Cost of care is related to the advancements in medicine

Much is being written about the ever increasing cost of health care in the US, especially compared to the rest of the developed world.

As a nation, we spend nearly 16% of our GDP on health care.  All estimates predict that this amount will continue increasing unless costs can be controlled now.  Hence the passage of the Affordable Care Act.  Not only was it designed to extend coverage to more people, but make no mistake, it wants to do it at a cheaper cost.

Cutting the fat and leaving the lean in health care is much like going on a diet.  The math is simple; take in less and/or burn more calories.  Health care math is similar; spend less and/or take in more money.  The ACA is attempting to do both.  In this analogy, the dieter, or the taxpayer/economy, is going to be a mere anorexic shadow of its former self.  The government plans to extend this coverage to 35 million plus, currently uninsured individuals, while slowing the rate of health care expenditures.  This means that as providers we will be receiving less (again) for the same amount of work, while we get taxed at a higher rate to pay for what we are not receiving ourselves.

So many people complain about their health care that it makes me wonder whether or not they would like to return to “the good ol days” when a physician made house calls, patients paid with chickens, pies, etc..  Oh, and don’t forget that a lot of people died from their diseases.

Back ”in the day” when there was no such thing as “modern” health care, people accepted the fact that death was a part of life and that certain diseases or conditions were uniformly fatal.  Prior to 1923 when Banting and Best discovered, and Eli Lilly mass produced insulin, all type I diabetics died from diabetes within a few months to years.  The treatment at that time was a low carbohydrate diet that allowed the person to live but with the knowledge that death was soon coming.

Alexander Fleming discovered penicillin in 1929 but it wasn’t isolated until 1940 as a potential antibacterial agent.  It was produced  in quantity just in time to save countless lives during WWII.  Penicillin was used to treat routine bacterial infection, diphtheria, syphilis and tuberculosis.  Certainly a miracle drug if there ever was one.

Patients with kidney disease also anticipated a slow death, but not always so painful.  Hemodialysis was first used in a laboratory setting in 1913 on dogs but not perfected for human use until 1945.  Advancements since that time have made dialysis more efficient and available to many more people.  In the US alone there are approximately 400,000 people on hemodialysis.  The most, if not all, are receiving Medicare benefits to pay for this service at a cost of $55,000 per year per person. That’s 2.2 billion!

Something as simple as the annual flu has wreaked havoc on humans as long as we have inhabited the earth.  The ability of the influenza virus to undergo change and merge with other strains of virus made sure to cause much morbidity and mortality over the millennia.  First described by Hippocrates in 404 B.C., and recently causing worldwide scare as the swine flu in 2010, influenza continues to cause tens of thousands of deaths annually and many more during pandemics.  One can only imagine the number of deaths we would see yearly without the availability of the annual trivalent flu vaccine.

Mechanical ventilation and the modern intensive care unit became a standard of care after the “iron lung” was replaced by the more efficient positive pressure ventilator came into widespread use.  Over the years, the use of vasopressors, powerful broad spectrum antibiotics, in depth understanding of the physiology of stress and its effect on the human body have meant that even the most ill patient has a chance of beating death.

The cost of care is directly related to the advancements we have made in medicine over the past century.  The real change in the ever increasing costs of care is related to our refusal to accept that death is a natural part of life.   Along with that denial is the need to hang on at any cost.  Most of our health care dollars are spent in the last two years of life, many times in futile efforts to restore someone to a previous level of functioning.

As a nation we view health care and insurance as a right, an entitlement.  As such, it falls under the auspice of the federal government to manage.  In other countries the health care rationing you hear so much about has more to do with trying to make sure that the scarce resource of health care is being utilized where it will have the greatest benefit, have the largest impact and most efficient.

We aren’t ready to accept “rationing” just yet and that means costs will continue to rise or many, many people will be unhappy with their health care entitlement.

“Doc B” is a physician who blogs at One Doc’s Opinion.

