class, is a composite of many different factors, including income, net wealth, education, occupation, and neighborhood. In general, people in lower classes are less healthy and die earlier than people at higher socioeconomic levels, a pattern that holds true in a stepwise fashion from the poorest to the richest. In the United States, the association between health and class is usually discussed in terms of racial and ethnic disparities; but in fact, race and class are independently associated with health status, and it can be argued that class is the more important factor. For example, U.S. racial disparities in adult smoking prevalence are relatively small among whites, blacks, and Hispanic Americans (Fig. 5-2), whereas there are huge differences among smoking rates by educational level (Fig. 5-3). U.S. physi- cians have reduced their smoking prevalence to a record low of only 1%. In part, the relationship between class and health is mediated by the higher rates of unhealthy behaviors among the poor, such as the inverse relationship between educational attainment and cigarette smoking, but unhealthy behav- iors do not fully explain the poor health of those in the lower socioeconomic classes. Even when behavior is held constant, people in lower socioeconomic classes are much more likely to die prematurely than are people of higher classes. Of interest is that first-generation immigrants appear to be more protected from the adverse health consequences of low socioeconomic status than are subsequent generations. It is unclear which of the components of class—education, wealth (either absolute wealth or the extent of the gap between rich and poor), occupation, or neighborhood—makes the greatest impact on a person’s health. Most likely, it is a combination of all of them. For example, the constant stress of a lower class existence—lack of control over one’s life circumstances, social isolation, and the anxiety derived from the feeling of having low status—is linked to poor health. This stress may trigger a variety of neuroendocrinologic responses that are useful for short-term adaptation and bring long-term adverse health consequences. What can clinicians do with this knowledge? Clearly, it is difficult to write prescriptions for more income or for better schooling or neighborhoods or jobs, but physicians can encourage healthy behavior. At key times of transi- tion, such as during discharge planning for hospitalized patients, clinicians should be attentive to social circumstances. For patients who are likely to be socially isolated, clinicians should encourage or arrange interactions with family, neighbors, religious organizations, or community agencies to improve the likelihood of optimal outcomes. In addition, physicians should seek to identify and to eliminate any aspects of racism in health care institutions. Finally, in their role as social advocates, physicians can promote such goals as safe neighborhoods, improved schools, and equitable taxation policies. ECONOMIC ISSUES IN MEDICAL CARE Medical care today is on a collision course. On the one hand, an ever-expand- ing science base continuously generates new technologies and drugs that promise a longer and healthier life. Add a public eager to obtain the latest breakthroughs touted in the media and over the Internet, plus a well-stocked medical industry eager to meet that demand, and it is easy to understand why expenditures continue to soar. On the other hand, payers for medical care— health insurance companies, government (federal, state, and local), and employers—increasingly bridle at medical care costs. The United States continues to lead the world in health care expenditures (Fig. 5-4). In 2008, it spent about $2.4 trillion, amounting to 17% of its gross domestic product. It is projected that expenditures will continue to rise, exceeding20%by2014.Mostpolicyanalystscontendthatthisrateofincrease in medical care expenditures is unsustainable, but the same has been said for many years. Few other countries have double-digit health care expenditures, and none comes close to 15% (see Fig. 5-4). A potent combination of supply and demand factors explains why the United States spends so much. On the supply side, it far exceeds other countries in the availability and use of expen- sive diagnostic technologies, such as magnetic resonance imaging and com- puted tomography (E-Fig. 5-2). For example, the United States has four times as many magnetic resonance imaging machines per capita as does Canada. Similar patterns exist for therapeutic technologies, whether coronary angio- plasty, cancer chemotherapy, or joint prostheses. The differences are espe- cially dramatic in older patients. For example, in the 65- to 69-year age group, the United States performed 1.95 more carotid endarterectomy procedures per capita than did Canada; but above the age of 80 years, the ratio was 8.7. Other supply factors that drive high medical expenditures in the United States include a fee-for-service payment system that compensates physicians much more for using expensive technologies than when they do not; a medical professional work force that earns much higher incomes relative to the population than in other nations and that emphasizes specialist rather than generalist practice; accelerated development of new and costly medica- tions that are directly marketed to consumers; much higher administrative costs; higher rates of fraud and abuse; and a high rate of defensive medicine in response to pervasive fears about medical malpractice suits. Supply factors that do not appear to be unique to the United States are the number of physi- cians or hospitals. Many other developed countries have a much larger 0 50 100 150 200 250 300 350 400 450 20 85 43 29 17 112 365 435 * Sexual behavior Alcohol Numberofdeaths(thousands) Motor vehicle Guns Drug induced Obesity inactivity Smoking * Also suffer from mental illness and/or substance abuse FIGURE 5-1.  