Quotes from Students Papers 2003
           University of Minnesota, Carlson School of Management
           Topics in Health Economics
           Masters in Health Administration MHA 6-755 

The energy of youth is replaced with the wisdom of the old.  What we do with that wisdom is what will define our lives.

The NCI panel did not conclude that mammograms are worthless but rather that there is no evidence they help – a subtle but important difference (Begley et al., 2002).  Dr. Harris states there is probably a small benefit to mammograms for some women.  Those women he identified as “Goldilocks”, meaning women with tumors growing not too fast but not too slow.  The reason is that slow-growing tumors pose so little danger that with or without mammography, they are usually curable, typically by lumpectomy.  So skipping regular mammograms would hardly budge survival rates.  At the other extreme, aggressive breast tumors are so fast-growing that catching them early may be still too late.  In this case, mammograms also make little difference to survival.  Women in there [sic] 40s have much faster-growing and more dangerous tumors than older women, for reasons that remain unclear.  Only tumors in the middle, which make up maybe 15 to 20 percent of breast cancers, might benefit from early detection by mammography.

—    Randy Anderson,

A Study on the Controversy Surrounding Mammography Screening

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 “We are at our best when we give the doctor who resides within each patient a chance to go to work” (Albert Schweitzer, M.D.).

 “Science is the knowledge of consequences, and the dependence of one fact upon another,” (Thomas Hobbes).

 Scenario – NHII Supports Population Health in the Future.

Each month, a certain number of people across the city are seen in emergency rooms and doctors’ offices with symptoms of severe diarrhea and vomiting.  During one month however, software that is capable of picking up patterns detects that a patient database for a large managed care plan has a significant increase in the incidence of these types of gastrointestinal symptoms.  The software automatically generates a message to the city public health department, provides a statistical summary by street and zip code about the residence of the affected patients. Almost simultaneously, an algorithm built into the inventory control system for one of the largest supermarket chains in the metropolitan area identifies an unusually large number of sales of anti-emetics and anti-diarrheals in one part of the city, and sends an automatic alert to the city public health department, identifying the addresses of the stores involved. (Lasker, et al, 1995).

 The city public health department investigates the problem using geographical overlay plots of the addresses of patients and stores and the distribution of known sources of infection from the city Geographic Information Systems (GIS) which distinguishes residents, roads, and public works in various locations of the city.  This system reveals that 63% of the patients use a common water treatment plant.  Public health officials are immediately dispatched to investigate the plant, where they identify and resolve the problems: a clogged chlorine additive tube and a manager who is not paying attention to what he is doing. Upon closer evaluation, it was noted that the treatment plant has had overflow problems. While appropriate experts are dispatched to investigate the sewage plant, electronic alerts are sent to clinicians in the area, directing them to collect appropriate samples for analysis, and suggesting effective treatment procedures. The epidemic is controlled in less than one week. Later, the lab reports the results of its analysis, describing a previously known virus as the culprit, with the sewage plant as the probable source. (Lasker, et al, 1995).

— Sheila Green-Shook,

 National Health Information Infrastructure:

Will the American People Ever be Ready?

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 Economic historians have concluded that 30% of the estimated capital growth in Britain between 1780 and 1979 was a result of improvements in health and nutrition (WHO, 1999) . . . . Sachs (2001) claims that a typical statistical estimate indicates that improving life expectancy at birth by 10% is associated with an increased economic growth of at least .3 to .4% per year.

 A study focusing on the greatest excess mortality in poor countries found that in males age 5-29, 68% of total mortality was considered avoidable, while for females of the same cohort the result was 82%. (Sachs, 2001).

 WHO (1999) states: “Life expectancy at birth alone is one of the strongest explanatory variables of growth in GDP.”

— Becky Martin,

Improving the Health of Women in Nepal:

 An Economic Argument

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Of particular interest is research that demonstrates that the age of first alcohol use is a risk factor for developing alcohol abuse.  The group at greatest risk of developing alcohol abuse included subjects who started to drink alcohol at ages 11 – 14 (Appendix B), (DeWit, May 2000).  The relationship between age and risk of later developing alcohol abuse was not linear in this study.  People under age eleven did not show a linear relationship with probability of alcohol abuse.  The results demonstrated that it wasn’t until six years after initial alcohol use that the group under age eleven had a dramatic increase in probability of alcohol abuse.  The three age groups who had the highest probability of alcohol abuse were the <11 years, 11 – 12 years, and 13 – 14 years age groups.  The fifteen to sixteen year old age group had just greater than the total probability for alcohol abuse.  The age group [greater than or equal to] 19 years was dramatically less probability of alcohol abuse [sic] than the groups that started younger.  It appears from this study if a person makes it to adulthood without using alcohol, the probability of going on to abuse alcohol is much less.

