Thursday, August 1, 2013

Medical Care: The Good, The Bad, and The Ugly.

Staff of Aesclepius
                  As many of you readers know, I am a retired doctor. I had always suspected that health care was far more expensive than any of us physicians were aware. Now I have reached an age where my husband and I are approaching the medical office reception counter from the other side--the patient side. Since I retired, my husband has had a number of non lethal health issues: treatment for prostate cancer, placement of a renal artery stent, and most recently a diagnostic workup for back pain. The medical bills have been arriving over the last couple years of these treatments and the costs are quite shocking. Radiation treatments for the prostate cancer near $20,000. Placement of the renal stent which was a relatively short procedure in the interventional radiology suite cost about $5000.  I am diabetic, and recently had a severe hypoglycemic episode in the middle of the night in which I was incoherent, didn't have control of my body and fell out of bed striking my head on the night table and sustaining a small laceration. The hypoglycemia was so severe that I was also hypothermic i.e my body temperature was only 91 degrees. Although I responded to just getting some sugar into my body, due to the severity of the episode I had to make an emergency room visit. They had to apply some glue to a laceration/abrasion to my temple, and it was deemed advisable to get a CT scan of my head to make sure something else wasn't the cause of this episode and also because I had sustained a head injury. My blood sugar was corrected before I arrived at the ER but it took a couple hours for my body temperature to normalize. I was in the ER for about 3 hours. The doctor spent about 10 minutes with me and then glued my laceration which took about 5 minutes. I had no IV, but they did use the heating blanket to warm me up. And I had a CT scan of the head. Price: $4500 total. A bargain correct?

     Recently the weekly Grand Rounds at my former hospital, Columbia St. Mary's, was entitled: US Healthcare: The Good, the Bad, and the Ugly. The speaker was the Associate Dean for Clinical Affairs of the Medical College of Wisconsin, and Chief Medical Officer of Froedtert Hospital. To protect this gentleman, I am not naming him here. But his presentation was quite candid.  He presented a lot of numerical facts about health care in this country compared in cost and value to countries in the rest of the world. And he has some theories about why health care is so expensive in this country. I paraphrase his presentation here.

     The first fact is that health care expenses are now 18% of the Gross national product (GDP) in the United States. The rest of the world spends a much lower percentage of their GDP on health care. And yet that large percentage that we spend on caring for our citizens has not increased our life expectancy to keep up with other countries. Some examples: The current life expectancy in the US is 78.7 years. That's an increase of 8.7% in the last year. We are the 33rd country in this ranking. The following countries rank above us in this order: Japan, Switzerland, San Marino, Italy, Singapore, Iceland, Andorra, Australia, Spain, Qatar, Israel, Monaco, France Sweden, Canada, Luxembourg, Cyprus, Norway, New Zealand, Netherlands, Austria, Greece, Ireland, South Korea, Finland, Germany, United Kingdom, Belgium, Malta, Slovenia, Portugal, Kuwait, Denmark, Chile, Costa Rica, and Bahrain. And many other countries also improved their life expectancy last year much more than we did. Our neighbor, Mexico, which has a life expectancy of 75, close to us but below us, improved their life expectancy 17% last year.  So certainly value for our health care dollar is not demonstrated by our life expectancy or its rate of improvement.

     Let's look at the UK a little more closely. The UK has a life expectancy of 80, considerably higher than that of the US. And they spend 1/2 the percentage of GDP, about 9% on their health care. So what could be the difference? Is it the doctors, the nurses, and other health care employees, or the hospitals? Well, compared to the UK, we have an equal number of doctors, of health care employees, and of hospitals per capita, so differences here are not the issue. What is different?

     Sometimes we hear that the reason some Scandinavian countries have such good health care outcomes is the fact that their population is so much more homogeneous. It is said also that their is also economic homogeneity in these countries. There are few poor. We have more poor and therefore it cost more to take care of these poor people. But in fact public versus private insurances show the same outcomes. So Medicare and Medicaid get equal results to those of all the private insurance products in this country.

     Our Grand Rounds speaker states that one area where we excel is in the care of the critically ill. We do a very good job in trauma centers. . We have many more low birth weight babies (8.2% of all live births), but they are much more likely to survive here in the US than in most of the rest of the world. Among dialysis patients , their survival is second only to such patients in Japan. And renal transplant patients survival is also 2nd in the world, only exceeded by Portugal. If you have a serious MI in the United States, you are much more likely to survive and do well. We accomplish these numbers by spending a lot more on specialists and much less on primary care (12% of docs in the US, 25% of docs in most of the rest of the world.) We do a lot more tests and imaging procedures. For example, we lead the world in number of CT scans performed per capita, number of  scanners per capita, and number of scans performed on each patient. We also spend a huge amount on medications which by the way are more expensive than in other countries.

