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How to save a trillion dollars in health care

| Policy | May 5, 2012

It is both conventional wisdom and factual truth that, unimpeded, American healthcare cost inflation will bankrupt the United States economically, educationally, socially, and politically in the not too distant future.

The inexorable upward trend line is unsustainable.

In 2009, I described six ways to save nearly $1,000,000,000,000 per year without serious harm, and with positive benefit to the public health.

They were:

  1. Use intensive medical therapy instead of coronary artery bypass grafts and invasive angioplasty and stents for most established coronary artery disease.
  2. Stop using PSA screening for prostate cancer in asymptomatic men.
  3. Stop using mammography screening without clinical indications for women under age 50 and decrease its frequency for those over 50.
  4. Sharply diminish use of CT scans and MRIs since they are mostly habitual art forms.
  5. Decrease the practice of routinely administering untargeted chemotherapeutic false hope and real suffering to patients with widespread metastatic cancer.
  6. Recognize death to be normal and endeavor to make it as dignified and free from pain as possible. Do not prolong dying to keep the revenue flowing.

I did not itemize the cost savings, but merely stated many billions or tens of billions for each item.

In 2012, writing in JAMA, Dr. Donald Berwick described six ways to save $558,000,000,000 to $910,000,000,000 per year.

They were:

  1. Adopt known best care processes including proven patient safety systems and preventive care practices … savings $102 to $154 billion.
  2. Coordinate fragmented care … savings $25 to $45 billion.
  3. Stop overtreatment with unneeded antibiotics, surgery, and intensive care, especially at the end of life … savings $158 to $226 billion.
  4. Simplify inefficient administration, rules, and billing procedures … savings $107 to $389 billion.
  5. Price medical products and services transparently to cover costs and a fair profit … savings $84 to $178 billion.
  6. Decrease illegal medical fraud and abuse … savings $82 to $272 billion.

Two different but similar ways of viewing how to cut medical waste, fraud, and abuse.

I would add today that the institutionalization of “defensive medicine” into “standard of practice” is also a nine-figures problem annually.

But every dollar not spent on medicine comes out of some other American’s pocketbook.

So, who matters most? The American nation, or the all-powerful American Medical Industrial Complex (AMIC).

For the past 50 years, when this battle has been engaged, AMIC has won every time.

It is past time to put the nation and its people first.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

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  • http://www.facebook.com/profile.php?id=1070726165 Anela Izadi

    This is a great way to cut the cost but the hospitals would lose a lot of money if they stopped performing unnecessary diagnostic tests and procedures. They WANT the doctors to do these things.

  • sFord48

    I don’t see anyone in the medical system giving up their profits.  

    When the USPSTF recommended routine mammography was no longer recommended for women under 50, I received advertisements from a local breast center refuting the USPSTF, using fear to make sure their doors stayed open.I also saw a doctor who owned his own MRI machine.  While an MRI might have given more information about my condition, it wouldn’t change the treatment plan.  He bullied me in to agreeing to the MRI and when I asked if I could have an MRI closer to home, this request was ignored.  That afternoon his office called to set up the MRI.  

  • http://www.facebook.com/cunningham.lizzy Elizabeth Diop

    no insurance this year for me or my son.  and it’s been our healthiest year ever.  apparently, running to the doctor with every runny nose really ISN’T necessary.  i’ll be excited to get insurance again in case we have a real need, but i’m going to be FAR FAR more judicious in my use of medical services.  

  • southerndoc1

    Easiest and cleanest way to save a bundle: eliminate “facility fees” for all out-patient care, both procedures and E&M codes. It would also get hospitals out of the practice acquisition arms race.

    Don’t hold your breath, though.  Most of the powers that be, including the gurus of cost savings, get a good bit of their income from this.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    The funny thing is that although most people agree that we need to put people first and everybody engages in all sorts of soaring rhetoric to that extent, we are doing the exact opposite.

    Consolidating care delivery into mammoth systems, consolidating payers, vertically integrating payers and providers, chasing small practices out of business, adding complexity everywhere we can through a tangled web of rules and regulations and incentives and penalties…..

    The “all-powerful American Medical Industrial Complex” seems to have no complaints with the general direction.

    • southerndoc1

      And the really strange part is the medical societies enthusiastic participation in this process. One can assume that the AMA, with its lock on the CPT system, is totally corrupt, but the primary care groups? The only explanation I can come up with for their attempt to lead patients and docs over the cliff is a degree of political naivete that approaches village idiot standards.