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  • MassachusettsPCP

    Besides not holding patients accountable for their adverse health behaviors (overeating, sedentary, smoking, alcohol abuse) I have long wondered how printing up new Medicaid or low-cost insurance cards and distributing them to a public that sees new tests and meds being developed all the time (not another PPI or ACEi mind you, brand-new drugs such as oncologic and immunologic modifiers) and — in just the post below this — genomic medicine personification will bring in health care costs. Patient accountability seems to be limited to having an insurance card. Doctor accountability is vast – “guidelines” that more often than not are committee-based and not level I evidence, insurance and governmental concerns. Somehow controlling what doctors prescribe (meds, therapies, procedures, tests, specialist referrals) will lead to lower costs while the rates of new imaging, new meds, new therapies continue to climb. But we can’t capitate the latter. No that’s medical “innovation” and must be paid for. But the PCP’s rate for E&M services should be capitated and ACOs should be formed and like any religious dogma, it is faith-based. The rest of the health care providers – those providing tangible “goods” rather than services – are expected to work under a traditional business model and capitation would never work there. The public is sick of stories of doctors salaries and think that everytime a doctor orders a test he gets more money (Stark law anyone?) and 10 minute visits do not justify these outrageous costs. So the solution is to capitate the field in the most dire straits – primary care – and then hold them responsible for costs they either can’t control (social and economic factors for the patient), or would be negligent if they didn’t refer for X procedure or Y drug because clearly this patient’s “unique case” clearly indicated they were out of the guidelines. Don’t forget most guidelines are not just consensus-based but also the basis of the populations being studied rarely had multiple disease states and comorbities with lots of exclusions. The typical world of the PCP but not of the research done to promote X procedure or Y drug.

  • Kristin

    Pretty much the only people making real money–corporate-level money–off health care right now are a) insurance companies b) pharmaceutical companies and c) device manufacturers.

    If you want to trim costs, how about starting with them? Insurance companies pay their executives millions while rejecting claims for legitimate illnesses. Pharmaceutical companies engage in unethical marketing practices (“seeding” trials, anyone?) and spend far more of their budget on marketing than on R&D. (I will certainly agree that R&D is expensive–the way the big companies do it. Most innovations in drugs are currently coming from either academic backgrounds or from small biotech start-ups.) Device manufacturers act like pharmaceutical companies, complete with highly aggressive marketing tactics.

    You want to make health care cheaper, stop some of the leeches. Regulate the role of lobbyists for these companies. And maybe rework the RUC so that specialists aren’t so heavily over-represented.

    You say we aren’t ready to accept “rationing,” as if rationing is a dirty word. Maybe it should be, but you’re looking in the wrong direction. Health care is already rationed. It’s rationed according to socioeconomic status. I don’t get as much medical care, or of as high a quality, as someone who has more money than I do. Maybe you think someone who has more money than I do deserves more and better medical care than I do, but I disagree. And it seems frankly inhumane to suggest that a human being’s worth is dependent on their bank account. Particularly given that the socioeconomic inequalities in American society have so little to do with personal merit (cultural mythos to the contrary aside), and so much to do with where you’re born and to whom.

  • Muddy Waters

    The fundamental problems with our society can always be linked to one of the following factors: greed, apathy, and overpopulation. The rich get richer, the poor get poorer, and the most rapidly enlarging portion of our society contribute next to nothing to the survival of our way of life. Healthcare is but one resource that will be rationed in the near future. Oil, energy, and clean water are a few more. We need to focus on the big picture here. We are simply outgrowing our resources, and the human race will be controlled one way or another.

  • Hospice and Palliative Care Doctor

    While I agree w the authors post that our increased technology has subsequently increased our healthcare costs, the true culprit to our high, & ever increasing higher cost of healthcare is futile & costly end-of-life care (eolc) & obesity. The largest percentage of Medicare dollars are spent on the last year of life, & the patient still dies. I have seen pace-makers placed in patients just a week before the doctor sent him/her to hospice to die within 3 months (for real, you can’t make that up guys). Gosh, I’ve seen complete surgeries. I’ve seen pts in vegetative states within months of their deaths due to end stage dementia still cholesterol medication. What I see is absurd. And society wants it that way. Remember the cries of “death panels!” by some? The ACO, despite it’s great attempt to address the high cost of healthcare, will not address this issue.

