(this is really long compared to my usual stuff, but some people may want to read it anyway. It is a compressed synopsis of my many mini-essays that I delivered today at church.)
I love my job. It is possibly the best job that anyone could ever have. I get the chance to meet people of incredible diversity, and participate in decisions that they make about some of the most important aspects of their lives. I hear amazing stories. I get to solve mysteries, or at least try to solve mysteries. I get to interact with other doctors, who are some of the most interesting and committed people I know.
In the years I have practiced medicine I have been impressed often with the compassionate and effective care we can give to people regardless of their ability to pay for it, regardless of their social status, race or nationality.
So when I say that the American health care system is broken, I say it with love, and with the frustration that comes of knowing how good it can be.
The major problem that I see with American health care is that it simply costs too much, which is the reason that we are not providing adequate care for a sizeable proportion of our population. If we can untangle the causes for the high costs of medical care and thus free up resources we can provide care for everyone and start to focus on what is really of value to all of us.
I grew up very close to my two grandmothers who weathered the depression well because they really had very little to lose and were already incredibly thrifty and hard working. Although they were comfortable by the time I knew them, owning their own houses and with plenty of food to eat, they always considered cost and good value in making decisions. So when I began doing my clinical rotations at John’s Hopkins, I sometimes found it difficult to come to grips with testing and treatment that we did that seemed to lead to nothing of value in patients’ lives. I have practiced medicine as if cost matters since I have matured, but certainly not to the extent that my grandmothers would have, if they had been in my place.
As the health care debate has heated up, I began to hear figures related to costs in medicine that were and are increasingly disturbing. Figures like 2.3 trillion dollars spent on health care yearly in the US, and 17% of our GDP going to health care. I looked at a book of facts and figures that came to me by chance a couple of years ago, and saw various health indicators for developed countries that showed us to be merely average, despite our higher per capita spending on health. I asked my friends, other doctors, why they thought we were so expensive, and they all knew. And I knew too. We all know that, for various reasons, we order too many expensive tests, procedures and medications, without considering the costs and the benefits. There are 4 reasons that we do this: we don’t really know what medications and tests cost, we feel that our patients have come to expect this kind of care, we don’t have time to discuss care with our patients, and we think that ordering these medications or tests or procedures will protect us from being sued for malpractice.
One day I sat down and calculated about how much money we might really be wasting on testing and procedures that do nobody any good, and came up with a ballpark figure of 20,000 dollars wasted in a half a day. I’ll tell you the story of a busy doctor on an average morning. The story is entirely fictional, but happens all the time in the US. The costs are approximate, because they vary considerably.
8AM—arrive at the hospital, perform two treadmill tests with nuclear imaging, ordered by physicians for patients at low risk, because of concern about malpractice should they have a heart attack. Each costs $3000, one unnecessary, the other of which could have been done without nuclear imaging at my office for $200.
9AM—see two patients at the hospital. One remains in the hospital because she can no longer live at home and can’t afford to go to any of the extended care facilities that have openings, at a cost of $1000 for the day. The other is there because she wasn’t insured and waited too long to see a doctor for her migraine headache, costing $2500 for her MRI scan of the head and $1200 for her day’s stay at the hospital, and $600 emergency room fees.
9:45—get to the office late because the uninsured patient was news to me, so I didn’t plan on seeing her. See my first patient who has a physical scheduled. She wants “a complete lab workup” even though all of her labs were normal last year and nothing has changed, because her insurance will cover it. She has been having back pain. Since I don’t have time to talk to her about the natural history of back pain I order an MRI scan and physical therapy. Labs: $120, MRI$2500, 8 physical therapy appointments $1000.
10:30—next patient has numbness in his fingers when he is anxious. He can’t afford counseling and I don’t have time to discuss relaxation techniques with him so I refer him to a neurologist. He will see the neurologist 3 times, at a cost of $150 per visit, and she will order a head MRI scan for $2500.
