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The cost of health care and who is going to pay?

March 15, 2010

I’m sure we’ve all been entertained by the debate in Washington regarding health care and where we are headed. I give credit to President Obama for trying to have all the participants in the room, even if it was mostly political theater. Perhaps the best comment I heard is the suggestion to lock them all in the room in the Blair House and not let them out until they came to an agreement on a piece of legislation. Of course the issue would be whether it would require a simple majority or not to pass.


Like many physicians I continue to evaluate and treat the patients who present for care. Shockingly in a ‘broken’ system we continue to schedule physician appointments, operate hospitals, deliver medical supplies and get our medications at the local pharmacy. So what does all this talk of reconciliation and ‘nuclear option’ mean to most docs. I get the feeling most of us will find some way to survive. More regulation, of course, and more challenges on how to continue to manage seeing patients and keeping out practices alive as functioning businesses.


In the back of our minds I think docs know the future will hold extreme challenges. When you look at graphs such as this one from a recent National Geographic article you can’t help but wonder how long this difference, which is accelerating, can be tolerated by our country.

I’m sure much can be argued regarding the statistics involved. What can’t be argued is that there is a significant disparity between the US and the rest of the world. Is this a bad thing? I guess that depends on where you stand regarding the debate. How much more than the current 16% of the total economic output of the US can be spent on healthcare? Same answer as the previous question although I think at some point the system may collapse under its own weight.


I had the opportunity to testify in Annapolis recently on some health care legislation. As part of this process I spent 8 hours listening to the testimony involved in other bills which preceded my issue. It was enlightening to hear from individuals to CEOs of health plans on the struggles that many faced. Granted I had a little less sympathy for the healthcare CEOs. The underlying issue was the significant accelerating costs which have continued to layer year after year over the last decade.


There is no doubt that there is significant waste and overuse in the current system. The aggressiveness with which we approach care towards the end of life certainly contributes to the cost escalation. Of course when it’s my life that you are talking about than no sum is too great! That is not to say there aren’t areas of flagrant waste in our system which needs to be addressed. There is and always will be.


We also know there is a significant practice of ‘defensive medicine’ by very good docs. In my specialty of emergency medicine I know the vast majority of patients I admit with chest pain are unlikely to have an acute cardiac event. That said there is no way I can assume the risk of missing that atypical presentation of acute coronary syndrome that may result in a patient’s death or having and MI when we know the malpractice attorneys will be circling to claim medical malpractice. It is simply the world in which most emergency physicians live. I’m sure every specialty has their areas of defensive medicine practice that contributes to the burgeoning cost of care.


I was curious to know where the dollars are spent in health care and came across this graph:


National Health Expenditures, 2007

Total = $2.241 Trillion

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.

Of course as we know the cost of pharmaceuticals and new medical devices is continuing to make up a larger and larger percentage of the graph. The price of progress, perhaps. It is obvious looking at the graph where the significant impact needs to come when we talk about ‘bending the cost curve’ come. Just like most large business entities we need to go where we spend the money. In our case that is the areas of hospital care and physician compensation.

Does that mean that physicians are headed to poverty? Of course not. I think physicians also need to realize that there will be some degree of ‘give’ wherever we end up. Like some docs I am willing to ‘give’ in exchange for less hassle regarding filing of multiple forms and protection from frivolous lawsuits when we don’t diagnose the 35 yo patient with chest pain and no risk factors who turns out to have an MI due to atypical symptoms. Patients also need to understanding that outlandish expenditures of care with little return needs to be reigned in. This involves sometimes difficult conversations about not getting the CT scan or treating with the latest cutting edge therapy that may give very little in terms of life expectancy. The biggest ‘crisis’ in health care in America is our general lack, as a society, to assume responsibilites for our bad habits; whether that be smoking, obesity or lack of exercise.

These are all difficult issues and it is not suprising that there is heated debate on where we are going to go, who is going to pay and how we are to get there. The great thing about America is we will aggressively debate the issue and come to some compromise that many will complain does not address the issue. It is probably the same debate we have had for the last 2 centuries on issues critical to our country. The fact that we do so without violence is a lesson we give to much of the rest of the world. As someone once said (apologies for not citing the source) ‘ The Americans will get it right, after they have tried all the other possible options’.

