The braying of politicians and policy wonks sometimes makes it seem like the most important goal is to bend the cost curve, or to champion consumerism, avoid crowd-out and foster comparative effectiveness, or put an end to "never" events. Confused?
We're here to help.
Here's a field guide to health care jargon that can help clarify the often mystifying and obscure debates over health care.
Adverse events -- Harmful side effects, or adverse events, come with every medical test or treatment -- even the so-called "breakthroughs" hyped in the news and by the companies that sell them. A study found that less than a third of news reports ever mention that cancer treatments can cause harmful side effects. Survivors accounted for more than three-fourths of people portrayed in news reports, when in reality only half of those diagnosed with cancer survive. Such unrealistic depictions "mislead the public about the trade-offs between attempts at heroic cures and hospice care," Jessica Fishman of the University of Pennsylvania and co-authors wrote in the Archives of Internal Medicine.
Bending the curve -- Since fixing everything that's wrong with our health care system seems a bit pie in the sky to some experts, they've fixed sights on the more modest goal of slowing the rate of increase in spending on medical care, or bending the cost curve to make it rise less steeply. One relatively easy way to do that would be to get wasteful, high-spending states such as Florida to perform more like thrifty, low-spending states such as Oregon (see "evidence-based medicine" below). In Miami, the federal Medicare program spent $16,351 per enrollee in 2006 and costs rose at an annual rate of 5 percent. That was twice as fast as in Salem, where Medicare spent $5,877 per enrollee in 2006 and the growth rate was 2.3 percent, according to the Dartmouth Institute for Health Policy and Clinical Practice. Dartmouth researchers conclude that if Medicare reduced its annual spending growth from the national rate of 3.5 percent to something closer to that of Salem or San Francisco, the program could save about $1.4 trillion during the next 14 years and avoid a projected deficit of $660 billion.
Broken, fundamentally -- Until recently, everyone across the political spectrum seemed to agree that our health care was totally messed up. "The health care system is fundamentally broken," Bush administration Health and Human Services Secretary Mike O. Leavitt said in a September 2007 speech at Harvard University. His words echoed those of then Sen. Barack Obama, who in 2006 told Illinois medical graduates, "At some point in your residency, you'll see firsthand that there is something fundamentally broken about our health care system." As Democratic health reform legislation became a reality, however, opponents began singing a different tune. Fox News commentator Glenn Beck passionately argued both positions, as pointed out by Jon Stewart's "The Daily Show." After undergoing surgery in 2008, Beck reported on his "personal voyage through the nightmare that is our health care system." In more recent shows, Beck takes up the argument put forth by Sen. Richard Shelby (R-Ala.), who said Democrats' reform proposals "will be the first steps in destroying the best health care system the world has ever known."
Comparative effectiveness -- About 200,000 men every year in the U.S. find out they have prostate cancer. But even with such a common disease, doctors don't really know how best to treat it. Some favor radiation therapy, some more often recommend surgery and others advocate close monitoring rather than any treatment for early stage tumors. The lack of research comparing the effectiveness of treatments is a widespread problem. In a study this month in the Journal of the American Medical Association, researchers found that less than a third of 328 medication studies recently published in six top medical journals made any attempt to determine which available treatment works best. Most stopped short, at merely showing that a new drug worked, often by comparing it to an inactive placebo. Why the lack of comparative studies? "The answer lies in the fact that pharmaceutical companies fund nearly half of all medication research, including the lion's share of large clinical trials," study authors Dr. Michael Hochman and Dr. Danny McCormick wrote in a Los Angeles Times commentary. "Once these products have won approval for clinical use, companies no longer have incentives to study exactly how and when they should be used." But the tide is turning. In the economic stimulus legislation, Congress directed $1.1 billion toward funding comparative effectiveness research.
Crowd-out -- Expanding government-funded Medicaid coverage for the disabled and poor could have an unintended consequence: crowding out private insurance by making it easy for employers to stop offering coverage and for privately insured people to switch to publicly funded programs. The significance of this problem depends in part on your worldview. If you think the private insurance market better serves low-wage families, then any crowd-out is bad. If you think such families do well with Medicaid coverage, than some crowd-out should be acceptable. In Massachusetts, where state-level reforms massively expanded government coverage to the uninsured, most studies have found little or no evidence that employers are dropping coverage or that adults who can afford private insurance are going on the dole.
Diagnostic yield -- Under the health care payment system, doctors and hospitals can boost their income by performing lots of expensive diagnostic tests, without much regard to the costs and benefits. Consider cardiac catheterization, a diagnostic procedure in which a doctor threads a wire probe from an artery in the groin to the heart to look for dangerous blockages. Most of the time, the expensive and invasive test fails to provide information needed to make a diagnosis. In a study of nearly 400,000 cases performed across the U.S., nearly two out of three patients -- 62.4 percent -- turned out to have no meaningful sign of coronary artery disease, Duke University researchers reported this month in the New England Journal of Medicine. Diagnostic yield is even worse for widely used screening tests such as mammography for breast cancer and PSA blood tests for prostate cancer.
