Friday, November 20, 2009

When will we face the real issues?

An obsession with technology coupled with consumerism has led to the excesses so evident in today’s practice of medicine. An excellent example was recently published by F. Knauf and P.S. Aronson, ESRD As a Window into America’s Cost Crisis in Health Care, Journal American Society of Nephrology 2009; 20:2093-7, which describes how nephrology (kidney) treatments are now being applied far in excess of the original indications.

Kidney dialysis and transplantation first became available in the early 1960s. Because of cost, most people were excluded from these life saving benefits. To meet this public need, the Bureau of the Budget created a committee headed by the highly regarded nephrologist, Carl Gottschalk. This committee submitted their report in 1967 calling for federal funding to make dialysis and transplantation available through Medicare to all Americans. In 1972 this concept was approved by Congress.

The Gottschalk committee proposed that dialysis would be limited to otherwise healthy people mostly under the age of 54 years. Thus it was anticipated that dialysis or transplantation would be appropriate in 1 of 5 patients with ESRD (end stage renal disease). Maintaining these criteria would add about 40 patients/million population to the dialysis and transplantation cohort yearly. But now that number is about 400/million, with patients over the age of 75 the fastest growing sub-group, most with serious co-existing diseases causing an increase in patient suffering, hospitalization rates, and a dramatic increase in costs.

Is this good medicine? Does this liberalization of criteria lead to better medical care? Data clearly demonstrate that older patients who are non-ambulatory or with other co-morbidities frequently die in the hospital rather than in the community while receiving little or no benefit. Another recent paper in the New England Journal of Medicine, 2009:361; 1539-1547, demonstrated that nursing home patients, after one year on dialysis, have a death rate of 58 percent and a significant decrease in an already limited functional status. Instead of the careful and thoughtful use of technology mixed with insight and compassion, we in America seek an inappropriate technological solution no matter how great the evidence that it will not be beneficial. Thus, the only pathway to successful health care reform is to develop mechanisms to alter the present medical culture. The approach should be based on the individual characteristics and needs of each patient.

Unfortunately the present plans for health care reform do not in any way address these basic problems. As stated in a recent (Nov. 16, 2009) op-ed essay in the Washington Post by Robert J. Samuelson,
There is an air of absurdity to what is mistakenly called "health-care reform." Everyone knows that the United States faces massive governmental budget deficits as far as calculators can project, driven heavily by an aging population and uncontrolled health costs. As we recover slowly from a devastating recession, it's widely agreed that, though deficits should not be cut abruptly (lest the economy resume its slump), a prudent society would embark on long-term policies to control health costs, reduce government spending and curb massive future deficits. The administration estimates these at $9 trillion from 2010 to 2019. The president and all his top economic advisers proclaim the same cautionary message. So what do they do? Just the opposite. Their far-reaching overhaul of the health-care system -- which Congress is halfway toward enacting -- would almost certainly make matters worse. It would create new, open-ended medical entitlements that threaten higher deficits and would do little to suppress surging health costs. The disconnect between what President Obama says and what he's doing is so glaring that most people could not abide it. The president, his advisers and allies have no trouble. But reconciling blatantly contradictory objectives requires them to engage in willful self-deception, public dishonesty, or both.

There is no doubt that this country needs health care reform that addresses our aberrant medical culture. There certainly is no sign of that at this time.

Saturday, November 14, 2009

The Health Care Crisis: Lack of Resources or Sick Medical Culture?

Health care in the U. S. consumes 17% of gross domestic product (GDP). That’s $7000/person - about one and one-half times more than the next most expensive nation (Switzerland). Costly health care means costly health care insurance. Businesses that provide health insurance for their employees make up for the ever-rising costs by raising the price of goods and services and laying off workers. We lose jobs and lose our competitive edge in global markets. Those people not covered by employers or those out of work drop their insurance because they simply can’t afford it. That means more and more people added to the tens of millions already without insurance or who are grossly under-insured. And for all that high-cost medical care, our health outcomes in many categories are dismally inferior to other industrialized nations. That is definitely not a good return on the investment!

So, who is responsible for health care delivery? Who decides what procedures and treatments will be done? These decisions play an enormous role in health care costs. In the September 24, 2009 issue of the New England Journal of Medicine, the former editor of that journal, Dr. Arnold S. Relman, writes:
Doctors, in consultation with their patients – not insurance companies, legislators, or government officials – make most of the decisions to use medical resources, thereby determining what the Unites States spends on health care.

This being the case, why are doctors spending so much with such unacceptable results? Multiple sources suggest that about one-third of all health care spending is non-beneficial. Presently doctors deliver disjointed, overly technological, irrational care for several reasons.

1. As documented by the Dartmouth Atlas of Health Care, our major teaching centers, where costs for the same diseases vary from center to center, emphasize specialists delivering expensive technology while de-emphasizing history taking, physical exam and wise use of resources. This has taken place in large part, because Medicare reimbursement emphasizes technology rather than thinking.

2. We have a critical shortage of primary care doctors. This is largely a result of Medicare payment policies. Primary care doctors earn significantly less than specialists while having to see 30-40 patients per day. This makes a meaningful patient-doctor relationship virtually impossible and keeps young doctors from entering primary care.

3. The public is overly demanding and confused because of drug and device advertising and the recent over-emphasis on patient autonomy. They often demand procedures or treatments that are costly, but non-beneficial, and doctors are reluctant to refuse for fear of malpractice suits.

The Massachusetts universal health care experiment is a shining example of what can happen when you throw money at symptoms (millions uninsured) without treating the disease (lack of effective physician oversight). This state now has big problems with access and high costs causing extreme budgetary distress. Sadly, Capitol Hill is headed down the same road.