 In addition to the environmental issues identified above, one study demonstrated that people who had prenatal exposure to alcohol are at greater risk of development of drinking problems. (Baer, April 2003).  As stated in the Baer et al study, this is not well understood and requires further study to explain the relationship.

 The premature death calculation requires an estimate of the number of deaths attributed to be caused from alcohol.  Chronic liver disease and cirrhosis is the 12^th leading cause of death in the United States (National Center for Health Statistics, May 2003).  In addition to chronic illness and disease, the country is impacted by premature death from alcohol related automobile accidents.  In 2001, 17,448 people died in alcohol-related motor vehicle crashes.  That represents 41% of the year’s total traffic deaths (National Highway Traffic Safety Administration, 2002).  In certain age groups, death related to motor vehicle accidents is particularly concerning.  In late teens, motor vehicle accidents are the leading cause of death.  That is not to say that all of these accidents have alcohol involved, but many do.  Alcohol abuse is also related to comorbidities such as certain cancers, stroke, diabetes, and pancreatitis.  Many people die of these diseases and they are often not directly attributed to alcohol abuse.

 Productivity losses associated with illness make up the vast majority of the calculated productivity loss.  Illness accounts for about 65% of the total productivity loss (U.S. Department of Health and Human Services, 2000).  The loss in the category of illness is primarily made up of calculations of decreases or lost productivity in the workplace and in the home for individuals with a history of alcohol dependence.  Illness related unemployment and reduced earning secondarily to ill time fall in this category.

 —Sarah H. Nurse,

The Economic Impact of Alcohol Abuse in the United States

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Morbid obesity is associated with significant medical complications such as sleep apnea, hypertension, osteoarthritis, diabetes mellitus, and other degenerative conditions (Livingston and Frank, 2003).  In their study (Must & Spandano,1999) it was found that for both men and women, high blood pressure was the most common overweight and obesity related health condition, and its prevalence showed a strong increase with increasing weight status category.  The prevalence of type 2 diabetes mellitus, gallbladder disease, and osteoarthritis increased sharply among both overweight men and women corresponding with increasing weight category.  High blood cholesterol level was very prevalent in both sexes but showed no increase in prevalence with increasing weight category.  However, men and women with BMIs of 25 or more were more likely to have high blood cholesterol levels.

 The researchers also found a significant increase in the prevalence of type 2 diabetes mellitus and hypertension, even in the overweight class. The finding was striking given that individuals with the mildest degree of overweight comprise more than 42 percent of men and 28 percent of women in the United States (Must & Spandano, 1999).  For hypertension and chronic heart disease (CHD) the relative risk associated with overweight declines with age.  The researchers observed that the cross-sectional relationship of obesity class to the comorbidities studied was strongest among the youngest age groups.

 Obesity has also been shown to shorten life expectancy (Fontaine & Redden, 2003).  White men aged 20 years with BMIs greater than 45 are estimated to have 13 Years Life Lost (YLL) relative to white men aged 20 years with BMIs of less than 25.  This represents a 17 percent reduction in life expectancy, or a 22 percent reduction in remaining life expectancy. White women aged 20 to 30 years with BMIs greater than 45 are estimated  to have 8 YLL due to obesity.  The maximum amount of YLL, 20, was found among black men aged 20 years with BMIs greater than 45.  The researchers concluded that obesity appears to lessen life expectancy, especially in younger adults.

 Cerulli and Malone (1998) concluded that on the basis of epidemiological data using the prevalence of disease and associated body mass index, it is generally accepted that weight reduction of 5 to 10 percent in obese patients is associated with significant health benefits.