Evidence-based medicine -- Less than half of existing medical treatments are supported by scientific studies, the Institute of Medicine concluded in a 2007 report. That's one reason why treatment choices vary drastically across the country. End-of-life care shows the most dramatic variation. During the last two years of life, a Portland resident dying of cancer, diabetes or heart disease is likely to be hospitalized 16 times and spend two to three days in intensive care. In Los Angeles, the same patient could expect to be hospitalized 77 times and receive more than 11 days of intensive care. Some experts think that developing more uniform, evidence-based practices across the country could save tons of money by eliminating wasteful spending (see "Bending the curve").
"Hamster" medicine -- When faced with cuts in payment for service, doctors can boost their income by churning more patients through their offices and running more tests. This treadmill effect has been called "hamster" medicine. This unintended consequence has emerged in the current debate over how to reward quality and discourage poor performance with payment incentives. Some experts worry that ham-fisted incentives could allow poor performers to compensate with hamster medicine.
Healthy -- Medical technology is blurring the distinction between healthy and sick, as illustrated by a study in which 1,192 healthy women and men had their entire body scanned by X-ray computed tomography, or CT. Abnormalities showed up in 1,030 of them, nearly 90 percent, and doctors advised 37 percent of the patients to get further tests. An essayist writing in the Journal of the American Medical Association hit the nail on the head: "A colleague of mine recently asked a resident how he would define a well person. With no hesitation, the resident replied that a well person was merely someone who had not been thoroughly worked up."
Iatrogenic -- The Greek word for physician is "iatros." Most people in the U.S. don't know Greek and so probably wouldn't guess that the iatrogenic problem listed in their medical record refers to an injury or infection caused accidentally by a physician or other medical caregiver. Some words seem meant to obscure rather than clarify (see also: "'Never' events").
"Never" events -- Extreme blunders, such as operating on the wrong body part or the wrong patient, are never supposed to happen. Efforts to eliminate "never" events began nearly a decade ago, and yet such errors continue to occur on a regular basis in hospitals across the U.S. In Minnesota, one of a handful of states mandating public reporting, surgeons left objects in 37 patients, operated on the wrong body part in 21 patients and performed the wrong procedure on 16 patients during 2007-2008. In 2008, the federal Medicare program began denying payment for treatments made necessary because of "never"-event-type errors, and private insurers are following the government's lead.
Overdiagnose -- While it's clear that screening tests such as mammography save lives, they also can lead to overdiagnosis: the detection of tumors that are dormant, destined to regress without treatment or growing so slowly the patient dies of other causes before the tumor causes any harm. In the U.S., studies suggest that 1 to 10 percent of women given a diagnosis of breast cancer are overdiagnosed and subjected to unnecessary cancer therapy. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy and sometimes chemotherapy. The overdiagnosis dilemma was one of the leading reasons cited by the U.S. Preventive Services Task Force last year when it changed its recommendations for mammography, saying most women could wait until age 50 to begin screening unless they are at high risk for breast cancer, and advising women to get screened less frequently -- every two years, rather than annually. The threat of overdiagnosis has also stirred experts to caution against routine PSA screening for prostate cancer.
Surrogate endpoint -- Some new drugs became blockbuster sellers based largely on indirect study results. Relying on so-called "surrogate endpoints" is risky. For instance, the biotechnology drug epoitin alfa, widely prescribed to cancer patients with anemia, works well at boosting blood levels of hemoglobin. But as researchers have gotten around to conducting studies of more meaningful effects, they've found epoitin alfa doesn't improve quality of life or survival (see also "Evidence-based medicine"). The diabetes drugs called glitazones gained federal approval because they lower blood sugar, but experts continue to debate whether they help or harm patients with diabetes. A major federal study in 2008 found that intensive efforts to lower blood sugar might actually increase the risk of dying in older people with advanced Type 2 diabetes.
Will Rogers phenomenon -- When the Okies left Oklahoma and moved to California, they raised the average intelligence in both states, according to a joke attributed to comedian Will Rogers. When a new and more sensitive diagnostic test allows doctors to detect tumors earlier, it can create an illusion of improved patient survival. Medical researchers have called this the Will Rogers phenomenon because the false appearance of gain is really just the result of changing the way patients were categorized. The problem continues to confuse decision-making about the effectiveness of screening and diagnostic tests.
Winner's curse -- The experimental Alzheimer's drug tarenflurbil seemed like a potential breakthrough when the first human clinical trials suggested it prevented mental decline. Then came the results of a more definitive clinical trial involving 1,600 patients. Those taking the drug fared no better in any measure than those taking a placebo, researchers reported in December. The winner's curse pattern repeats every year, dozens of times. A "promising" new drug makes headlines based on the first study to cross the finish line. More thorough studies taking more time to complete reveal the truth, seldom with much fanfare. In a 2008 report in the journal Science, researchers looked at what happened to some of the most widely acclaimed drug discoveries of the past decade. They combed scientific journals for studies that attracted more than 1,000 mentions in subsequent research papers, and came up with a list of 32 highly cited studies on new drug treatments from 1990 through 2004. A surprisingly high proportion of the treatments, two of five, or 40 percent, later proved partially or completely ineffective. Among them: hormone replacement for preventing stroke and heart disease, and vitamin E for preventing heart disease.