Professor Victor Fuchs and Dr. Arnold Milstein, both of Stanford University, have an article in a recent issue of The New England Journal of Medicine that asks: Why is it so difficult to reduce health care costs in the US? The article is available in its entirety online, but for those short of time, here’s a concise (and depressing) summary.
The graphic accompanying the article is dramatic in its simplicity. Health care spending in the US is 17% of GDP. In other developed countries (Western Europe, Canada, Australia), the number fluctuates around 10%. And yet life expectancy in the US is the lowest of these countries – almost four years below that of the number one country.
We know that some physicians and health care providers manage to operate at less than 20% of the average cost of care, without sacrificing quality. If everyone followed their example, the US could save $640 billion a year (US health care costs for 2008 were $2.3 trillion). Why doesn’t that happen, or as Fuchs and Milstein put it: “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer comes down to perceptions and behaviors.
- Insurance companies resist the standardization needed to reduce costs because they would lose their competitive advantage over other companies and their profits would go down.
- Large employers are afraid of alienating employees; plus they’re determined to resist any efforts that would increase the government’s role in health care.
- The public opposes change because they do not understand who really pays for their health care. “The media, with rare exceptions, is the principal source of this misunderstanding.” Workers see employment-based insurance as a “generous” gift, rather than the reduction in wages that it actually is. The media emphasize misleading statistics: the relative benefit of clinical interventions, rather than absolute benefit. Plus: “Misleading headlines, designed to attract larger audiences, can make life difficult for physicians who want to practice cost-effective medicine but are beset by patients’ requests or demands for costly new therapies: the public reflexively mistrusts any apparent withholding of widely touted diagnostic or therapeutic interventions, even when they might do more harm than good.” Overuse leads to the dangers that come with overdiagnosis, but the public does not understand this. (Iatrogenesis is the third-leading cause of death in the US.)
- Legislators, otherwise known as politicians, oppose cost-effective health care because their re-election depends on contributions from “health industry stakeholders who benefit from the current inefficient arrangements.”
- Hospital administrators are afraid their revenues will decline; plus, they are afraid of any attempt to change the behavior of physicians, who might decide to use another hospital.
- Physicians are resistant to change out of a fear of loss of autonomy and a concern that incomes would decline. “[I]ndeed, physicians in highly paid specialties would probably lose income in a more cost-effective system, though primary care physicians would probably come out ahead.”
- Academic health centers fear cost-reduction because they’re concerned about possible conflicts of interest with their research and education objectives.
- Manufacturers of drugs, medical devices, and equipment have the most to lose if accountable care or managed care organizations were free to negotiate for the best prices. “To preserve the present system, manufacturers of health care products spend heavily on federal lobbying.” See “legislators” above.
Physician, manage limited resources wisely and cost-effectively
Altogether, not a pretty picture. Is there any hope? Fuchs and Milstein propose that the problem could be solved with tax-supported universal coverage and/or “disciplined managed competition among health insurers.” They immediately add: “Neither solution is politically feasible.” But they have this caveat: not politically feasible “without robust physician support.”
[T]he public’s visceral distrust of policies aimed at improving the cost-effectiveness of health care can be neutralized only by their confidence in what their physicians support. … [P]hysicians are the most influential element in health care. The public’s trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care. Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.
A modern version of the Hippocratic Oath, the Physician Charter, commits physicians to work toward “the wise and cost-effective management of limited clinical resources.” But there’s little physicians – or anyone else – can do to change the behavior of politicians, insurance companies, pharmaceutical companies, or other entrenched stakeholders.
It would be heartening to see visionary, public-minded physicians emerge as leaders of the medical profession in the fight to solve this important and extremely difficult dilemma. Perhaps they could inspire individual physicians to influence their patients, the public. And then …. Who knows? This is still a democracy, isn’t it?
Related links:
Doctors eliminate the middle man: Insurance
From MD to MBA: The business of primary care
From healthism to overdiagnosis
Out of Practice: The demise of the primary care practitioner
The states’ rights argument against health care: An ugly tradition
A doomed and dysfunctional medical culture
Are doctors tired of practicing medicine?
Can better care for the neediest patients lower costs?