A treatment program can have positive effects.  Weight loss has been reported to improve blood pressure, lipid levels, and glucose tolerance among overweight persons with hypertension, dyslipidemia, and diabetes, respectively.  It has also been found to reduce medication requirements among both hypertensive and diabetic patients. While weight loss yields important benefits, recidivism is inordinately high.  On average, two-thirds of the weight that is lost by patients who complete weight loss programs is regained within one year, and almost all is regained within 5 years (Oster & Thompson, 1999).  These findings led Oster and Thompson (1999) to the conceptualization of obesity as a chronic disease condition rather than a problem caused by overeating, inadequate physical activity, and lack of willpower.

 While there is positive news about weight loss, studies have shown that weight loss is difficult to achieve and maintain.  Livingston and Frank (2003) concluded that although the comorbidities associated with obesity respond to weight loss programs, individuals who have morbid obesity rarely achieve long-term weight loss with dietary interventions.

 The Veterans Administration studied the economic burden of caring for veterans with clinically severe obesity and its comorbidities.  All obesity-related health care costs, including hospitalizations as well as outpatient visits, medications and home health devices were calculated for the 12 months before and after gastric bypass surgery.  Health care costs for the year prior to gastric bypass was $10,558 per patient.  The cost of care in the year following gastric bypass was $2,840.

 Following surgical intervention, there will be some pain and discomfort that reduces QOL in the perioperative [?] period.  For the first 2 to 3 months after gastric restrictive surgery patients had difficulty adjusting to their new eating restrictions.  However, once the wounds had healed, the postoperative pain has resolved, and the weight has been lost, there was a marked improvement in the ability to undertake various physical activities, especially sexual functions (Livingston & Fink, 2003).

They also found that 3 years following surgical induced weight loss, self-image, happiness, and social and sex lives were all markedly improved, at the expense of increased smoking and drinking.  While only 38 percent of the patients were employed before surgery, 60 percent had full or part-time employment after surgically induced weight loss.  Significantly improved employability has been observed in other studies.

—    Michael Schafer,

 The Socioeconomic Costs of Obesity and Bariatric Surgery as a Treatment Option

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 . . . Examples of potential cost savings that can be achieved through weight loss alone are numerous and could result in billions of dollars in cost savings. A one unit increase in body mass index raises all healthcare cost 1.9 percent, diabetes raises costs 137 percent and one extra day of physical activity a week reduces costs 4.7 percent (Pronk, Goodman, O’Connor and Martinson, 1999).  Body weight losses of 6 – 10 percent reduce monthly pharmacy costs $122.64 for insulin-treated diabetics (Greenway, Bray and Marlin, 1999).  The cost of all drug therapy for patients more than 60 pounds overweight is double that of those with normal weight (Caan, 2002). Participation in a weight-management program reduces healthcare costs $1,648 a year (Berkson, 2002).

 The second problem area is the fact that the healthcare system does not address chronic disease more aggressively.  The current healthcare system is designed to respond to chronic disease only after a patient has acute symptoms.  This results in a small portion of the population receiving most of the services and incurring most of the cost.  For example, in Olmsted County in Minnesota 10 percent of the Medicare population consumes 55 percent of the health resources and the highest spending. 50 percent of that population consumes 92 percent (Nesse, 2002).  This issue will only be exaggerated as the population continues to age.

 . . . For example, there are six times as many angioplasties per 1,000 Medicare beneficiaries performed in Elyria, Ohio, as are done in York, Pennsylvania (Muney, 2002). The causes of medical practice variation are numerous. Such factors as specialty and subspecialty training, physician/patient age, type of insurance, disease severity, physician thresholds for ruling out disease, physician ability to interpret diagnostic tests, the practice of defensive medicine due to the threat of malpractice suits, the lack of adequate data and the skills to locate data regarding the safety and efficacy of most medical practices (Schwartz, 1984).

 A mandated self-insurance program will also create potential human resource type issues that will need to be addressed.  The most significant issue is the possibility that employers would terminate employees who incur high medical costs.  Rightful termination rules currently exist that would protect employees but a mandated self-insurance program would place significantly more stress on the rightful termination system.  Another potential human resource type issue that could arise is an increase in peer pressure for employees to maintain a good health status.  Friction among workers is growing in some small companies, where employees tend to know one another well and can see how a handful of serious illnesses push up the cost of coverage for everyone (Aeppel, 2003).  Things that used to be no one else’s business such as what people eat for lunch are becoming everyone’s business (Aeppel, 2003).

