Is rationing necessary to reduce health care costs?

Healthcare costs keep rising. Your insurance premiums go up, your deductible and co-pays go up, pharmacy benefits go down. Despite the high cost you get little time with your physician, insurance statements are complex beyond belief and “customer service” seems to be a foreign concept. To combat high costs we are often told that rationing will be necessary. Is that true?

Why are costs so high in this very dysfunctional healthcare delivery system?

There are many reasons. New technologies and drugs are often cited as major culprits. There is some truth to this of course but the real culprit here is inappropriate use. Think of the stomach acid blockers for reflux (heartburn). Good drugs for sure but maybe some lifestyle changes such as less caffeine, less alcohol, raising the head of the bed and waiting a few hours after dinner before going to sleep will work just as well with no cost whatever.

Worst yet is when an expensive test is ordered when diagnosis could have been figured out through a careful history. Did you need an endoscopy with its negative results when the reflux would not abate? Or did you really need a careful history that figured out you were sensitive to gluten? A dietary change solved the entire problem; no pills or procedures needed.

Our lifestyles are a major reason for the escalation of costs. As a society we eat a non-nutritious diet and far too much of it, we are sedentary, we are chronically stressed and 20% still smoke. The results are complex chronic illnesses such as diabetes, cancer, heart disease and stroke. These are lifelong once they develop, difficult to manage and expensive to treat. The real answer is to adjust our lifestyles and to prevent the epidemic of obesity which is a precursor to many of these illnesses. But until we do, costs will escalate rapidly as more and more individuals develop these chronic illnesses – which are where about 70+% of health care claims paid go.

The population is aging as well and with aging come problems such as visual and hearing impairments, joint dysfunction and Alzheimer’s disease. These too incur substantial expense.

There remains in healthcare delivery far too many preventable errors with probably 100,000 individuals dying each year and an equal number dying of hospital acquired infections. Dealing with these two problems will not only markedly improve quality but will also save billions of dollars each year.

And at end of life, often there is a decision made by either patient (or patient’s loved ones) or recommended by the physician to “do one more thing.” All too often this is a mistake with no real benefit to the patient and often more time spend with distress. It is much better to have a realistic discussion between patient (and or loved ones) and the physician and from that a realistic plan for care. This, I hasten to add, is neither a “death panel” nor does it mean no more care and attention. What it does mean is that the care going forward will be just as complete and compassionate but with the more realistic goal of best quality of life possible for as long as possible. Here again, quality ends up costing less.

These are just some of the most notable reasons for rising costs. Many, perhaps most with the exception of those that come with aging, could be addressed with changes in lifestyle, good preventive medicine, attention to quality and more emphasis on patient-physician interaction rather than on testing and referrals to specialists. Add to this good palliative care at the end of life and a very substantial amount of money could be saved while providing better quality.

Physicians can take the lead by agreeing to eliminate those tests and procedures that are often done but which have not been found to add much to the care of the patient. A good approach to this has been presented by Dr. H Brody in the New England Journal of Medicine which was followed up in the oncology field by Smith and Hillner also in the NEJM . The basic concept was that each specialty society create a “top five list” of those tests or procedures that offer little or no benefit to most patients. In Smith and Hillner’s article they suggested – just one of their  examples to reduce costs in medical oncology -that no patient (other than certain well defined exceptions) should receive chemotherapy if he or she was unable to walk into the clinic unaided, there being good data that such patients rarely benefit but often suffer adverse consequences.

Rationing is not necessary. We need to correct the dysfunctional delivery system so it can offer higher quality care at a reasonable cost. It is not impossible to do and no rationing is required.

Stephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery, published by Potomac Books. 

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