Sunday, September 22, 2013

Controlling the cost of health care by doing the right thing

The cost of health care and ways to decrease it are a recurring drumbeat in politics, including on this blog. However, I like many others, have also emphasized the need to increase access to necessary health and medical care to all people who need it, and to create social conditions that decrease the burden of ill health. Federal efforts have finally come up with the Affordable Care Act (ACA, Obamacare), passed in 2010, and since 2012 object of continued efforts by Republicans in Congress and in those states in which they control the governor’s office and state house to repeal or gut it. In states, most effort is focused on Medicaid, which is funded by both federal and state money. In some states, most notably Oregon (“The Oregon Lottery: Far from enough, but at least they are doing something”, July 19, 2012), this effort has been combined with increasing access; in most it has just been about cutting expenditures.

On August 4, 2013 (“Why poor people choose ERs: we need a system designed to meet everyone’s needs”), I wrote about an article from Health Affairs 1that studied the reasons that poor people use hospital emergency rooms “inappropriately” for care, to the frustration of the ERs, primary care doctors, payers (in this case, where patients were either uninsured or covered by Medicaid, mostly government) and health policy experts. The 3 major groups of reasons were quality (perceived quality, which I believe is not valid), cost (a matter not of overall cost but out-of-pocket cost to the user at the time of service) and convenience, which I argue is a misleading word for describing a place that is actually open and will see you when you can get there.  “…it is not “convenient”,” I wrote, “to wait 6 hours in an ER to be seen; if this is better than the alternative, the alternative is seriously flawed!”

What would be a mistake, however, would be to presume that it is just inappropriate use of health services by poor people that drives up the cost of care. Indeed, this is only a small part of the “excess” cost (defined as “cost in excess of what would be needed to be provide quality care to everyone) in the US. Another good definition of “excess cost” might be the additional cost per capita spent in this country compared to many other developed countries whose health outcomes are much better than ours. For this, there are different reasons. I have discussed many of them in earlier posts, and they include procedures that didn’t need to be done, over-utilization of high-technology, under-utilization of primary care, and poor geographic distribution of medical care. To a large extent, these are summarized by the two quotes I used in The high cost of US health care: it's not the colonoscopies, it's the profit”, July 28, 2013: “Using health care as a driver of corporate economics as opposed to a public good is the fundamental cause of our medical inflation,” (Richard Wender, MD) and “The US health care system is not designed to get you the care you need, it is designed to get you the care that someone can make a profit giving you.” (Lee Green, MD).

There are other causes as well. One big one, referred to above and discussed at some length in “To improve health the US must spend more on social services”, December 18, 2011, is the fact that the US does not provide anywhere near the overall social service safety net that other developed countries do. In those other countries there is much more spent to ensure that people have adequate food, housing, education, and a living wage, which are all drivers of health status.

Another big cause, though, are our preferences, our desires, as consumers, for “all that money can buy” when it comes to our health. While this may be especially true when, as health economists often point out, it is not directly your money, but your insurance company’s, I know plenty of cases in which families have wiped out their life savings, wiped out their retirement accounts, wiped out the money that could have supported the survivors (especially true when the patient was the primary breadwinner) in pursuit of “one more” vain attempt at cure. I do not mean to suggest that treatments with reasonable probabilities of meaningful benefit should be withheld. Nor do I mean to blame just the individuals and families; clearly in most of these cases there were doctors and other health professionals holding out hope (“well, maybe we could try another bone marrow transplant and it might help”) without making sufficiently clear what both what they meant by “help” and what the odds were of success.

Yet, many doctors (including me) and hospitals will tell you that they have often recommended against interventions because they have little or no likelihood of meaningful benefit, and often a significant risk of harm, only to be told by the patient and/or family that they want to “do everything”. Often these people suspect that if they had more money, or if they were a different color, or if they were in a “better” hospital, the providers wouldn’t be suggesting that they forgo further intervention. I don’t doubt that this is sometimes justified, and I’m sure that if a patient has enough money to spend there will be someone, somewhere, whether “quack” or a “legitimate” medical center, who will take it to “do something”. But this doesn’t make it right or good. I have not seen such studies but would not be surprised if it were shown that many of those with the most resources are among those with the most unpleasant deaths; our culture values intervention, and they have the money to find some who is willing to make a profit intervening.

Everyone dies. We would all like, and like for our loved ones, to live as long as possible if our lives have meaning – some physical and/or intellectual function, some ability to contribute to or benefit from others. We would like, and like for our loved ones, to be comfortable and pain-free as we approach death. We don’t want to think that money which could help us or our loved ones is being “saved” just so it can be used to provide services to others who are richer or louder. But when something will not “help” in any meaningful way that we understand it, and which may hurt, it should not be done, and we should demand that it not be done. Not doing is often more appropriate and more powerful than doing. We must shame health care providers who advertise and promulgate interventions that are unproven, or will not help, or will harm, because they can make a profit doing it.

If we are to get to this place as a society, where the US health care system is one designed to get you the care you need rather than to get you the care that someone can make a profit giving you, we are going to have to change our attitudes. And that change of attitudes and behavior needs to start at the top of the social and economic scale, not at the bottom. No unnecessary stents for President Bush, no “executive physicals”, no inappropriate end of life interventions for the wealthy. Where the “best” in healthcare is not defined as the “most”, but the most effective and most appropriate.

A health system in which health and health care for everyone is the goal of our society.

1  Kangovi S, et al., “Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care” , Health Aff July 2013   vol. 32  no. 7  1196-1203; doi: 10.1377/hlthaff.2012.0825  

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