I have been thinking over the past several weeks about a topic that is very near and dear to the hearts of many of us, and that is the cost of health care.
Let me put a couple of my longstanding, personal guiding principles on the table for your consideration:
1) We spend way too much on “health care” in this country, and don’t get value for what we spend.
2) I do believe that there is sufficient money within our current health care spending to provide better care to more people at lower cost.
I know I am not alone in those thoughts. The problem is how we move from the reality of today into the vision of tomorrow, and improve the quality of the care we provide while we create a system where the costs of that care more reasonable and rational so we can extend more care to more people.
A couple of weeks ago I was in Washington DC and participated in a panel on health care reform for volunteers attending the annual meeting of the Ovarian Cancer National Alliance. I showed a slide during that presentation that I have shown many times before. The slide details the per-person spending for health care in about 30 developed countries and compares it to life expectancy.
When you look at the slide, what you quickly see is that most developed countries in the world spend within a fairly limited range per person per year on health care. One country stands out however, and that is the United States. It ain’t even close: we spend a lot more than other countries per person on medical care.
Maybe that wouldn’t be so bad if we had a life expectancy to show for it, but we don’t. We are actually near the bottom of the pile when it comes to the number of years the average American lives compared to other countries. We are actually right next to Cuba, who spends almost nothing on providing health care to its citizens. (By the way, Japan leads the list with about 80.5 years per person.)
Usually when I show this slide (which was prepared by my colleague and Chief Medical Officer of the American Cancer Society Dr. Otis Brawley), it gets some attention from the audiences, which are usually made up of people familiar with the subject such as doctors or human resource directors. But this time, there weren’t a lot of doctors in the audience, just committed volunteers committed to their cause.
There was an audible gasp and reaction in the room when I explained the slide. Clearly it struck a chord. It is that graphic a representation of where we have failed to get “value” no matter how much we pay for “health”.
We have the most expensive health care in the world and we have the most technologically advanced system in the world (at least with respect to machines, but certainly not in relation to health information technology). But if we tried to measure the quality of the care we provide, the fact remains we would have an impossible task to show that we offer a reasonable quality of care for the money we spend. There is simply very little accountability built into our processes of providing medical care.
Now I don’t want to imply that a lot of doctors don’t care about their patients. They do, and they are for the most part exceptional, committed people. But listen carefully to all the discussions surrounding the current health care debate, and most of what you will hear is about money and costs. No major medical organization—pro or con the larger issue of health reform—is out there waving the quality flag in front of costs and income. They just aren’t doing it.
And yet accountability and quality are really at the heart of the issue. Getting the right care to the right person in the right place at the right time would take us a long way to getting our arms around the problems we face when it comes to providing affordable, accessible quality health care.
It’s not just the doctors who are responsible for this dilemma. Talk to them and you hear about patients demanding all sorts of treatments, even to the extreme of sending someone to the intensive care unit when they are near death with no reasonable options remaining. You constantly hear docs talk about defensive medicine, and the fear of being sued for not doing every test possible.
I call this “zero order” medicine. Zero order meaning nothing is left to chance, and nothing is left to judgment. It means every test possible is expected, and gets done or risks a malpractice suit. It is a love affair with technology that implies that if the test is done with fancy equipment, it will work better and tell us more than perhaps doing nothing for the time being. It means there must be one more medicine available that is going to cure a cancer, or one more stay in an intensive care unit that will allow a lung to breathe on its own once again, after years of damage from smoking.
A couple of examples recently have refocused me on this issue.
One example was an article in the New Yorker magazine where a doctor eloquently described the differences between two towns in Texas, and where he tried to figure out why health care was about twice as expensive in one town vs. another while there was no significant difference in health care outcomes by any measurement he could determine.
Another was an article in the New York Times recently where the reporter asked if we were getting our money’s worth from very expensive prostate cancer treatments compared to “watchful waiting.” He noted for many men it was not possible to demonstrate that one approach to prostate cancer treatment (depending on the underlying characteristics of a man’s prostate cancer) was necessarily better than the other, while some of the more “advanced” approaches were incredibly more expensive. (And this is in the face of recently reported research which has shown that it is very difficult to show a real difference in survival as a result of prostate cancer screening.)
There are research studies that show prostate cancer is found with about the same frequency in men who are screened vs those who are not (and were biopsied anyway as part of a research study). That has led some of us start asking the question what difference does PSA testing really make?
And then there is the fallout from a number of prostate cancer survivors (and doctors) who are upset about what we say, since many of them believe—because they have been led to believe—that the PSA test in fact saved their lives.
So where is the honesty that can say to men that maybe the PSA test did save your life, but there are many more men who had the test and debilitating, expensive treatment where it didn’t make a difference because we can’t tell you whether or not your prostate cancer would have been a “bad” one?
Here is another example:
I returned from vacation to find a letter on my desk—sent certified mail to me and a number of other thought leaders in medical oncology—from a woman who had a strong family history of breast cancer. She had discovered a lump in her breast and saw her doctors. She had a mammogram and ultrasound which were inconclusive as to whether or not the lump was a cancer. One of her doctors—a breast surgeon by specialty—ordered an MRI of the breast.