10: 45—next patient has a cough and a stuffy nose for 4 days. I think it is viral, but she is sure she needs antibiotics. I don’t have time to explain the side effects and futility of antibiotics so I prescribe an antibiotic. She says the generic doesn’t work. Cost is $120 for that and $200 for an inhaler which is what I think will work, though if she just waited she wouldn’t need that. Because she smokes and I am worried about being sued if she eventually gets lung cancer, I order a chest x-ray. That is another $200.
11:00—patient comes in for follow-up of his diabetes. It has been in poor control, but since I don’t have time to counsel him on diet and exercise in a way that will probably have an impact, I prescribe a new medication. He is already on generic pills, so I have to prescribe insulin, and because time is an issue, I use the newest insulin delivery system which is easier to explain. This costs $150 and doesn’t make him any happier, plus his risk for complications is just as high because he will continue to gain weight.
11:15—the next patient comes in for follow-up of an abdominal CAT scan I ordered because I didn’t have enough time to counsel the patient on how to avoid constipation which had then given him belly pain. The CAT discovered a cyst on his kidney and a nodule on his adrenal gland. He is beside himself with worry, even though both of these things are usually normal findings. I reassure him that I will get a follow-up CAT scan to make sure they are normal, which will use a better technique and cost $2000 (but I don’t tell him this because I don’t know what it will cost and have no idea what his insurance will pay.) Because he is so worried I don’t have time to see my next patient who has to leave and go to the emergency department with her pneumonia at a cost of $1500.
With over half a million practicing physicians in the US, this may add up to 100s of millions of dollars every day. It has become clear that many of the expensive things we do are the things that don’t make patients healthier or happier, and that costs related to what I think of as stupid care may make up a sizeable portion of our health care budget.
So let’s move away from my personal experience a little bit. Trends in health care spending have changed some, but why have the American people all of a sudden noticed that something is wrong? Our economy took a nosedive about a year ago. Insurance prices finally became too high for individuals and companies to afford them, and the services they provided became inadequate to cover the medical care that people were receiving. People are now commonly bankrupted by paying for medical care, insured or not. We got a new president who started focusing on health care, and began talking about making changes that would allow more people access to it, and about ways to bring the spending on that health care in closer line with most other developed nations. Focus has moved to improving the cost and service provided by the insurance companies, and we have become alarmed by their high profits. But even if their prices come down and profits are reduced, the budget for health care will still be unsupportable.
Because medical care is so expensive now, people who are uninsured have virtually no access to non-emergency care.
So what do we need to do?
We obviously need to allow access to good medical care for everyone. We also need to substantially reduce the cost of that medical care.
If we substantially reduce the cost of medical care, all sorts of options become possible for extending access to everyone. The point that our democratic legislators have failed to emphasize is that if we do not reduce the cost of medical care, extending access to everyone becomes economically unsupportable. The really miraculous thing about this situation is that reducing costs can directly improve the quality of medical care. When we spend money on things that don’t really help people to become healthier, we are also spending time and energy on those things, and that is time and energy that could be spent giving better care.
One way to reduce costs and improve health will be to provide adequate primary care for everyone, so we can take the time that is needed to do what is most valuable to each individual. Patients need to be able to see a provider who knows them and their issues for problems as they arise, rather than having to go to emergency rooms or urgent care offices where costs are much higher and procedures are ordered much less conservatively. When you go in to the emergency room for a condition, the doctor focuses on the many life threatening conditions that you might have, and with no familiarity with you or what makes you tick, will order many blood tests and imaging tests that will be done while you wait. In some situations this is just what should happen, but in most situations you will get way more tests than you actually need.
Allowing everyone access to a primary care doctor will mean changing the way medical care is paid for so that primary care is a more desirable field. When a new doctor finishes medical school, that person is in debt for about $150,000. Going into a medical specialty guarantees a much higher salary than going into primary care, and this has driven a progressive trend away from training physicians in primary care fields. When I graduated from medical school over half of graduates became primary care docs, and now that number is just above 10%. This trend does not allow us to even replace the internists and family doctors who retire, much less increase the work force to take care of the patients who we hope will soon have access to medical care.