     All of this can be summarized by saying that in the United States we are great at so-called rescue care as the speaker called it. If you are critically ill you have a much better chance of surviving in this country. But these vast amounts spent on a small percentage of patients do not alter our  overall life expectancy. Here is an example that illustrates how we spend our health care dollars and why it has so little effect. Let's look at two health care expenditures. The first expenditure is a renal transplant for one 55 year old man. The complete cost for this procedure and its post surgical care is $400,000. The profit margin for this procedure is $100,000. That means the health care industry earned $100,000 out of this $400,000 expenditure. Now look at the second expenditure. We wish to give stop-smoking counseling to 100 55 year old smokers. This will also cost $400,000 but the profit margin for the health care profession is only $5,000. There is no great amount of money to be made by doing the counseling so it probably doesn't get done. But which medical expenditure of these two do you think would have the most effect on the health of this nation? The answer of course is the smoking cessation counseling. A recent advertisement for Froedtert Hospital says that this hospital has the gamma knife to do very precise radiation treatment of cancer. But it doesn't talk about the hand washing protocol that sometimes reaches 95% compliance. Which of these health actions is likely to have the highest impact on health care outcomes? Basically the United States over performs on the micro level and under performs on the macro level.

      There is another reason that our life expectancy is so low here. Forty percent of our health care outcome determinants are based on our own bad behavior. Tobacco use, obesity, teenage pregnancy, sedentary lifestyle, type II diabetes (now present in 10% of the population), and HIV prevalence all create the vast majority of our poor health. The United States is 3rd in the world in the prevalence of HIV, obesity, and diabetes mellitus.

     In some cases, these behaviors are not entirely our own fault. It is now thought that our obesity and diabetes mellitus epidemic may be related to the pervasive use of corn syrup providing cheap calories to the masses and leading to an increase of the chronic health conditions related to these diagnoses.

     Another reason for many of the huge costs are the vast differences in standards of care throughout the United States. For example the number of cardiac surgeries directly relates to where the heart patient lives. Where numbers of cardiac bypasses are highest are the cities with the highest number of cardiac surgeons. There are multiple examples of utilization being directly correlated with the number of providers or imaging machines that are present in that area. Yet we do not see vast improvements of health parameters in these cities where many procedures or imaging studies are done.

     So what is the solution to this expensive and broken health care system? Well, I can tell you right off the top that the solution is not Obamacare. But I am not going to say anything more about this political view.

     As part of the solution, we need to take a closer look at several health programs of other countries. Particularly much of Scandinavia seems to have a system that works quite well. They are quite high in the life expectancy list and for 1/2 the cost  per capita of our health care system. The characteristics of the Swedish program includes more primary care doctors supervising a team of health care professionals who practice using detailed quality protocols and pathways and the health care providers get regular feedback about how they are doing in following these care protocols. In the United States primary care physicians are only 70% the number of specialists. In Denmark on the other hand, primary care is 120% of the number of specialists.  In addition in the US primary care physicians who have the most effect on the greater health care of the populace are paid the very least. Another issue in the US is that 1/2 the cost of health care is paid by business. With our current economic woes, business is going to be unwilling and unable to continue to pay this big bill.

     There are some specific steps that need to be taken to improve our basic health at the level of our mass population and to reduce the cost of this health care. We need to standardize care by using automated well researched guidelines, protocols and pathways that reduce or eliminate excess and inappropriateness of care. We need to reduce care associated patient injury by using these protocols to guide care. There are today still 98,000 preventable deaths per year caused by care associated injuries.  A book was written by an airline pilot which tells we doctors how to apply the airline safety protocols to health care with the obvious changes to apply it to medical care. In my mind this is exactly what is needed to standardize the care and avoid medically unnecessary tests and procedures.
 The book: Why Hospitals Should Fly: The  Ultimate Flight Plan to Patient Safety and Quality Care by John J. Nance.
     Doctors often blame the high cost of health care on malpractice insurance expenses and also the need to practice defensive medicine to protect their career practices. But if there were well thought out protocols and pathways for all common illnesses and doctors were rewarded for following these research and outcome based pathways, many of the problems of malpractice would go away. If doctors followed the protocols , they would be protected from malpractice suits.

     We must alter the entire focus of our health care. Our speaker told us that currently our care model is a resource based focus. He said we must change any future model to a process focus. And we must alter the payment system so that payments reward high impact health care, such as the smoking cessation counseling and the hand washing protocols.

     I don't know if a government health care system can produce such a system in this country but it has been done in Scandinavia and in the UK. In order to pay for such a system and get widespread compliance to the pathways there needs to be vast changes from the current system. But there are models elsewhere that lead us to believe it can be done.  

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