    Obesity is the other main problem as it is the root cause of a MYRIAD of other health problems- diabetes, heart attacks, strokes, arthritis, pain, high cholesterol, coronary artery disease, falls, kidney disease…the list continues. 30% of the US is obese, not overweight, OBESE. I see no solution to that crisis. None. Come up with a population based, proven method to cure obesity, and you will earn the Nobel Prize. Really.

    Sure, we can medically do alot more due to our higher technology, but it’s obesity & eolc that killing us financially.

    • stitch

      We have a population based method to cure obesity. It will be due to food shortages with climate changes and insufficient food production to meet the demands of an ever-expanding human population. The rise in food prices is real; it will continue.

  • buzzkillersmith

    The impossible triad of medicine: Low cost, high quality, unlimited access. A society can have one of the three, maybe two if we’re lucky, but never all three. It was ever thus.

    • doctor1991

      Correct.
      Would also note that we are now treating conditions and giving treatments that practically did not exist even fifteen years ago- ex. bariatric surgery and chronic fatigue. Regardless of what one thinks, it adds to the costs.

  • solo fp

    Why are we doing CTs/MRIs and intubation on 90 yo stroke patients who have only a few days to live who already have the diagnosis of end stage dementia but who the family still asks for everything done? It is easy to spend $100,000 on the last week of life with no better outcome. The reason is that many seniors are covered by Medicare/Medicaid, and no financial responsibility goes to the patient or the family. The government picks up the tab, the docs get paid, and the hospitals get paid. Part of it is liability fear, but part of it becomes that it is easier to simply order tests than to discuss the ethics of doing it. I have seen families fire docs at the end stages for docs who talk to them about comfort care and doing the right thing. Making families financially responsible for the excessive studies and tests would greatly reduce unecessary testing. We all can order $100,000 workups, but rarely does it make a difference in the quality and quantity of life at the end.

    • Hospice and Palliative Care Doctor

      You are 100% correct.

      But since it will never happen, I see little hope for significant improvement in our healthcare crisis, Obamacare or not.

    • linda

      Amen. As a Diabetes Educator who deals with obesity on a daily level and has lived where death is still a daily event =, we need to let the Docs know about NO FINAL treatment and refuse to be treated at the end stage. Death is normal and acceptable. We do not need to morgage our grand children to insure we live for five more days. We need to take personal responsibility and get moving while eating what we need ( 1,400cal, 40gm PRO, & 35gm fat) for most adults. That 2,000 calorie person on the NutritionFacts label is allowed 2,000calories because he is breaking a sweat for 2.25hours/day!!!!! Not a very “normal” American.
      Blessings and good weight goals for all.

      • Hospice and Palliative Care Doctor

        “=, we need to let the Docs know about NO FINAL treatment and refuse to be treated at the end stage”

        While I agree with you 100%, and doctors drive a portion of the high & useless costs of end-of-life care, it is still the patient, and more often than not, the families that demand this nonsense. Believe me, I do hospice for a living as well as primary care.

        Society needs the education even more.

  • wayner

    All: From the research literature, some facts (as opposed to lots of opinions):

    Commonwealth Fund, based on 2004 data, estimated the waste in healthcare spending to be ~ $0.5T in ~ $1.9T that year, or ~ 27%. Here are a few reasons why the waste is so high:

    “…takes an average of 17 years to turn 14% of original research findings into changes in care that benefit patients.”
    EA Balas & SA Boren, Managing clinical knowledge for health care improvement. In: Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany; 2000:65-70.

    “The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.”
    McGlynn, et al., NEJM 2003; 348:2635-45 –> basis of conclusion:
    • 12 metropolitan areas; most recent two yrs medical records
    • Evaluated performance on 439 indicators of quality of care
    • Acute / Chronic / Preventive care
    • Participants received 54.9% of recommended care
    • ~ same result whether acute / chronic / preventive care, whether screening or follow-up
    • Differed across medical condition
    o 78.7% for senile cataract to 10.5 % for alcohol dependence

    “Society invests billions in the development of new drugs and technologies but comparatively little in the fidelity of health care, that is, improving systems to ensure the delivery of care to all patients in need.”
    “In two examples (development of anti-platelet agents and statins), we show that enhanced efficacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients.”
    Woolf & Johnson, Ann Fam Med. 2005; 3(6):545-552.