Resources:
Image: The Independent Report
Victor R. Fuchs, Ph.D., and Arnold Milstein, M.D., M.P.H., The $640 Billion Question — Why Does Cost-Effective Care Diffuse So Slowly?, The New England Journal of Medicine, May 26, 2011, Vol. 2011 (364), pp 1985-1987
An Alternative Approach to the Health Care Cost Problem
The Iceberg
There is a popular image in the field of intercultural communications that depicts culture as an iceberg. The top of the iceberg floats above the surface of everyday perception. Under the surface of the water is the unseen bulk of the iceberg extending farther out than the visible upper portion. It is this submerged assortment of cultural thoughts, feeling, beliefs and taboos that determines how we behave and what choices we make. It informs us about right and wrong, good and evil, sane and crazy. When addressing the costs of health care most of us never explore our subsurface iceberg. We assume that we are all floating through life on the same frozen platform when in actuality families, religious groups, nations, even individuals are often kept from reaching common conclusions because the underside of their cultural icebergs are keeping them apart. To find areas in which we can cut costs and streamline care we must first bring our varied cultural assumptions to the surface of our consciousness so that we can examine and compare them.
With the ‘help’ of the media we see what medical procedures are in demand, how much physicians charge us, the way insurance companies handle our claims, the immense corporate profits made in the drug and medical supplies industries. What is below the surface, our values, attitudes and perceptions about medical care for ourselves and our loved ones, is rarely addressed. This blog offers an opportunity for us to examine our underlying beliefs about both the health care we give and receive and how our unexamined cultural beliefs unwittingly reinforce economic practices that keep health care costs extremely high.
A deep, thoughtful dialog on solving the health care cost problem will take more than one blog post. Today I’ll pick out two issues and propose a context for discussion. As the interchange continues we can take up the topics participants find most interesting. Jan Henderson has done an impressive job of laying the groundwork for us with this web site. Our challenge is to respond to each other, to the health care industry and to our elected officials.
Doing whatever we can in the name of science
One major subsurface factor that impacts the cost of health care in the US is our enthusiasm for using the latest, greatest technology to understand and control natural processes. Here’s an example. I recently had a panel of x-rays to try to diagnose the source of my chronic back pain. After locating a series of bone spurs and compressed disks my doctor squinted at the images on her computer screen and said, “And besides all this, your bones are too transparent. You can go and get a bone-density test if you want but I’ll treat you just the same regardless of the numbers that come back from the tests. I want you to take…” I already know I’m at risk for osteoporosis. A bone density scan may give my doctor and me more precision in the extent of my bone loss. But neither of us believe that such a high level of precision is necessary.
There is a lot of science involved in medical treatment – as well as a lot of art combined with trial and error. Our cultural predilection to want and trust the kind of exact measurement so important in the physical sciences does not always transfer to medical practice. Gathering large amounts of detailed data is important for medical research. It often has no impact at all on routine diagnosis. Even if Medicare will pay for expensive tests such as bone scans there is still a cost for it. Our underlying, almost magical, cultural belief that science can cure what ails us fuels our reliance on complex tests that require high capital investment in cutting-edge machines. Further, this belief makes it seem sensible to sue the doctor for malpractice in the event that an expensive test might possibly have led to a different, possibly more effective treatment. If we consumers continue to demand diagnostic tests that far exceed the need for a treatment decision medical and malpractice insurance costs will continue to spiral upwards.
Rights to life and death
Another strong impact on the cost of health care is US attitudes toward death. Some medical economists claim that close to 50% of lifetime treatment expenditures occur within 6 months of death. Who are the people who make up this statistic and what beliefs lead them to consume so much medical service in such a short period of time?
In some situations doctors are struggling to prevent the immediate death of a patient with every expectation of many happy years ahead if only the current crisis can be overcome. If the treatment fails or if some other condition causes the patient’s untimely death within 6 months one more data point is added to this statistic. Increasingly these patients survive the 6 month window. Their crisis care, whether the result of accident or disease, may be very expensive but the cost is averaged over their lifetimes, not at the very end.
More common are those individuals and families who can see the grim reaper at the door and decide to hold him off as long as possible ‘at all costs’. We are talking about babies with severe birth defects, sufferers from chronic diseases, people in vegetative states and the very elderly, to name a few. As a culture, it is not our practice to let Grandma die at home in her own bed when we could prolong her life for a few months in a hospital. We do not sacrifice a severely handicapped child in favor of the economic welfare of rest of the family. These are cultural, not universal, decisions. Although the urge to morn the death of a loved one seems to be similar among humans around the globe, choices about when to let someone die are not. We tend to tell ourselves that we are ‘playing God’ if we remove someone from medical life support but not when we put them on.
