Thursday, December 05, 2019

Which Interventions Can Be Paid For: The Explanatory Power of “Prasad’s Law”

There’s a huge amount of money that floats around our medical system (about 18% of GDP), and yet, for some things, there is never enough money.

One of those things there is never enough money for is truly adequate nurse staffing in hospitals. A recent story in the Houston Chronicle about a recently released CMS report on MD Anderson relates how overworked nurses there are, resulting in problems such as inadequate monitoring that have led to deaths.
The report concluded that MD Anderson’s inadequate number of licensed registered nurses “to provide care to all patients to meet their needs” resulted in “an inability to provide care ordered for the patient.”
MD Anderson is a very wealthy institution, but . . . that didn’t prevent this. There is seemingly never enough money for adequate nurse staffing.

In a similar vein, Andy Lazris laments in his book, Curing Medicare, that he can easily arrange, with the stroke of a pen, to overtest and overtreat and hospitalize his patients, but it’s impossible for him to arrange home assistance or meal delivery, and - though sometimes possible - crazy difficult and time-consuming for him to get home health visits or an electric wheelchair for his patients.

Vinay Prasad, the hematologist-oncologist who, with Adam Cifu, wrote Ending Medical Reversal and who hosts the Plenary Session podcasts, complains in those podcasts that there are a number of things patients really need that he is powerless to get for them (e.g. rides to his office); but, with no problem, he can order up marginally effective and super-expensive chemotherapy regimens.

Prasad has a theory about which actions that would improve patient health will get paid for by the “system” and why. He elaborates on this (while acknowledging he doesn’t have proof) in a discussion with Dr. Stacie Dusetzina (Plenary Session podcast 1.67 from 44.50 minutes into the podcast onward) and in a discussion with Dr. Gilbert Welch (Plenary Session 2.21 1.55 into the podcast). He states, in the Welch discussion:
There are interventions that disperse wealth, … and they give people jobs, and they send them out in the community; and there are implantable drugs, implantable devices, there are drugs, there are cancer screening tests, and we will always prioritize interventions that consolidate money in the hands of the few, over interventions that disperse money to the hands of many, with the same levels of evidence.

And, in the Dusetzina discussion:
Because we would rather . . . and we will always, in healthcare, we will pay for interventions that consolidate or concentrate wealth in the hands of fewer parties than we would ever pay for interventions that disperse wealth, and one of the things that disperses wealth is if you have a labor force of people who would provide care, would go pick up my patients, and bring them here . . .and if we took all the money we spent on like marginal and useless and mediocre drugs, and we put all that money in that social system, you’re going to hire a lot of people and you’re going to spread wealth out, but you’re not going to concentrate wealth in the hands of a few investors and that kind of thing, and so that’s why – the way in which lobbying and pressure in the society work is always to push it the other way.

My briefer version of Prasad’s Law (as I’m dubbing it) is:  
  • Prasad's Law: Medical goods and services that concentrate wealth can be paid for; medical goods and services that disperse wealth are "unaffordable." I think this is an enlightening law with broad explanatory power; and I imagine each reader can think of their own examples.
It is not, in reality, a particularly surprising result, because the true purpose of the U.S. healthcare system is by no means to supply medical care (although that is indeed the goal of many who work within it), but instead to serve one overarching purpose – to make money for capitalists. Adequate nurse staffing does not make money for capitalists (even if it makes money for nurses); and crazy expensive, marginally effective, cancer drugs do make money for capitalists. It’s that simple.

And to change it - ever - will, in my mind, require a lot of change, not tinkering at the edges. As long as those who control our system now (now including private equity investors) continue to control our system, it cannot change. Wresting control from their hands will undoubtedly be a hell of a fight, but it is a fight essential to alleviate the serious issues that cause so much suffering.


Sharon Moon said...

What I see is the system does not value time - cognitive services, the midwife model for prenatal care, psychologists, peer counselors . . - that Big Healthcare [medical device makers, pharmaceutical companies, group purchasing organizations and the like]cannot take a cut from. This may be another way of saying "Dr Prasad's law" and another way of thinking about the point you are making. There is no payment for taking time to do root cause analyses either - as a result, where do you think they fall in a healthcare professional's priority list? (What about patient's? Sigh.) We end up paying a lot for services that require buying devices and pharmaceuticals but not for services that are a function of a professional's time and care. In a free market, there is no way for Big Health to profiteer off of time. No FDA to game. But time is what everyone in healthcare wants and needs. What a mess.

Unknown said...

in 2013, dedicated primary care physicians at Allina's Abbott Northwester Hospital in Minneapolis, funded by the Robina Foundation, demonstrated significant improvements in health outcomes/"quality measures" via the addition of minimum wage "care guides" to usual care.

The results were published by the Annals of Internal Medicine here:

If the aim was to improve health outcomes, then the program would have continued. However, as soon as the Robina Foundation money disappeared, so did the Care Guides...even though the cost was a very small fraction of the clinic's overhead.

And although the evidence looks favorable, I am not aware of anyone promoting minimally-paid care guides in primary care clinics.

APeticola said...

Hadn't heard of "care guides," pretty interesting - and a good illustration of the point.