Another way to bring down costs is to make them part of the discussion when deciding what should be done to take care of a problem. Procedures are often ordered in place of spending time with a patient. A discussion of costs, risks and benefits would likely reduce the number of procedures done, and make sure that they will actually contribute to a patient’s health. To have such a discussion, doctors and patients need to know what they cost. As odd as it may seem, it is quite difficult to find this information. When I order an antibiotic for a patient or a CAT scan I truly have no idea what the total cost will be or what the patient will end up needing to pay, and that situation is simply unacceptable.
Worries about being sued for malpractice drive doctors to order tests and consultations that are not necessary. We need to have a system of dealing with medical malpractice that is designed to improve quality rather than lead to defensive medicine. The way things are now, very few people who injured due to a medical mishap are compensated, and the process of completing a malpractice case takes years of a patient’s and a doctor’s time, leading to bitterness rather than quality improvement, in most cases.
What can we do, as patients and families of patients? We can look honestly at what we want to get from our medical care. We need to realize that the resources to pay for everything are, in fact, limited. Money we spend for medical care is money we don’t have to spend on food and shelter, education, and having fun with our friends and family. We need to have honest discussions with our health care providers about costs of things and expected benefits. We need to consider ahead of time what we want the end of our lives to look like, whether we want intensive care, and we need to discuss these things with our providers.
Doctors need to look at the way we provide care, and seriously study what procedures and evaluations for common conditions work and which do not, and what methods of treatment give best value. We need to use our substantial clout to open up discussions of costs which are out of line with other countries, such as costs for radiology procedures and medications. We need to take the time with patients to provide the counseling that the patients need, and push for compensation for this that allows them to do this without going broke.
But what about insurance?
Insurance issues dominate much of the discussion of health care reform right now. About 58% of people have private insurance at this time, and about 34% of people have some sort of public plan. We pay insurance companies, by salary deductions, direct billing or through taxes, and they, mostly, pay for our health care. The way they pay for our health care is positively diabolical in its complexity, and separates us from having much direct effect on what things cost. When insurance pays for something, we are usually just relieved, and not very concerned if the cost is outrageous, because the money paid out does not really look like “real money” anymore. So the very fact of being insured contributes to the excessive cost of health care.
Until something can be done to reduce prices for medical care, and this will be a slow process, everyone needs insurance.
I do not have the solution to the proper way to insure everyone. Presently Medicare covers something like 17% of Americans, and in many cases pays half of what private insurance does for many services. It is because there is a mix of public and private insurance that many offices can afford to provide services to everyone. A simple extension of Medicare to cover all of those who can’t afford insurance would strain the ability of offices to provide care, and many of those insured publicly would find themselves without providers. If Medicare were reformed, and payment schedules were changed, this would be a viable option. Health care coops are an interesting idea, and seed money for an expansion of that system would eventually result in improvement in availability of care. Tighter regulation of private insurance companies, requiring that they compete across state lines, be portable from job to job, and cover pre-existing conditions will help, but if medical costs continue to rise, that improvement will be short lived as costs outstrip anyone’s ability to pay.
Many other countries have developed systems that work for them, and if we can be flexible, their ideas could be modified to work for us.
You may notice that I have not yet mentioned evil drug companies. Much like evil insurance companies, evil drug companies do exactly what they were designed to do which is make money. They will continue to make medications that are overpriced and over advertised as long as we continue to pay for them. We will continue to pay for them as long as we are unaware of their costs and alternatives.
So—there is much to think about. In my mind, there is huge balloon of hope at this time in history. Something finally will be done to improve the way health care is delivered, and liberate resources that have gone to buy medical care that makes no one healthier and happier. Doctors are seeing this, and are actively working to improve the way care is delivered, and the rest of us have the power to bring about change we have previously thought of as impossible. A very special thing about this crisis of costs in the US is the opportunity it brings us to focus on what we really want from medical care, rather than continuing with the “business as usual” which has become a very different thing.
Closing Reading: by Rachel Naomi Remen MD
For the past hundred years the goal of health care has been the curing of the body. Restoring the concept of healing to the heart of health care is no small thing. It requires rethinking the assumptions on which medical relationships are based, rethinking the goals of every health care interaction. It will require a revolution.
