We all agonize over the cost of health care. Each Senator has a unique, uneducated perspective on health care costs. Controlling costs can be done once we all understand that someone must ration care.
Yes, we cannot control costs if we indiscriminately order every possible test, every new expensive drug, and provide futile care. We cannot control costs without adequate primary care. Adequate primary care takes time. Inadequate primary care leads to excess testing, referrals and ER visits.
But yes we have to have some method of rationing. If patients had “skin in the game”, then they would participate in rationing. Clearly most people ration their food choices. Most Americans eschew fancy expensive restaurants. Most Americans make food choices based on price.
Few Americans make health care decisions based on price. Now some of my “self pay” patients can only afford low cost drugs. We jointly ration pharmaceutical choices, doing the best we can with the “walmart” list.
Two stories might help here.
1. Last month we diagnosed a patient with SIADH. I was excited to use tolvaptan, the new ADH anatagonist – until I heard that it cost $177 per pill – one pill per day. Democlocycline is not quite as good, but I could not justify the cost to society or the VA system.
2. I was taking to a family physician yesterday. She told me about a patient in their practice who was on home hospice. The family wanted the patient to die at home, but they became nervous and took the patient to the emergency department. 3 CT scans later, and multiple blood tests, the patient was finally admitted to the family medicine service. The family physicians, who know the patient well talked to the family, and discontinued the undesired therapies.
Our incentive system is wrong. Fee for service is likely the culprit. We are not paid to appropriately care for a reasonable number of patients, but rather we get paid for how many patients we see.
Hospital medicine groups generally have structured this appropriately. They know the optimal service size and put protections in place to achieve that size. Occasionally they have to see a larger number, but if it becomes a recurrent problem, they address the volume issue. They can do this because hospital administrators help pay their salaries, and the hospitalists have made the quality and efficiency case for approximately 17 patients per physician per day in the hospital.
We can control costs if everyone involved in health care – physicians, hospitals, insurance companies and patients – considers cost as a factor. We cannot control costs if we ignore the cost implications of our decisions. We can provide high quality care at a lower cost, but not with our current payment system.
Changing the system would create winners and losers. Because it would create major losers, we likely will not make the necessary changes. We will have half baked ideas from Senators who really do not understand the daily details of health care.
Our political system has made this country the most desirable place to live – just ask any immigrant about the virtues of the US. Sometimes our political system handicaps us. I believe that we will make only minor progress in health care reform. We do need to provide coverage for the uninsured. We could decrease health care costs, but too many special interests will prevent the changes we really need.