  • Bradley Evans

    Isn’t ANY trend line unsustainable… unless it’s absolutely flat?

  • john615

    As healthcare financing changes with more risk sharing,  physicians and hospitals will be motivated to find solutions to this problem. 

  • caduceusblogger

    Interesting article. But anybody can come up with a list, the implementation of the list is the diffucult part. Remember the firestorm that came about after USPSTF came up with their recommendations regarding #3 on your list? What followed were angered and misleading media reports, many as hellacious as the title of this article.

  • ScullyatFootscray

    But an essential missed is true engagement of the patient in their own health care, in the health care system, with all clinicans so that transparency and consultation become the foundation of decision making.

    The patient is a citizen who, like all of us expects safe care and is entitled to safe care. Clinicans need to be courageous and citizens need to engage.  

  • Dorothygreen

    Here’s how to save another trillion  Reform our eating culture – start with a RISK tax on sugar, fat and salt. Also, stop for-profit insurance for basic care. The rest of reform is then workable under ACA.  This would cut the need for so many cardiac and endocrine specialists, much defensive medicine and other sickness care services.  We study obesity ad nauseam at the expense of unpredicable diseases because they pay.  We should pour the money into wellness – gyms, bike and walking paths, public transportation, local vegetable growers – use every available space for vegetables. education in schools, senior centers – every where.  Jump on the Food Revolution bandwagon.  JOBS. 

    Switzerland, for example, is worried about rising cost of health care at 11% of GDP, 9% obesity rate (US almost 18% and 34% respectively).  They are also concerned about a fairer system (and they do have a system which is a lot fairer than ours).  They provide 10% of the world’s pharmaceuticals – the US pays full price, we subsidize Switzerlands pharmaceutical industry and the US taxpayer subsidizes the US. 

    Why are we so blind to all of this?  An article in the NEJM recently spoke of the changes like “choose wisely” and how it might negatively impact this 2.5 trillion dollar industry.  It was remarkable in the absence of any reference to the SAD – Standard American Diet and all the chronic preventable diseases.   Instead focusing on how a decrease in services might take away jobs in AMIC.   

    Does the AMIC, Big Ag and Big Insurance think this unsustainable path can continue?  Other countries  are already imposing taxes on sugar, fat and sodium while our Congress allows the USDA to justify a farm Bill that subsidizes unhealthy food  (mostly corn fed for cows and wheat) AND food stamps for soda and other unhealthy items.  This is grossly unfair to taxpayers – especially those who really try to eat heathly (unfortuantely the minority but rising).  RISK model like the tobacco model would make a huge difference and allow the US to again take the lead in the world’s most pressing problems.  BTW,  calculations for RISK are $100 B a year in revenue.    

    So please add REFORM OUR EATING CULTURE to the top of the list.    

  • http://www.facebook.com/profile.php?id=1039832658 Tim Leavitt

    The second list kind of touched on this, but, how about adopting a set of standards regarding medical equipment and supplies? If all connectors were made to a standard that ambulances, clinics, and all departments would save the patient costs, the insurance company and everyone overall. I work for an ambulance service, and it never fails that the disposable SPO2 cable never fits our monitor nor the receiving facility on a transfer. IV tubing, defibrillator pads, anything with a connector that could be standardized so that supplies aren’t changed out simply because the manufacturer makes it proprietary to their machine. Also, how about a national medical record database accessible by EVERY hospital and doctor’s office in the country?

  • katerinahurd

    I agree with you that medicalization of the death process is prolonging the death experience in order to keep the revenue flowing.  How do you think non- medicalization of the dying process plays out with a disabled person.

  • Les Stettner

    I agree in theory, but this kind of simplification will only be achieved through a Single Payer Health Care System. There are a lot of claims of savings but not enough supporting information. It is not about liberal or conservative labels, Single Payer is the most equitable, fairest, effecient and cost effective way to deliver healthcare at it’s best in a diverse country like the US. I agree that many industries will have to change the way they do business, but that is not a take away from Americans. In fact, just the opposite. Your points are well taken, tho’ I don’t agree with all of them. There is a happy medium which would change the way healthcare is delivered in the US. You make a startling point of where we could potentially start reform that is good for America, tho’ reform is a dirty word right now because it accomplishes so little at such a high cost. Staking claim to the much needed changes in the American medical delivery system is what our political process is doing. Both parties are jockeying for positon which gets nothing done…a track record we are all familiar with. So, my question is how are you going to advance your points, so we all can benefit from it?

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