Recent months have seen the start of the great debate on health care in the US. The facts are clear- there are 45 million uninsured citizens in the richest country in the world which has the highest cost of health care but with no comparable favorable outcomes.
While the next months will see this debate demagogued no end, as a user of this health care system, some things are absolutely clear- there is absolutely no incentive in this system for anybody to control costs. Not the patient, who is insured, and has no interest in shopping for more cost effective care, just the best that is available; not the doctors, who on the plea of malpractice suits possibilities, order all or any tests that may be relevant ( and some of them performed by facilities owned by them); not the hospital which is happy to provide all the latest facilities needed or not as it adds to their profits; not the pharmaceutical companies who encourage new and costlier drugs rather than the generics on the plea of need of funds for further research, not the insurance companies who are happy to pass on the costs of all this health care to the public through rapidly rising premiums. In short everybody is happy with their health care - that is till the bill comes due!
An average US family today pays $ 500-1000 per month in health premiums, deductibles, medicines etc. I could see a tip of why after I insisted on a bill from the hospital I had just returned from -- in the itemized bill, an aspirin pill was charged at $ 8-- yes $ 8-- and a simple blood sugar test at $ 25 while every intern who visited me even for five minutes along with the team was happy to add his wages to the bill leading to a cost of almost $ 2500 per day for a simple stay in the hospital without any major surgeries. Clearly it is a system where the costs have run amok. In some ways it is the inverse of the major damage caused in the recent collapse of the financial system- in the financial system people were investing other peoples money in the riskiest of bets; in the medical health care system, people are spending other peoples money to ensure the least possible of risks for all operations !
But is that the way it should be ? Are there any no alternatives that offer cost effective care? Atul Gawande in a recent article pointed out that indeed there are alternate ways of delivering health care that are both effective and less costly since they align the patients well being with cost effective care. He does that by describing two operating systems in different parts of the country to make his point.
McAllen is in Hidalgo County, Texas has the lowest household income in the country but it has one of the most expensive health-care markets in the country. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns. The place has virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and yet there’s no evidence that the treatments and technologies available at McAllen are any better than those found elsewhere in the country. Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse on average. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.
Why is this so? It seems that doctors here order unnecessary tests just to protect themselves. Doctors were racking up charges with extra tests, services, and procedures- patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.Thus the primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine. This is further exemplified in its newest hospital in the area which is physician-owned which has a reputationfor aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given, providing physicians an unholy temptation to overorder. It was clear that a few leaders of local institutions in this area took profit growth to be a legitimate ethic in the practice of medicine and a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
On the other extreme of medical practice lies the Mayo Clinic model, which is among the highest-quality, lowest-cost health-care systems in the country. Its core tenet “The needs of the patient come first”—not the convenience of the doctors, not their revenues is as different from McAllen as is possible. The doctors and nurses, and even the janitors, sit in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. Decades ago, the Mayo Clinic recognized that the first thing it needed to do was to eliminate the financial barriers. It thus pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their own personal income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates- on patient well being rather than on profit maximization.
When you look across the spectrum from the Mayo Clinic to McAllen—and the almost threefold difference in the costs of care—you come to realize that there is a battle being waged for the soul of American medicine. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.
It is interesting that the solution most opposed by the right wing ideolouges actually embraces the twin principles of market competition and individual choice !
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