IT'S LIKELY you have noticed there's an election about to happen. Whichever candidate gets in is going to have to deal with a broken and very expensive health care system and a huge deficit. Not a good combo. They will be trying to make a silk purse out of a sow's ear.
This prompts me to give them my take on how to reduce costs.
There's a lot of noise about malpractice insurance, inefficient insurance companies, cost of drugs, poor communication systems.
But the effect these have on the cost of care is chicken feed compared with the money that doctors have control over, especially with hospitalized patients, in an environment where there is no incentive to save costs.
SOARING COSTS
Let me present you a few depressing statistics. Health care costs have skyrocketed--the U.S. spends twice as much per head as France, for example, and this has doubled between 1970 and 2006 (from 7 percent to 15.6 percent of GDP). It is projected to double again in the next 10 years.
We spent $2.3 trillion in 2007--making the bailout look paltry by comparison. But the U.S. health care system is ranked 37th by the World Health Organization--France being No. 1. And there are those oh-so-troublesome 47 million uninsured still, all in the wealthiest country on the planet.
Of all these big bucks,
We doctors are a capricious lot, or so it would appear from the likes of journalist Shannon Brownlee, whose book "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer" seems to jibe with my own observations.
We do what we do in large part due to attitude and tradition, she claims. She cites a study by Dr. John E. Weinnberg of the Dartmouth Institute for Health Policy and Clinical Practice. In the study, two towns, with no significant difference in health profile, showed 10 percent of children in one town had had tonsillectomies, versus 70 percent of children in the other--just because that was the culture in the second town.
Evidenced-based medicine (i.e., doing things that have been proven to be beneficial in independent clinical trials) is the holy grail of practice. But only some 50 percent of decisions are made according to such evidence, according to Brownlee and the National Institute of Medicine.
Spinal fusions for back pain are performed to the tune of $16 billion a year,
Other than tradition, motivations for performing tests and procedures are:
Fear of being sued
Concern that if we don't "do everything" the patient wants, they will go to some less scrupulous doctor
Most important of all,
Most doctors get paid "fee for service" (not for results, incidentally), so the more visits, tests and procedures your patient has, the more the doctor gets paid.
The Green Carrot
It is a cynical observation, but very often people are motivated by money. And the motivations for us doctors are all toward more expensive care.
It would be foolish and provocative to imply that the only thing that drives doctors' health care decisions is money.
But if doctors were paid in a different way, so there was some financial incentive to the doctor not to do the test/procedure/treatment, I have a sneaking feeling "traditions" would change, and there would be big cost savings--especially if this was combined with protection against being sued.
I think we need a massive revamp of the way our insurance system works. But I'll hold off on my thoughts about capitation (a complicated term involving fixed, per-person payments) for now and instead talk more about motivation.
The other person who needs to be financially motivated is, of course, the patient. Patients are often anxious and not fully informed, and are often pushing to have more rather than less. They don't feel they are really paying when the insurance picks it up, so they want every possible test.
Some insurance companies are offering discounts
There are a lot of ways to save money--through things like computerized medical records, which improve efficiency, for instance.
But if the patient and the doctor were in an alliance and financially motivated
Our "sow's ear" system at present, where people are getting sick or bankrupt for lack of adequate coverage,
Whoever becomes president will have to wrestle with hot-button issues like dealing with insurance and the pharmaceutical industries. But it seems to me that where the money is--if you'll pardon the pun--is
Dr. Patrick Neustatter is a family practitioner in North Stafford. He can be reached at newsroom@freelance star.com.
Motivated by the madness and expense of health care and insurance, some people can't wait for the politicians. Two such groups that I have been involved with are the Fredericksburg Regional Chamber of Commerce Health Care Council, which is trying to put together a group insurance plan to give small employers the bargaining power of big companies. The other is the Rappahannock Healthcare Repair, working under the auspices of the Virginia Organizing Project (an organizations that helps empower local communities). The group has scheduled a forum for Wednesday, Nov. 12, at 6 p.m. at The Free Lance-Star building on Amelia Street in Fredericksburg to hear what you think of the health care system, in the hopes of coming up with some grass-roots solutions.
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