Number of U.S. deaths from behavioral causes. (Data from Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245; Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Correction: actual causes of death in the United States, 2000. JAMA. 2005;293:293-294; Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293:1861-1867. Adapted from Schroeder SA. Shattuck lecture: we can do better—improving the health of the American People. N Engl J Med. 2007;357: 1221-1228.) 0% 10% 20% 30% 40% 50% 36.4% American Indian/Alaska Native* 21.4% White* *Non-Hispanic 19.8% Black* 13.3% Hispanic 9.6% Asian* FIGURE 5-2.  Prevalence of adult smoking by race/ethnicity, United States, 2007. (From Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2007. MMWR Morb Mortal Wkly Rep. 2008;57:1221-1226.) 0% 10% 20% 30% 40% 50% 24.8% No high school diploma 44.0% GED diploma 23.7% High school graduate 20.9% Some college 11.4% Undergraduate degree 6.2% Graduate degree FIGURE 5-3.  Age-adjusted prevalence of cigarette smoking in 2007, among persons 25 years of age or older, according to educational level. GED = General Education Devel- opment test. (From Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2007. MMWR Morb Mortal Wkly Rep. 2008;57:1221-1226.)
  3. 3. CHAPTER  5  SOCIOECONOMIC ISSUES IN MEDICINE 19 physician work force relative to their population, as well as a much higher ratio of primary care physicians to specialists. The number of hospitals and hospital beds, the frequency of hospitalizations, and the length of hospital stay are relatively low in the United States, although it does have a much greater proportion of intensive care beds. Finally, recent analyses suggest that a principal driver of high expenditures on health care in the United States is the much greater price charged per unit of service compared with other developed countries. Demand factors also drive medical expenditures. The extent to which the media and the medical profession feature medical “breakthroughs” is exten- sive and one-sided. New promising treatments merit front-page stories and commercial advertisements, whereas subsequent disappointing results are buried or ignored. The cumulative result is to whet patients’ appetite for more and to leave the impression that good health depends only on finding the right treatment. This same quest explains the popularity of alternative medi- cine, for which patients are willing to spend $34 billion annually out of their own pockets (Chapter 38). It could be argued that rising expenditures for medical care are not a bad thing, as what could be more important than ensuring maximal health? There are several rebuttals to that argument. First, it is not clear that money spent on medical care brings appropriate value in the United States, given that its health statistics are worse than those of virtually every other developed country. Second, there are substantial regional differences in the supply and use of medical care, such as a two-fold difference in the supply of acute hos- pital beds in metropolitan regions (even with adjustment for demographic variables) and a four-fold difference in the risk of being hospitalized in an intensive care unit at the end of life. Similar regional differences exist for procedures such as transurethral prostatectomy, hysterectomy, and coronary artery bypass surgery. Yet there is no evidence that “more is better” on a regional basis. In fact, geographic areas with higher consumption of medical services have been shown to have worse outcomes for some conditions, such as acute myocardial infarction. Money spent on medical care means less to spend on other important social priorities—schools, the environment, job creation, and competition with overseas manufacturers that spend less on health care. Furthermore, many businesses are reducing their health insurance contributions to employ- ees and retirees, passing those costs along to the beneficiaries. Consequently, health insurance coverage has emerged as the most important issue in labor contract negotiations and strikes. In addition, rising health care expenditures are stressing public programs such as Medicare, Medicaid, the Veterans Administration health system, and municipal hospitals, with budget requests outstripping the tax base to pay for them. Medical debt is by far the most important cause of bankruptcy. Finally, as health care becomes less affordable 5.75.9 10.811.0 UnitedStates France Switzerland Germany Belgium Canada Austria Portugal(1) Netherlands Denmark Greece Iceland NewZealand Sweden OECDAverage Norway Italy Australia(1) Spain UnitedKingdom Finland Japan(1) SlovakRepublic Ireland Hungary Luxembourg(1) Korea CzechRepublic Poland Mexico Turkey(2) % GDP 16.0 2 4 6 8 10 12 14 16 0 FIGURE 5-4.  