Angelo Falcone, MD

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6 Comments leave one →
  1. Mark T permalink
    March 16, 2010 10:08 am

    Hi Ange, I enjoyed your post very much. Congratulations on the birth of your new son!

    I have done a lot of reading on cross-country comparisons of life expectancy and I think health insurance accounts for but a small part of the difference. First, the demographics of the US are quite different from those of the comparisons in W. Europe. Second, there are significant differences in the US itself, with northern states doing much better than southeastern, excluding Florida which has a lot of well off retirees. Here is a good link showing that:

    http://www.manhattan-institute.org/html/mpr_04.htm

    So when you line up parts of the US that are demographically similar to Western Europe, the gap narrows quite a lot.
    Third, much more auto fatalities and gun violence and military deaths in the US. Fourth, obesity is very different. There may be a statistically significant correlation between scope of health insurance and life expectancy but there are many explanations other than a causal relationship.

    All the best!

    Mark

    • March 16, 2010 10:56 am

      Mark,

      Thanks very much for your comment. I agree with all of them and will take a look at the info you have done on this issue. My comments on the graph relate specifically to the overall cost and whether we, as a society, can sustain the continued overall cost increases. I think we practice exceptional care in the US in certain areas. Much of this is related to acute care where I think we are clearly #1. At some point there is an overall diminishing rate of return for what we contiue (on a global scale) to pay. We are rapidly approaching that point if not already there. Thanks again for your insightful comments.
      Angelo

  2. Hippocrates permalink
    March 17, 2010 4:18 am

    Dr. Falcone I’m concerned health care cost as well. Thanks for your efforts to highlight how to best cut cost and pass those savings on to the patients. Certainly the biggest problem is that physicians are over qualified and cost too much. I think to cut costs and save money for the public we should have more physician’s assistants and have them do the duties doctors used to do. But I agree costs are way too high. So wouldn’t it make more sense to have every position in the hospital filled by physicians assistants and have just a few doctors at the top to oversee them all?

    • March 17, 2010 10:41 am

      Mid level practitioners, both PAs and NPs, fill an important role in the health care delivery system. In my emergency medicine group, MEP, mid level practitioners comprise about a third of the staffing we provide to our hospital partners. We have tried various staffing strategies and found that to be about the right mix depending on acuity of patients seen. As you know many medical specialities effectively utilize mid-levels in various inpatient and outpatient settings. I do not think they should provide the majority of hospital care as you suggest and are an important part of the team providing that care.

      • Hippocrates permalink
        March 17, 2010 2:59 pm

        I see what you are saying mid-levels do need to play a part. Some of the mid-levels I work with are extremely talented and I have no doubt that they could be doctors and I would be proud to work with them. But you bring up an important point how do we best use the physician assistants to assist the physician. But in reality times are tough economically and we can afford to pay for a Board Certified Emergency Physician to fill in the gaps. So unfortunately to make ends meet and keep the group afloat we have to have PA’s managing chest pain, traumas, sepsis, abdominal pain, congestive heart failure, cardiac codes, strokes ect. and unfortunately we have had some bad outcomes and I know the public wouldn’t understand why we had to use PA’s instead of Physicians but in reality there’s no money to pay for them in our current system. We just have to hope for the best out comes and cross our fingers. How would you recommend we resolve our dilemma. I can’t see any other option other than hire more PA’s and have them see high acuity patients rather then hire more doctors because we can’t afford it right now in this recession. Any advice would be greatly appreciated.

      • March 23, 2010 3:51 pm

        One of the issues with being a working doc is I occasionally work a series of shifts. Apologies for the delay in responding to your comments. Your comments touch upon what we can afford and I think the focus should be how do we deliver care care better. You are right there is not enough boarded EM docs to see the 120 million plus patients who visit the ER every year, nor should they. Mid level practitioners do manage higher acuity patients effectively in some ERs. Most are because they sit side by side with a doc and have them there to assist and run cases by when necessary. When teamwork is tight then we can deliver effective (from a quality and cost standpoint) care. I do not think we should give up and say we can’t do it so quality has to suffer. I work with many excellent PAs and NPs who provide excellent care. We do so as a team and each person has a sense of when they need to get me involved. The mix of MD-MLP is dependent on the acuity of patients seen and volume in the individual department.

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