Obamacare and Romneycare extend coverage of medical care but they don’t deal with the problems that threaten the program and the American economy.
Political attacks don’t help to fix a problem that could be fixed with common sense. Congress and candidates have taken a ready-fire-aim approach to scuttle the other fellow’s plan.
Meanwhile, astronomical costs are producing a system that can’t be maintained.
I have personal insights based on a half-century of practice. I’ve been one of the cost generators. I understand the issue isn’t purely scientific and I have to guard against my own biases.
Medicine is often regarded as partly science-partly an art, but the data are objective and the conclusions are yours.
The Institute of Medicine has released a new report. It indicates we could improve care and cut costs at the same time. Potential savings of more than $700 billion comes from cutting fat from several places. That number is consistent with a 2008 estimate by the Congressional Budget Office that, “as much as $700 billion in health care services are delivered in the United States that do not improve health outcomes.”
Since 2008, the list of ineffective medications and procedures has grown. Many of the ineffective therapies are also dangerous. Reports come from a variety of sources.
Seven hundred billion dollars is approximately a third of the $2 trillion budget and enough to cover everyone without increasing any costs. Let me share one story of hundreds from my own experience. It may help understand the problem.
A cancer patient from Alaska developed a new, worrisome pain and flew to Seattle. His physician told him he had a metastatic site in a bone. He suggested a two week course of radiation, promising that more than three-fourths of patients improve substantially. This gentleman faced two weeks of expenses in Seattle, separation from his family and the realization that his life may not last more than several months.
The physician offered an alternative approach that involved one treatment and a plane home the next day. Either approach achieved the same level of pain control, although about one in five who is treated with the single dose will require a second shot within three months.
Don’t be quick to label the physician as money grubber who went for a treatment that generated the most income. It is true the reimbursement system is perverse because it pays for the number of treatments and not the outcome.
When I was at the university, the incentive for productivity was a minimal part of our reimbursement. Situations vary, but most doctors have contracts that buffer income from the number of treatments on the prescription.
If we could climb into the doctor’s head, we might find that he was more comfortable doing what he has done for a long time and what has become a customary approach.
Being an agent of change is hard to defend if there is a complication or a lawsuit. The radiation oncologist is very likely aware of the studies that support the single dose, but he has also heard arguments against it. Those don’t seem compelling to me, but there is usually an available argument against anything.
The hospital or clinic that owns the equipment will remind the doctor that patient throughput keeps the institution viable and makes the next purchase feasible.
Next, consider the mindset of the patient. If he was told that a single treatment was the only approach approved by the government, he may be angry about rationing or “death panels.”
Of course, insurance companies often deny care, but they tend to agree with established patterns, because they can pass the costs along to policyholders.
Companies that sell machines or medicines are motivated to promote their products. The most powerful lobbyists in Washington protect the system and they have opposed cost controls since 1920. Legislators aren’t popular if they want to cut services, even bad or deadly ones — lobbyists control money for the next campaign.
The Affordable Care Act, Obamacare, has no knife to cut through the fat that clings to the dying carcass of our current approach. Romney’s Massachusetts program differed mainly in supporting a system that reimburses insurance companies, without involving employers, but the old idea of paying for the number and complexity of services persisted.
Some current federal programs are investigating ways to promote outcome-defined payments but they haven’t been successful in negotiating the prices of medications or equipment.
An educated public could help move the program toward sustainability and common sense.
First, we have to think through the dynamics of the process. We have to replace labels and stand up to reality.
Next time, I’ll describe some systems we call socialized and ask a few questions. Are Medicare and the VA socialized? What does the best medical care in the world really mean and why do most evaluators say that we’re doing poorly? Can competition work to improve care instead of promote market share?
What should America do to save our best features and scrap our failures?
Dr. Larry Mulkerin is a retired clinical professor. He can be reached at firstname.lastname@example.org.