Questions that probe culture
From cultural beliefs to medical economics
When contemplating the cost of medical tests and treatments one is always vulnerable to the accusation that we are ‘putting a price tag on a life’ which sounds unbelievably heartless. But in fact, it is our cultural trend to monetize all our resources that leads us to express in financial terms the decisions that families and communities have always made. Our medical technology has made it possible to extend both the years and quality of countless lives. Now we are faced with four dilemmas:
1) How can we be more efficient in our use of medical know-how?
2) How much of our collective resource should we allocate to medical care?
3) How should we spread the cost of that care among members of our community?
4) Is it appropriate for individuals or corporations to profit from decisions about the allocation of medical care?
My first example on using medical tests in routine diagnosis speaks to Dilemma 1, efficiency. My second example of the cost of end-of-life care speaks to Dilemmas 2 and 3. Dilemma 4 underlies many of the comments made in the original blog post. I leave discussion of our submerged beliefs about who should profit from what for another day.
Addressing legislators, hospital and research administrators, physicians, and manufacturers, as suggested by the blog, is important but it will not lead us to answer the “Why” part of the health care cost question. To understand “Why” we must examine the underside of our cultural iceberg.
Thanks for your thoughtful comments, Liza, and for the perspective you bring to these issues. In my experience, that point of view is all too rare. I have long operated with an idea similar to the metaphor of the iceberg. We inherit a stock of knowledge, embodied in language, conceptual categories and social institutions. So much of that knowledge is taken for granted that we aren’t even aware of the beliefs that determine our thoughts and actions. We assume the way things are is inevitable, never realizing there are choices available to us if only we’d acknowledge our unrecognized assumptions.
I’ve always found this idea – similar to becoming aware of the submerged portion of the iceberg – extremely liberating on a personal level. Over the years, however, I’ve become disillusioned with the prospect of extending this liberation to the world at large. There was a period in modern European history when philosophers believed rational thought not only could, but would prevail. Unfortunately, human behavior turned out to be much more emotional than rational, with greed being one of most prevalent emotions.
But to speak to your specific points, which are quite valid. Starting in the 19th century, medicine – in an attempt to piggyback on the success and prestige of various branches of science – abandoned its bedside tradition of close observation, listening, and understanding patients as whole people. It turned instead to reliance on what could be measured. In many respects, this approach has been hugely successful (organ transplants is the often cited example). Would it be possible today to convince the public that – say — expensive diagnostic tests might actually be doing more harm than good? There are people who try (H. Gilbert Welch, eg) and they are my heroes. But such attempts are up against enormous financial interests and highly successful marketing campaigns that exploit the fear of disease and death. Making a difference in this particular battle is definitely an effort worth devoting one’s life to, but I’m not optimistic I’ll see progress in my lifetime.
The cost of medical care at the end of life. The thing about death is, it brings up the question of the meaning of life. It was only when doctors acquired pain killers that could ease the suffering of the dying that doctors replaced religious figures at the deathbed. Unlike religion, science could not offer the emotional comfort, meaning, and acceptance of death that was displaced by the worship of science. There are still many cultures that don’t have this problem, but ours does. We live in an economic system that would have us believe whoever dies with the most toys wins. In a society that lacks non-material sources of satisfaction, I don’t see a solution to expensive end-of-life care. A bioethicist who writes eloquently on this issue is Daniel Callahan.
Despite my pessimism, which waxes and wanes, I still have hope. Lately I’ve been referring to some thoughts from Charles Rosenberg (“Our Present Complaint”) that I find encouraging: Biomedicine is not a unique and necessary institutional expression of scientific knowledge and technical capacity; part of the power of our biomedical culture is that its contingency is ordinarily invisible to those who dwell within it; and because we ignore this largely invisible contingency, we fail to see that medicine need not be what it currently and temporarily is.
That invisibility is the submerged portion of your iceberg and my unrecognized and taken-for-granted assumptions. We are sleep-walking through the post-industrial world, either unaware of or feeling powerless against what seems inevitable. We could, in fact, change medicine — change the world — by our united and collective actions. In medicine, we desperately need to wake up and act before a crisis of Titanic proportions gets any closer.