—Craig Larson,

 Employer-Based Healthcare Reform:

 Realigning and Reaffirming the Roles of the Health Plan, the Provider, the Government and the Consumer

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 As a pediatrician, I work daily with the “New Pediatrics”.  This is a term in my field that is used to describe the changes that have occurred in our practices in the last 60 – 70 years.  At the turn of the last century, the leading causes of mortality in pediatric patients were primarily infectious diseases: whooping cough, diphtheria, tuberculosis, etc., with a smattering of agricultural trauma, birth defects, and other causes.  Today, the leading killer of children over the age of one is accidents; in teenagers the leading cause is specifically motor vehicle accidents. In half of these instances, alcohol is involved. The second and third leading causes of death are suicide and homicide, the order depending on whether the adolescent lives in the suburbs or the inner city.  Unintentional drug overdoses and trauma figure highly on the list and AIDS is working its way up the list.  Morbidity in the pediatric age group has also changed to parallel the changes in mortality.  Whereas my predecessors spent many hours treating scarlet fever and rheumatic fever, I spend many hours dealing with conduct disorders, ADD, depression and the new morbidity of the 21^st century.  These problems which constitute the “New Pediatrics” have a heavy spiritual component, and many of the patients who are seriously afflicted by these problems do not have an adequate spiritual “ego” to help fend them off malign contributing social influences.

 The mechanism of action could be supernatural or natural.  The simplest explanation, but the one that typically raises the most skepticism, is that there is a caring God of the universe who answers prayer and helps those who seek Him.  In this light, it would not be surprising that patients with any problem, medical, mental health or psychological, would receive benefit and superior healing by enlisting the help of such a deity.  Many people easily accept the supernatural explanation, but others look for more scientific proof.

One explanation for effectiveness of spiritual healing is that a comparison of those who accept the premises of spirituality are inherently a preselected group, and any “control” group would by nature have different personality makeup and world view.  Plante & Sherman (2001) characterize the latter group as having a greater degree of “unforgiveness”, an inability to forgive others and an inability to feel that they themselves can be forgiven.  The authors associate unforgiveness with “a complex of related emotions: resentment, bitterness, hatred, hostility, anger and fear”. These negative emotions in turn are associated with increased stress, which translates into a less competent immune system, diminished neuroendocrine effectiveness and poor cardiovascular status (Seeman, Dubin & Seeman 2003), a perspective echoed by Koenig (1998).  Plante & Sherman (2001) conclude that “religion is a pro-virtue constellation of personality characteristics that foster forgiveness”. This lower degree of stress, together with “faith, hope and optimism,” is a second possible explanation of the healing nature of spirituality.

 A third possible explanation hypothesizes that a spiritual orientation confers a superior coping ability (Plante and Sherman, 2001).  Random events and adverse health events in particular may be more comprehensible or at least easier to deal with. The spiritual individual’s thinking may be transcendental and the emphasis may be on an afterlife rather than this imperfect life.  The spiritual orientation makes it easier to accept adversity and strive for improvement.  Levin (2001) adds that the increased ability to cope is facilitated by the active fellowship and support of other believers.  Boudreaux, O’hea and Chasuk (2002) note that a “reliance on spirituality seems to be associated with a range of positive outcomes in the form of an enhanced sense of well-being, improved feelings of resiliency, and decreased physical symptoms (e.g., pain and fatigue) and psychologic symptoms (e.g., anxiety)”.

Finally, an obvious explanation for superior health or healing ability among those in a spiritual subset is that they live a healthier lifestyle (Plante & Sherman, 2001).  Motor vehicle deaths among the Amish are almost nonexistent.  Violent deaths among Quakers are similarly rare. Seventh-day Adventists eschew tobacco and alcohol and generally espouse a vegetarian diet, conferring upon their members a longer average life span.  Similarly, Mormons avoid caffeine, tobacco and alcohol and suffer less cancer as a result.  Just as the dietary restrictions of the Israelites in the Old Testament probably helped their overall health, modern day lifestyles encouraged by various religious organizations improve overall health in specific instances.  Even religious sects that do not forbid alcohol or certain foods usually take a strong stance against excessive alcohol consumption and gluttony, which still contributes to an overall healthier lifestyle (Koenig, 1998)..