I love my job. It is possibly the best job that anyone could ever have. I get the chance to meet people of incredible diversity, and participate in decisions that they make about some of the most important aspects of their lives. I hear amazing stories. I get to solve mysteries, or at least try to solve mysteries. I get to interact with other doctors, who are some of the most interesting and committed people I know.
In the years I have practiced medicine I have been impressed often with the compassionate and effective care we can give to people regardless of their ability to pay for it, regardless of their social status, race or nationality.
So when I say that the American health care system is broken, I say it with love, and with the frustration that comes of knowing how good it can be.
The major problem that I see with American health care is that it simply costs too much, which is the reason that we are not providing adequate care for a sizeable proportion of our population. If we can untangle the causes for the high costs of medical care and thus free up resources we can provide care for everyone and start to focus on what is really of value to all of us.
I grew up very close to my two grandmothers who weathered the depression well because they really had very little to lose and were already incredibly thrifty and hard working. Although they were comfortable by the time I knew them, owning their own houses and with plenty of food to eat, they always considered cost and good value in making decisions. So when I began doing my clinical rotations at John’s Hopkins, I sometimes found it difficult to come to grips with testing and treatment that we did that seemed to lead to nothing of value in patients’ lives. I have practiced medicine as if cost matters since I have matured, but certainly not to the extent that my grandmothers would have, if they had been in my place.
As the health care debate has heated up, I began to hear figures related to costs in medicine that were and are increasingly disturbing. Figures like 2.3 trillion dollars spent on health care yearly in the US, and 17% of our GDP going to health care. I looked at a book of facts and figures that came to me by chance a couple of years ago, and saw various health indicators for developed countries that showed us to be merely average, despite our higher per capita spending on health. I asked my friends, other doctors, why they thought we were so expensive, and they all knew. And I knew too. We all know that, for various reasons, we order too many expensive tests, procedures and medications, without considering the costs and the benefits. There are 4 reasons that we do this: we don’t really know what medications and tests cost, we feel that our patients have come to expect this kind of care, we don’t have time to discuss care with our patients, and we think that ordering these medications or tests or procedures will protect us from being sued for malpractice.
One day I sat down and calculated about how much money we might really be wasting on testing and procedures that do nobody any good, and came up with a ballpark figure of 20,000 dollars wasted in a half a day. I’ll tell you the story of a busy doctor on an average morning. The story is entirely fictional, but happens all the time in the US. The costs are approximate, because they vary considerably.
8AM—arrive at the hospital, perform two treadmill tests with nuclear imaging, ordered by physicians for patients at low risk, because of concern about malpractice should they have a heart attack. Each costs $3000, one unnecessary, the other of which could have been done without nuclear imaging at my office for $200.
9AM—see two patients at the hospital. One remains in the hospital because she can no longer live at home and can’t afford to go to any of the extended care facilities that have openings, at a cost of $1000 for the day. The other is there because she wasn’t insured and waited too long to see a doctor for her migraine headache, costing $2500 for her MRI scan of the head and $1200 for her day’s stay at the hospital, and $600 emergency room fees.
9:45—get to the office late because the uninsured patient was news to me, so I didn’t plan on seeing her. See my first patient who has a physical scheduled. She wants “a complete lab workup” even though all of her labs were normal last year and nothing has changed, because her insurance will cover it. She has been having back pain. Since I don’t have time to talk to her about the natural history of back pain I order an MRI scan and physical therapy. Labs: $120, MRI$2500, 8 physical therapy appointments $1000.
10:30—next patient has numbness in his fingers when he is anxious. He can’t afford counseling and I don’t have time to discuss relaxation techniques with him so I refer him to a neurologist. He will see the neurologist 3 times, at a cost of $150 per visit, and she will order a head MRI scan for $2500.
10: 45—next patient has a cough and a stuffy nose for 4 days. I think it is viral, but she is sure she needs antibiotics. I don’t have time to explain the side effects and futility of antibiotics so I prescribe an antibiotic. She says the generic doesn’t work. Cost is $120 for that and $200 for an inhaler which is what I think will work, though if she just waited she wouldn’t need that. Because she smokes and I am worried about being sued if she eventually gets lung cancer, I order a chest x-ray. That is another $200.
