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.


Liz said...

Dr. Norman Makous makes the point (in a book, "Time to Care," that the main problem with health care today is that there's no personal attention the patient anymore! Technology has become more important than the patient -- and while yes, new technology has saved lives -- the personal approach, the personal touch is also critical. (Seems pretty self-evident, doesn't it?)

Doctor Kenneth Fisher said...

You are correct; we physicians have got to re-learn to take care of the whole person, not just symptoms or dysfunctional organs. Thank you for your comment. Kenneth A. Fisher, M.D.

G. Rivers said...

Dr. Fisher, one might argue that we should pay or incentivize primary care physicians in a way that they will carry a lower number of patients. This may help balance the payment structure that is weighed heavily by specialists. I also think that evidence based medicine is what's lacking. While it is difficult to get a bunch of "experts" to decide what is the "right" thing to do at certain occassions; it is difficult for me to understand why things that are basically accepted as appropriate care, such as giving antibiotics pre- and post-op, are not performed consistently throughout the field. This is a problem. There are different results because not all patients are treated the same. Additionally, there isn't enough separation between doctors and salespersons who pitch the greatest new pill or device. We see now that these pills often grant no new benefits to patients yet cost much more.

Doctor Kenneth Fisher said...

G. Rivers,
Thank you for taking the time to visit and writing on my blog. I encourage greater participation by all.
As Massachusetts has demonstrated, the problem of access is caused by an inadequate number of primary care doctors. I agree that primary care doctors should spend more time with each patient, but to accomplish this we will need many more doctors providing primary care services. This can be accomplished by having internal medicine sub-specialists also provide primary care.
I agree that practicing evidence based medicine is important; however, it must be kept in mind that the evidence has to be adapted to the individual needs of each patient. This requires judgment and thinking, a human quality that cannot be computerized.
I completely agree that drug and device companies have too much influence with doctors. Unfortunately they also have too much influence on Congress which through Medicare has a tremendous effect on how we practice medicine. Kenneth A. Fisher, M.D.