    Only ~10% of “total health” is due to healthcare delivery:
    • ~40% due to behavior
    • ~30% due to genetics
    • ~20% due to environment / public health measures
    McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10).
    McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).

    • MassachusettsPCP

      Only ~10% of “total health” is due to healthcare delivery:
      • ~40% due to behavior
      • ~30% due to genetics
      • ~20% due to environment / public health measures

      No. No. No. Faith-based dogma in ACOs (the fancy new word for capitation) will save the healthcare system and the country’s financial expenditures as a percentage of GDP. Not patient lifestyle and behavior modification! This is irresponsible, parental, and condescening to patients, presenting such research and statistics.

    • http://www.WhatsTheRealCost.org Susan

      Thank you for calling out that stat on taking 17 years for research to get into practice. Take the surgical checklist to reduce line infections that Dr. Peter Prevnost pioneered at Johns Hopkins in 2001. When tried in Michigan in 2003, it saved 1500 lives and $175 million in 18 months – just one hospital. In 2007 – Atul Gawande writes an article in New Yorker about it, and subsequent efforts: http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

      It’s been 10 years and counting – how many hospitals are using the checklist to save lives and money? Not enough.

      So it’s not just the new care options that are costing money, we still have to get better at using what we already know works.

  • Laura, Peds EM

    When I make similar comments to folks in their 70′s, they are aghast. Just as we have polluted our world, wrecked our economy we are robbing our children and grandchildren of their future by continuing to overuse healthcare till the end. I’m only in my early 50′s, but when my body fails me, I’m ready to go.

  • Marc Gorayeb, MD

    “As a nation we view health care and insurance as a right, an entitlement. As such, it falls under the auspice of the federal government to manage.” Stated as a foregone conclusion.
    Well, not so fast. Why aren’t shelter, food, transportation or credit a right or an entitlement? Any of those things are arguably more important than health care. Other than what our state or federal constitutions proclaim are our rights, or what our legislatures proclaim are our entitlements, I would argue that there is broad agreement on only one other thing: a social safety net that provides basic necessities to those who are unable to provide for themselves. Outside of that, many Americans don’t accept your foregone conclusion.

  • stitch

    We continue to pursue immortality at any cost. Small wonder that the costs are continuing to escalate in chasing this impossible dream.

    Until we wake up to that simple fact, that we do all die, we will do nothing to contain costs.

  • jim jaffe

    unaware of anyone who wants to return to the good old days when many conditions that now have cures didn’t. that’s not the issue. the issue is care creep that doesn’t yield better results and the realization that much of what it is added doesn’t necessarily help the patient. that’s not to minimize the difficulty of defining what can be cut without compromising care, but does suggest we start by abandoning the belief that more is better

  • http://www.womeninpainawareness.ning.com carol

    Of course care is rationed. The insurance company tells you what you can have and what you cannot.
    (As for end of life, this is why it is so vitally important to make sure that your patients have drawn up a living will. Without one the hospital, from what I saw with my mother before they were aware she had one, feels they must do everythiing despite, in my mother’s case, 2 strokes that left her aphasic, completely paralyzed, and in coma..)
    Carol Jay Levy

  • http://none joe

    “The insurance company tells you what you can have and what you cannot.”