11:00—patient comes in for follow-up of his diabetes. It has been in poor control, but since I don’t have time to counsel him on diet and exercise in a way that will probably have an impact, I prescribe a new medication. He is already on generic pills, so I have to prescribe insulin, and because time is an issue, I use the newest insulin delivery system which is easier to explain. This costs $150 and doesn’t make him any happier, plus his risk for complications is just as high because he will continue to gain weight.
11:15—the next patient comes in for follow-up of an abdominal CAT scan I ordered because I didn’t have enough time to counsel the patient on how to avoid constipation which had then given him belly pain. The CAT discovered a cyst on his kidney and a nodule on his adrenal gland. He is beside himself with worry, even though both of these things are usually normal findings. I reassure him that I will get a follow-up CAT scan to make sure they are normal, which will use a better technique and cost $2000 (but I don’t tell him this because I don’t know what it will cost and have no idea what his insurance will pay.) Because he is so worried I don’t have time to see my next patient who has to leave and go to the emergency department with her pneumonia at a cost of $1500.
With over half a million practicing physicians in the US, this may add up to 100s of millions of dollars every day. It has become clear that many of the expensive things we do are the things that don’t make patients healthier or happier, and that costs related to what I think of as stupid care may make up a sizeable portion of our health care budget.
So let’s move away from my personal experience a little bit. Trends in health care spending have changed some, but why have the American people all of a sudden noticed that something is wrong? Our economy took a nosedive about a year ago. Insurance prices finally became too high for individuals and companies to afford them, and the services they provided became inadequate to cover the medical care that people were receiving. People are now commonly bankrupted by paying for medical care, insured or not. We got a new president who started focusing on health care, and began talking about making changes that would allow more people access to it, and about ways to bring the spending on that health care in closer line with most other developed nations. Focus has moved to improving the cost and service provided by the insurance companies, and we have become alarmed by their high profits. But even if their prices come down and profits are reduced, the budget for health care will still be unsupportable.
Because medical care is so expensive now, people who are uninsured have virtually no access to non-emergency care.
So what do we need to do?
We obviously need to allow access to good medical care for everyone. We also need to substantially reduce the cost of that medical care.
If we substantially reduce the cost of medical care, all sorts of options become possible for extending access to everyone. The point that our democratic legislators have failed to emphasize is that if we do not reduce the cost of medical care, extending access to everyone becomes economically unsupportable. The really miraculous thing about this situation is that reducing costs can directly improve the quality of medical care. When we spend money on things that don’t really help people to become healthier, we are also spending time and energy on those things, and that is time and energy that could be spent giving better care.
One way to reduce costs and improve health will be to provide adequate primary care for everyone, so we can take the time that is needed to do what is most valuable to each individual. Patients need to be able to see a provider who knows them and their issues for problems as they arise, rather than having to go to emergency rooms or urgent care offices where costs are much higher and procedures are ordered much less conservatively. When you go in to the emergency room for a condition, the doctor focuses on the many life threatening conditions that you might have, and with no familiarity with you or what makes you tick, will order many blood tests and imaging tests that will be done while you wait. In some situations this is just what should happen, but in most situations you will get way more tests than you actually need.
Allowing everyone access to a primary care doctor will mean changing the way medical care is paid for so that primary care is a more desirable field. When a new doctor finishes medical school, that person is in debt for about $150,000. Going into a medical specialty guarantees a much higher salary than going into primary care, and this has driven a progressive trend away from training physicians in primary care fields. When I graduated from medical school over half of graduates became primary care docs, and now that number is just above 10%. This trend does not allow us to even replace the internists and family doctors who retire, much less increase the work force to take care of the patients who we hope will soon have access to medical care.