The bottom line of her letter—with the supporting documents—was that her insurance company had denied the MRI. The woman thought that was terrible. She wanted the MRI, her doctor had ordered the MRI, and the insurance company had denied the MRI. Her argument was that she should have been allowed to have the MRI, which I believe she eventually did get.
I read the insurance company letter, and guess what: I think they were correct. The mammogram and the ultrasound were inconclusive and cancer could not be ruled out. They very clearly stated that medically she needed to have a biopsy. The MRI wouldn’t help make that decision.
They made the exact correct recommendation. There was nothing about the MRI that should have deterred the physician from proceeding with the biopsy. She needed a biopsy of the mass. That's what the insurance company said. Medically, it was the correct recommendation. From my view, it had nothing to do with cost. It did have to do with "good medicine."
But, you may say, patients aren’t doctors. They want to do what their doctors say they should do. They say, “Dr. Lichtenfeld, you are a trained physician. You have much more knowledge than the average person.” Yes, that’s correct. I do. And so did the doctor who recommended the MRI. I just hope the MRI wasn’t in the doctor’s office, which I have seen advertised by other “breast specialists” or in a hospital that employed the surgeon who made the recommendation.
By the way, I haven’t seen in the correspondence that anyone who saw this lady suggested she have genetic counseling for the BRCA test. Her history certainly suggested that would be appropriate.
In another example, I sat next to a very healthy and admittedly active gentlemen in his mid-30’s on another plane flight. He was a successful consultant and exercised regularly. He appeared very fit. He told me about his back problem, which flared about once a year for a couple of weeks and then resolved.
For the past four years, he would see his primary care physician when the problem recurred. Every time, his primary care doc sent him to a back specialist, who ordered an MRI. Every year the report came back that they cannot identify the cause of his pain. The back specialist recommended an over the counter pain medication and told him to call if it didn’t get better. He always got better.
Having treated a fair number of patients with low back pain just like his, I asked him if anyone—particularly his primary care physician—ever had a conversation with him suggesting that he didn’t need the MRI or have to see the back specialist if his pain hadn’t changed or resulted in certain neurologic changes? Or, that even if they found the cause of the pain (something like a bulging disc) most surgeons wouldn’t operate unless there was severe, unremitting pain or a change in his exam?
The answer was “no,” and the gentleman indicated his frustration that he went through this every year, and all he got was a suggestion to go get and MRI and some NSAIDs. I asked how he felt about the necessity and costs of the MRI—which probably would be billed at a couple of thousand dollars—and he said that didn’t bother him. After all, he said, the specialist said he needed it and who was he to argue with a doctor? As to cost, he only had to pay $100, so why not get it?
I could go on and on—including the $1100 bill someone I know very, very well faces for a recent emergency room visit for a daughter who was injured while volunteering as a waiter at a faith-based camp. The bill was for medical services provided to her when she broke a glass in her hand and had to go to the emergency department for an examination, in an overabundance of caution. In the ED, she was found to have two minor lacerations with no shattered glass in them, and she had some surgical glue applied to each laceration.
- $62 for a vial of generic local anesthetic
- $109 for each of two surgical glue packets
- $339 for a low intensity emergency room doctor bill
- $244 for the use of the emergency department.
What would Medicare have allowed for the $339 doctor visit? The answer: $39.31.
That’s right: they charged the young lady almost 9 times what Medicare would have paid for the service.
I tend to be an optimist. Some people might say I believe in the tooth fairy (maybe it’s a carryover from the days when I played tooth fairy for my children). I have hoped for a long time that one day the folks that are engaged in health care would wake up and develop a sense of rmission and reasonableness when it comes to what they do, how they do it, and what their responsibility is to their patients—both with respect to quality and costs. Take the best practices and spread them around the country so everyone can benefit. Demonstrate that as a profession we take quality seriously as a core part of our work.
Would it be so hard for someone to say that a test or x-ray may be useful, but in fact it is reasonable NOT to do the study? Or to say that we really don’t have the evidence to support the usefulness of a test that a patient may want? Or that we find a way to protect those doctors who make good decisions in line with well thought out recommendations and guidelines, even if the eventual outcome may be that 1 in 10,000 chance of having missed something? Or that we learn—once again—on how to do a history and physical and advise our patients of their options, and engage them in a learning process together so they don’t go off and spend thousands upon thousands of dollars needlessly and with blind faith that the next test is the best test?
Is that asking too much?
I suspect it is, and unfortunately I don’t have an easy answer. There are places in this country that provide high quality, evidence based medical care. It is part of their core mission. The amazing thing is that these places are recognized as providing some of the best care in the country, but they frequently do so at substantially lower cost.
As a country and its citizens, we desperately need to rethink how we do this. I would prefer that we do this rationally and voluntarily, and commit ourselves to partnership, shared understanding of risk, quality care, fiduciary responsibility to each other and accountability for the care we provide and the care we receive.
But I fear—after almost 40 years of hoping to the contrary—that we aren’t going to see that day anytime soon.
I guess I will just have to accept the fact that the tooth fairy is a fiction, after all.