Thursday, April 21, 2011

The Cost of Medical Care

     I have read about various plans and schemes to pay for the present or for expanded medical care, and they all will involve rationing by available money, time, doctors, or equipment. While you are reading this blog, try to imagine how you yourself would design a medical care plan, with the proviso that you must operate behind the "veil of ignorance" that John Rawls popularized in his book "A Theory of Justice". That is, you must design a medical plan that would seem fair to you before you know your position in this self-designed society. Will you be an affluent white male living in an expensive suburb, or will you be  a poor pregnant non-white teenage girl with a single mother?

     Right now, although many Americans declaim against "Socialized Medicine", I know of no Medicare patient who would not like Medicare to continue. (And why not, since they get back much  more in medical services than they paid in Medicare premiums.) In addition, their middle-class children want Medicare to continue as well, so they can use their own savings to pay for their own children's college education rather than for their own  parents' medical expenses. The tobacco companies briefly had an ad showing how cigarette smoking benefited the country on the bottom line: If a smoker dies before age 65, the government pockets all his/her Medicare premiums and pays out not one dime.

     BTW former president Bush was economically unsound when he said that the Emergency Room was always available to patients without doctors. By law, the ER's must accept all comers, regardless of their insurance status. Now if you tell your family doctor you have a headache, he will make several suggestions and then tell you to come in one or two days if you are not feeling better. This all involves little expense. But if an unknown patient comes to the ER with a headache, he will usually get a set of blood tests, an EKG, a pregnancy test if female, a CT scan of the brain, possible a carotid Doppler study of his carotid arteries, and then a consult with a neurologist who in turn may order or do a brain MRI and/or a spinal tap. The ER does not know you the way your family doctor does, including facts not usually written in the medical record: are you an alarmist, a hypochondriac, a stoic, a cocaine user, etc. The fact remains that NO DOCTOR EVER GOT SUED FOR DOING A TEST or ordering a specialty consult, but only for not doing the test. So the best way for an ER doctor to minimize the chances of a malpractice suit is to do as many tests as can be thought of (including a temporal artery biopsy). An article in Archives in Internal Medicine several months ago which evaluated the cost of working up dizziness in the ER was over $20,000, and the cost in the family doctor's office was only a fraction of that. The jury doesn't ever want to hear the defense that the result of a test was unlikely to be useful if the patient died or was seriously damaged.

     Let me give you some examples of the rationing of medical care in this and other countries. Medicare only pays psychiatrists 2/3 of the fee for an internist for the same amount of time in a visit---I guess they feel that if you are only a little crazy it doesn't count. Your friendly drug management company has a "preferred" list of drugs for various maladies, because they do bundle deals with the manufacturers, so one company may say that Nexium is the preferred stomach-acid blocking drug, while the other prefers Aciphex and a third prefers Prevacid. All three drugs have the same end point, but it is highly unlikely that the same patient will benefit equally well from all three. So the doctor has to spend a lot of time (= non-reimbursed monetary expense) explaining that in this patient Allegra works as an anti-histamine,and Claritin does not. The company either agrees (surprise and hooray!), or disagrees, whereupon the patient has to decide to pay the lesser price for the drug that does not work so well, or the higher price for the drug that does. Medicare also rations the number of visits to a physical therapist per month for a given musculoskeletal condition.

     I have a good friend in Vancouver, Canada. He developed angina and needed CABG, or cardiac bypass surgery. Unfortunately, the hospital his doctor admitted to had an allotted ration of 150 open-heart surgeries per month. He had to wait from mid-January to Mid March for his open heart surgery. Fortunately he survived to have it. One year Canada decided to cap the annual salary (calculated by the number of patient visits) of all general practitioners. The result was that all GP's stopped practice by early or mid-November, because why should they work for free?

      In England, the National Health Service does not pay for kidney transplants, or for chronic dialysis over the age of 55. So if you have kidney failure, you may end up flying to India to buy a kidney (for about $10,000) to be transplanted into you by an English-trained doctor. The National Health Service also does not admit certain legal drugs to be sold in the country, including some made by British firms, because they do not want to pay for it (such as the inhaled anti-viral that shortened the course of the flu).

     In Germany, each doctor has a panel of patients, and is paid every three months for the number of patients plus the number of their visits. The state also pays for all drugs. But if the doctor's patients average drug cost is too high in one calendar quarter, the doctor's salary is cut the next quarter!

     We are hard up against the fact that the demand for medical care can never be saturated, and that the technical cost of medical care is driving costs through the roof, not the doctor's fees. An artificial hip can cost $8500,  before the surgeon's fee, the OR fee, the hospital room fee, etc. Technology costs money, but it works and saves lives. It also extends the useful working life of patients, but no economists calculates that if open-heart surgery cost $40,000, but the patient lived another 15 years and contributed $750,000 in income taxes the country gained. OTOH, try to flip the argument, and say that we could save $2B/year by banning open-heart surgery, and I don't think there would be any takers.

     First we had Xrays, which saved lives, at a cost of approx. $100 each. Then we developed CT scans, which sees much more than Xrays and saves more lives, but because of all the computers involved costs approx. $250/scan. Now we have MRI's, which save even more lives again, but which costs approx. $750 because of the huge magnets involved. No one would want to do without these wonderful devices, but no one really wants to pay for them.

     Until 10 years ago premature babies born with weights of less than 4 pounds generally did not survive. Now with neonatal intensive care units, etc, we can save babies weighing as little as one pound. They may spend three months in the NeoICU at a cost of $1M, but they survive.

     Finally medical economists and budget planners think that we could save a ton of money if we got patients with chronic diseases to take better care of themselves. The problem is that 50% of these chronic diseases were caused by or made worse by the patients precisely because they don't care that much to take care of themselves. I have never, with all the backup help and clinics in the world, ever gotten a ,male diabetic to lose weight to improve his sugar control. People  don't exercise as much as they should. (The exception to better diet and more exercise is any male who has a heart attack----they become rapid believers in healthy living.) Very few humans are willing to anticipate what may happen to their bodies more than 10 seconds in the future, so we don't worry about the current cigarette, or the unprotected sex, or driving without seatbelts, because none of these actions will cause a foreseeable problem in the next 10 seconds. Insofar as dietary changes are concerned, if you cannot get your two year old to eat spinach or your teen-age anorectic to eat at all, how do we get anyone to eat properly?  Videos of children playing volleyball in camp show that overweight campers move less on the court than others, but we don't know which came first, the overweight or the decreased athletic activity. I am certain that each and every one of my readers can recall several unhealthy (if not illegal) activities that they themselves did.

     So what is the answer? No one knows. What is the ideal percentage of our GNP that should be spent on medical care? No one knows. But everyone is certain that when it comes to their own health care or that of their families, then no expense is too great, and so once again we have the conflict of microbehavior vs. macrobehavior, which is precisely the problem with containing medical costs. (Recall that after the 2008 bank crashes, the government's desired microbehavior was for individuals to save, while the governments desired macrobehavior was for the country to spend its way out of the recession.) As a physician my professional commitment is 100% to my patient, and not to overall economic expense (even if malpractice suits did not exist). And expect no real help from Congress or your State Legislatures: They have voted themselves the finest medical plans that exist, all of which are cost-free to them in Congress and in most states (as are their pensions as well).

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