 I reflect, again, back to the previous centuries where physicians had little more to offer patients than a few marginally effective nostrums, occasional surgical relief and a good deal of spiritual comfort and the “laying on of hands”.  Yet, for millennia, many patients were grateful for these humble ministrations, a few were actually cured and many were reassured.  Even the symbol of medicine, a snake wrapped around a stick (the Caduceus) comes from a spiritual source, the Old Testament.  In our modern era, with all our miracle cures, I believe the pendulum has swung too far in the other direction, and most health professionals are afraid to bring up the subject of spiritual belief at all except near the time of death. By doing so, they are relinquishing one of their most potent tools to make many patients better. 

Medical science has achieved impressive accomplishments in the diagnosis and treatment of human disease.  However, the emphasis on science and technology has created a generation of physicians who find it difficult to relate to their patients about their suffering.  Time constraints and economic pressures also add to the challenge of giving meaningful time to patients.  Patients want to talk to their physicians about their concerns, but surveys indicate that this is not being accomplished . . . . The role of physician as a healer, attending to mind, body and spirit is encouraged. (McVay, 2000)

 William Nersesian,

Spirituality and Health:

 The often overlooked connection

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 For those of us engaged in the healthcare industry, we have a definite advantage to finding the care that we need and desire.  When we have a specific medical problem, we typically ask our co-workers that we know and trust where we can obtain the best treatment.  To make this available to the rest of the population who do not work in healthcare, or know someone who does, I would recommend inclusion of a “Referral Hotline” in the infostructure system.  This hotline would be manned by healthcare professionals who could refer patients to appropriate sources, dependent upon the patient’s specific priorities.  For example, perhaps the patient would prefer to have a reputable specialist that is in close proximity rather than traveling across the country to a specialist that is considered the “best” in the industry.

Parameters and guidelines would need to be developed and closely monitored in order to ensure that referrals from this hotline were being done to meet the needs of the patient(s) and not to benefit the person(s), or their healthcare network, who was referring the patient.

 There is a growing belief that consumers should be put in charge of health care. Currently, the health care industry has, for the most part, been shielded from consumer control – by employers, insurers, and the government.  As a result, costs have exploded as choices have narrowed.  Today, approximately 40% of all employers and 92% of small ones offer employees only a single health insurance plan (Herzlinger 2002).  And when more options are available to employees, there are little differences, if any, between the managed-care plans that provide the same benefits, have the same expenses, and reimburse providers in similar ways. Basically, managed care comes in just two varieties: one which places constraints on access to physicians and hospitals for a lower price and the other which offers access to preferred providers for a higher price.

Sara O’Loughlin,

Quality Report Cards:

 Proceeding with Caution

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  “Regulatory systems exist to protect the health and well-being of the public.  In long-term care, however, a tangle of state and federal regulations has been amassed over the years that is often duplicative, unfounded, conflicts with consumer preferences, and at odds with the provision of hands on care to the very individuals they are supposed to protect” (Long Term Care Imperative, 2003).  By creating a federal / state mandated long-term care insurance program, I believe we would be adding to this vicious, inefficient, nonproductive system.  (Reforming the regulatory oversight structure to assure efficiency, productivity and quality needs to be part of any financing reforms.)

 Residents who move into a nursing home will probably move into a building that was built in the 1960’s.  “They find their new lives include a roommate with whom they must share a 200-square foot living space – smaller than many people’s private master bedrooms” (Long Term Care Imperative, 2000).  Residents who come into a nursing home in the United States give up numerous freedoms and are removed from their community. Residents moving in will not have access to certain amenities, like a refrigerator or microwave [oven], and probably will no longer be free to take the car out for a drive.  Have you ever thought about what life would be like if you could not go to the refrigerator and get a cold drink? Residents typically are given the food that is being served that day, with little or no choices. Residents typically take baths and have the medications given to them according to the schedule that is convenient for the long term care facility with little say so as to what time is convenient for them.

 The current way of delivering long-term care to the elderly creates a total loss of independence, self-esteem and in many situations loneliness.  The stigma of “Nursing Home” in the United States is one of [sic], smells of urine and B.M., a place where the elderly come to die, where there is little life, much less a sense of community and therefore people are afraid to visit.  Is this really what we want for our grandparents, parents and ourselves?  How do we want to be treated in our last days?  “Years ago, there were not nursing homes or hospitals and the United States’ per capita income was much lower than what it is today, people would die surrounded by family and friends, in their own home. There was a sense of community” (Dahl, 2003). Is this not what we want for our society, our grandparents, parents and ourselves?