Another way to bring down costs is to make them part of the discussion when deciding what should be done to take care of a problem. Procedures are often ordered in place of spending time with a patient. A discussion of costs, risks and benefits would likely reduce the number of procedures done, and make sure that they will actually contribute to a patient’s health. To have such a discussion, doctors and patients need to know what they cost. As odd as it may seem, it is quite difficult to find this information. When I order an antibiotic for a patient or a CAT scan I truly have no idea what the total cost will be or what the patient will end up needing to pay, and that situation is simply unacceptable.
Worries about being sued for malpractice drive doctors to order tests and consultations that are not necessary. We need to have a system of dealing with medical malpractice that is designed to improve quality rather than lead to defensive medicine. The way things are now, very few people who injured due to a medical mishap are compensated, and the process of completing a malpractice case takes years of a patient’s and a doctor’s time, leading to bitterness rather than quality improvement, in most cases.
What can we do, as patients and families of patients? We can look honestly at what we want to get from our medical care. We need to realize that the resources to pay for everything are, in fact, limited. Money we spend for medical care is money we don’t have to spend on food and shelter, education, and having fun with our friends and family. We need to have honest discussions with our health care providers about costs of things and expected benefits. We need to consider ahead of time what we want the end of our lives to look like, whether we want intensive care, and we need to discuss these things with our providers.
Doctors need to look at the way we provide care, and seriously study what procedures and evaluations for common conditions work and which do not, and what methods of treatment give best value. We need to use our substantial clout to open up discussions of costs which are out of line with other countries, such as costs for radiology procedures and medications. We need to take the time with patients to provide the counseling that the patients need, and push for compensation for this that allows them to do this without going broke.
But what about insurance?
Insurance issues dominate much of the discussion of health care reform right now. About 58% of people have private insurance at this time, and about 34% of people have some sort of public plan. We pay insurance companies, by salary deductions, direct billing or through taxes, and they, mostly, pay for our health care. The way they pay for our health care is positively diabolical in its complexity, and separates us from having much direct effect on what things cost. When insurance pays for something, we are usually just relieved, and not very concerned if the cost is outrageous, because the money paid out does not really look like “real money” anymore. So the very fact of being insured contributes to the excessive cost of health care.
Until something can be done to reduce prices for medical care, and this will be a slow process, everyone needs insurance.
I do not have the solution to the proper way to insure everyone. Presently Medicare covers something like 17% of Americans, and in many cases pays half of what private insurance does for many services. It is because there is a mix of public and private insurance that many offices can afford to provide services to everyone. A simple extension of Medicare to cover all of those who can’t afford insurance would strain the ability of offices to provide care, and many of those insured publicly would find themselves without providers. If Medicare were reformed, and payment schedules were changed, this would be a viable option. Health care coops are an interesting idea, and seed money for an expansion of that system would eventually result in improvement in availability of care. Tighter regulation of private insurance companies, requiring that they compete across state lines, be portable from job to job, and cover pre-existing conditions will help, but if medical costs continue to rise, that improvement will be short lived as costs outstrip anyone’s ability to pay.
Many other countries have developed systems that work for them, and if we can be flexible, their ideas could be modified to work for us.
You may notice that I have not yet mentioned evil drug companies. Much like evil insurance companies, evil drug companies do exactly what they were designed to do which is make money. They will continue to make medications that are overpriced and over advertised as long as we continue to pay for them. We will continue to pay for them as long as we are unaware of their costs and alternatives.
So—there is much to think about. In my mind, there is huge balloon of hope at this time in history. Something finally will be done to improve the way health care is delivered, and liberate resources that have gone to buy medical care that makes no one healthier and happier. Doctors are seeing this, and are actively working to improve the way care is delivered, and the rest of us have the power to bring about change we have previously thought of as impossible. A very special thing about this crisis of costs in the US is the opportunity it brings us to focus on what we really want from medical care, rather than continuing with the “business as usual” which has become a very different thing.
Closing Reading: by Rachel Naomi Remen MD
For the past hundred years the goal of health care has been the curing of the body. Restoring the concept of healing to the heart of health care is no small thing. It requires rethinking the assumptions on which medical relationships are based, rethinking the goals of every health care interaction. It will require a revolution.
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