Health expenditure as a share of gross domestic product (GDP), 2007. OECD = Organisation for Economic Co-operation and Development. (Data from Organisation for Economic Co-operation and Development Health, 2009.) for businesses and government, the number of people without health insur- ance will continue to increase. Since the mid-1970s, a variety of strategies to contain rising medical expenditures have yielded limited success. These attempts have tried to restrict the supply of costly medical technologies as well as the production of physicians, especially specialists; to promote health maintenance organiza- tions that have incentives to spend less on medical care; to ration indirectly by limiting health insurance coverage; to institute prospective payment for hospital care; to use capitation payments or discounted fee schedules for physician reimbursement; to introduce gatekeeper mechanisms to reduce access to costly care; to put patients at more financial risk for their own medical care; to reform malpractice procedures; to reduce administrative costs; and to encourage less aggressive care at the end of life. The most recent suggestions—comparative effectiveness research to curtail unnecessary tech- nology use, electronic medical records to avoid duplication of tests, and payment for performance—all hold the promise to improve quality, but their potential for substantial cost reduction is only theoretical at present. Funda- mentally, all these strategies have failed because the political will to enforce them was missing. Americans—at least those with medical insurance— strongly resist limits on their choice of medical care, and the combined power of hospitals, medical professionals, and the pharmaceutical, medical device, and insurance industries overwhelms the meager forces pushing cost contain- ment. Add to that the continuous production of new technologies and drugs plus the public’s avidity for the latest innovations, and it is easy to see why medical costs are projected to keep rising. As a result, the costs of even modest health insurance plans are a challenge for most blue-collar and many middle-class families. Payment for medical care varies by country. In the United States, health insurance coverage is an incomplete patchwork, consisting of government- sponsored programs for elderly people (Medicare), poor people (Medicaid), and veterans, plus employer-based coverage for workers and their families. Medicare covers acute care services in the hospital and in physicians’ offices but has limited coverage for prescription drugs and long-term care. More than half of all Medicare subscribers also buy supplemental insurance. Medicaid covers more services than Medicare does, but Medicaid payments to physi- cians and hospitals are so low in many states that patients have restricted access to care. At any given time, more than 46 million Americans lack health insurance, and 70 million are without insurance at some point during the year. In addition, millions of immigrant workers are also uninsured. This large group must depend on charity care, often at community clinics and public hospitals, and it is well documented that lack of health insurance contributes to poor health, such as delayed diagnosis and undertreatment of asthma, diabetes, hypertension, and cancer.
  4. 4. CHAPTER  5  SOCIOECONOMIC ISSUES IN MEDICINE20 The 2010 Patient Protection and Affordable Care Act (PPACA) contains insurance reform measures that took effect in 2010 and 2011, as well as cover- age expansion that starts in 2014. About 32 million new people will be insured, about 50% privately and 50% in Medicaid. Revenue generating pro- visions are split about evenly between spending reductions and cost contain- ment. In contrast to the passage of Medicare and Medicaid in 1965, the PPACA did not receive bipartisan support, and it is difficult to predict which of its components—if any—will survive. Because medical care is both so valued and so expensive, physicians every- where will inevitably become more involved in issues of medical economics. As cost-containment pressures force patients to assume more of their medical expenses, they will become more aware of costs and more demanding about the price and value of care. Informed clinical decision making will require that physicians have accurate information about the risks, benefits, and costs of medical care and better ways to communicate what is known and what is not. SUGGESTED READINGS Aaron HJ, Ginsburg PB. Is health care spending excessive? If so, what can we do about it? Health Affairs. 2009;28:1260-1276. Analyzes the reasons the United States spends so much more on health care. Cubbin C, Vesely SK, Braveman PA, et al. Socioeconomic factors and health risk behaviors among adolescents. Am J Health Behav. 2011;35:28-39. Shows the strong link in adolescents. Hajat A, Kaufman JS, Rose KM, et al. Long-term effects of wealth on mortality and self-rated health status. Am J Epidemiol. 2011;173:192-200. Details the strong inverse relationship of wealth with poor health status and mortality. Marmot M, for the Commission on Social Determinants of Health. Achieving health equity: from root causes to fair outcomes. Lancet. 2007;370:1153-1163. The quality of health and health services within and across countries corresponds with health outcomes. Schroeder SA. Shattuck lecture: we can do better—improving the health of the American People. N Engl J Med. 2007;357:1221-1228. Reviews why, despite its high expenditures, the United States does so poorly in health outcomes. Seligman HK, Schillinger D. Hunger and socioeconomic disparities in chronic disease. N Engl J Med. 2010;363:6-9. Perspective.