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).

Thoughts re the Future of Single-Payer Medicine

I thought it might be useful to write down my observations and thoughts about the financial side of the practice of medicine, based upon 25 years of private and academic practice of internal medicine, 15 years with a partner, and the last 10 years solo.

First, I have been solo for the past 10 years, because no recent medical school graduate wants to practice (and I have a big-city practice and attend at a medical school) pure internal medicine without an enormous salary guarantee that only a large group can afford to offer (which includes fronting their malpractice insurance). The reason is that HMO's and MCR both pay much more for doing than for thinking and diagnosing, since the powers that pay can measure doing, but not thinking. It is ridiculous that MCR pays me more for a 5-minute rigid sigmoidoscopy than for a 15-minute intake interview. This is why dermatology is the most popular residency. Getting paid $500 for a Botox injection every 3 months is an annuity! And since no insurance pays for it, the physicians can charge whatever they wish. Man is an economic animal, and often will respond to economic stimuli. So when Massachusetts established state-wide health care, there were not enough primary care doctors, and the average wait for a new doctor was 60 days. Just imagine the shortage when the 45 million currently uninsured patients look for a new primary care doctor. We will need at least 10,000 new primary care doctors, and where will they come from? Actually, every doctor should do Botox and Restalen injections and skin biopsies one day a week, so he/she can practice the medicine they like the other four days. And since MCR pays psychiatrists less than they pay me for the same amount of office time, why would any psychiatrist ever want to see a new MCR patient?

Second, we have socialized medicine now, and it's called Medicare. Few MCR patients want to give it up. There are many advantages to the patient, and the main advantage to the physician is that we spend less time on paperwork, and time is our least fungible resource. For a MCR patient, unlike an HMO patient, I don't have to call anyone for permission to get an MRI,and I don't have to worry that the best shoulder surgeon I know is a Cigna MD, and my patient is an Oxford patient, so my patient can't get to see the physician I prefer. I don't have to ask the patient to fax me a list of the HMO ophthalmologists so I can see if I know anyone on the list.
Also, MCR patients get back 5 to 10 times the dollar amount in medical services of the MCR premiums they paid.The tobacco companies showed (but dropped the argument because it made for poor PR) that the government saves money on every patient who dies before reaching MCR age. I also (I hope) will not have to spend time asking someone for permission to prescribe a brand name rather than a generic drug, or to prescribe a brand name drug that is not on their formulary.

Third, if everyone has a private MD, they will "crash" in the ER less often with diabetes out of control, unstable angina, end stage renal disease, etc. If you look at ER visits in Canada vs. here, there are fewer (percentage-wise) visits for acute medical conditions. Having a private physician who you can visit regularly puts a basic floor under your medical condition, even if nothing more is done than blood pressure check, PAP smear, and stool for blood. Overall, since ER visits are extremely expensive because ER doctors do every test they can think of, since they don't want to miss anything (viz. the recent article in the July, 2009 issue of "Archives of Internal Medicine" on the ER workup of syncope in the elderly) we will save a lot of money.

Fourth, technology is expensive, but it works. No patient walks up to an orthopedic surgeon and says "I want a new hip". Instead, the doctor is told "I can't move without agonizing hip pain". No patient says "I need cardiac bypass surgery", or "I need cataract surgery".

Fifth point has to do with malpractice. The most common suit against a family MD is for failure to diagnose a condition. As far as I am aware, no physician ever got sued for doing a test, but only for not doing one. When I started practice,I used to spend 30 minutes to explain to a 40 year old man with no risk factors and atypical chest pain and a normal EKG why he did not need a stress test, and the problems that can result from false positive tests. Now I suggest a stress-echo, stress-thallium and consultation with a cardiologist to the same patient. Why risk being sued even if I know I will win the case? Why spend the time and stress?
As long as we have contingency fees, we will have malpractice cases, and doctors will do extra tests to minimize their exposure, as well as make any referrals any family member of the patient suggests.

Sixth, unless you have a boutique practice, the average MD has to see one patient every 10 minutes, which involves putting 4 patients into 4 rooms, and having the NP or PA take the interval history, do the vital signs, etc. No one can get proper medical care under these conditions. I was trained to spend 15-45 minutes in the office with my patient to take a history and discuss any family stresses, then examine the patient in the exam room, and then bring the patient back into my office to discuss the results. I don't know of any doctor under 60 who practices medicine in this way, and most patients don't know what they are missing.

Seventh, there is something very wrong with the practice of medicine when the majority of doctors advise their children not to go into medicine.

Eighth, every medical system in every country rations by money, time, or availability, since the demand for medical care is almost infinite. England NHS does not transplant kidneys over a certain age, so those who can afford it fly to India to buy a kidney. Some drugs are not allowed in England because the NHS pays for all drugs, and this is how the country caps pharmacy expenses. Canada rations hospitals as to how many open-heart surgeries they can do in a given month. Germany reduces the physicians state-paid salary if their patients' prescriptions cost too much. MCR pays for only so many physical therapy visits or hospital days a year.

Ninth, I still love the practice of medicine, and intend to see my patients as long as I am able.

P.S.: About 10 years ago, there was an article published in NEJM that showed that New Haven had 5 times as many cholecystectomies per capita as did Boston, while Boston had 5 times as many CABG's per capita as did New Haven. Did one city have too many operations, or did the other have too few? No one could determine the answer.

P.P.S. The best review of the current state of internal medicine was published by David. D. Norenberg, M.D., in the Annals of Internal Medicine(Ann. Int. Med. 2009; 150:725-726) accessible at www.annals.org: "The Demise or Primary Care". Please read it and share it with everyone you know, physicians, patients, and politicians.