    I think it only tells you what is covered by the policy you purchase and will pay for. You have the choice to do it or not. Stop blaming the industry that actually pays you. Dont like it, dont accept insurance and see how far that gets you with your prices you charge

    • http://www.womeninpainawareness.ning.com carol

      If we were to have the government rationing that is one of the lies behind health care reform bill we would also be able to pay out of pocket if we were able.
      I am disabled, on medicare and, thankfully so far, can afford a supplemental ins. Not all have the luxury of good insurance much less money in the bank to pay the costs of whatever the insurance will not allow. (I have had surgery refused by BC/BS because they decided it was ‘experimental’ despite their having previously paid for a similar, completely experimental (I am 12 or 13th in world to have it) procedure (brain implant for pain control). I have been told if, thru infection or wire failure, I had to have it removed insurance would refuse to pay for replacement. This is a highly refined neurosurg procedure. No way I could afford it and no way I could function as well without it.
      Ins certifies on case by case and often depends on which bureaucrat is to certify if it is approved or not.
      (By the way I am not now nor have I ever been (except when I was an ER ward clerk.) a doctor or in the medical profession. They don;t pay me. I pay them,
      Carol

      • Kilroy71

        Carol, I am very sorry for your illness, but as a taxpyer footing the bill for your care, I’d like to see a little more gratitude for the fact that you ARE getting medical care at someone else’s expense in addition to what you pay. The entitlement attitude is not going to win your argument. Also, sometimes a procedure actually is experimental with regard to one condition, but proven with another.

  • Kilroy71

    Sure you can, Tony. Just pay out of your own pocket for routine care from the nurse practitioner, and save insurance coverage for the truly heroic events. Change the insurance coverage you buy to a high-deductible and put your money in an HSA account, to pay your nurse practitioner. you already have this choice. Do you have the courage?

  • Hospice and Palliative Care Doctor

    Tony,

    You wrote:
    Where can a consumer go if they just want “reasonable” health care at a “reasonable” cost? …Some of us don’t want heroics when it comes to end-of-life care. Some of us don’t want lung blowers and heart machines keeping us alive. Some of us might just want treatment for pain and to make our passing dignified and comfortable at home.”

    Fantastic. Its called a living will, dude. That’s YOUR responsibility to write. YOU get to decide what you want at your end of life. If you don’t direct us physicians in what you want, we gotta by default think you meant for us to do everything. Go & get your living will, give it to your doctor, your family, & one to two close friends to make sure your wishes are carried out. Its called taking responsibility.

    You also wrote:
    ” Yet, we have doctors that will “fire” you and kick you out of their office when you talk like that.”
    Thats utter nonsense and stupidity. NO PHYSICIAN will do that. I have spoken over the years to hundreds & hundreds of doctors thru med school, residency, a fellowship, & years now in private practice with NONE espousing those views. You want only comfort measures at the end? Excellent. Put it in a living will.

    You wrote:
    “Where can a consumer go if they just want “reasonable” health care at a “reasonable” cost?”
    Um, that’s part of the point of this article & the point I made in an earlier comment above- obesity & the high cost of futile care, mostly demanded upon by the family are the causes of the astronomical health care costs. You can’t “go” anywhere cuz your society is screwing it up for you. Don’t like that? Go to a country with socialized medicine. But here in the US, what you see is what you get.

    You wrote:
    “Frankly, I’d like to choose to get my health care at a neighborhood clinic and be treated by a salaried nurse practitioner rather than a traditional fee-for-service doctor.”
    Ok, go see an NP but NP’s don’t know as much as doctors. How could they? Doctors have years of training more than NP’s. Therefore, when you DO have a problem- and you will cuz EVERYONE gets sick & acquires some chronic disease eventually-the NP will have to refer you to a specialist while if you had a doctor as your primary care physician there is a much better chance s/he will be able to manage you in his/her office without having to refer you. It sounds like you wanna see as few doctors as possible.

    But Tony, overall you sound very angry at doctors. Why?

  • http://www.facebook.com/hnbrody Harmon Brody

    The answer expressed in the title of this article misrepresents the truth.  thereis an average of 40% administrative costs attach to Health Insurance processing and related medical record keeping and overhead including duplkication of services and inadequate technology.  In Medicare and Medicaid , although fraud is a huge issue costs are at 3%.
               Providrs also increase billing prices to compesatefor bad payers.  Sometime markups on ordinary procedures can be horrifically inflated because providrs know that insurance will pay .
                Of courwse thre is the cost of R& D and new technlogy and equipment, but those enhancents like PETSCANS pay for themselves fairlyquickly over time at $1000 per MRI procedure.