Why is U.S. Health Care REALLY So Expensive?
Seriously? This is the best article on the problem of health care costs I have ever read. It’s clear, incisive, well-researched, pulls no punches for either side and stays dead on-point. I’m floored, and considering how often I torture myself with input about U.S. health care, that’s saying something.
Exerpt and link below. It’s a long article, but if you’ve ever wanted to know what exactly is making health care costs so high (surprise! it isn’t unhealthy Americans, or high-tech medicine, or malpractice suits, or government or insurer inefficiency) and what might really fix it, you WANT to read this, trust me.
The excerpt is my favorite bit (out of many favorite bits; this is really a stunningly well-written piece if you ask me) because it points out something that I believe really needs saying: It’s not just who pays that’s the problem. It’s why we pay; it’s what we pay for. The reason private insurance didn’t work is that it made it profitable to avoid prevention and stack on the expensive treatments — it put the focus on amount of care rather than outcome of care. Replacing private insurers with any other program (even if it’s a single-payer “universal” system) that focuses on the same thing won’t do crap. Behold A Marvelous Metaphor:
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.
This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.
via Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker.
3 comments
Interesting article. I can see both sides of the coin- I can understand doctors working in a way to maximise their income, but at the same time there is a need to reform and control things. However, I don’t think complex rules and proceedures will help. I bet I could work out a superior way. I just need to be given the chance. I would call myself Emperor Palpaltine. And I swear I would recind my power once the problem was fixed.
As a family physician, some of this article was tough for me read. It is absolutely true that we have costly practice habits in medicine. There are several reasons for this, some of which the article pointed out: 1) insufficient knowledge, experience or confidence in our ability to diagnose and treat leading to more testing and referrals, 2) unconsciousness of cost containment, 3) inadequate collegial communication between primary care providers and specialists that could obviate unecessary diagnostics, referrals and treatments, 4) fear of malpratice, 5) patient expectations, request and demands for certain tests and treatments, and, finally, 6) the way insurance companies pay or don’t pay) doctors. Here’s my opinion “from the trenches” about what needs to be done to curtail health care spending: 1) Teach fiscally responsible medical practice in medical school and incorporate this practice into graduate medical education. 2) Foster communication between health care providers by promoting community medical societies, including “virtual” medical societies, and a national electronic medical record. 3) Promote evidence-based practice by continous education of health care providers. 4) Negotiate salaried positions with physicians that includes bonus pay for productivity and performance. 5) Implement “gate keeping” strategies to minimize potentially unnecessary diagnosics and treatments that center on educating providers and are tailored to unique clinical situations and not on saving insurance companies money. 6) Make patients stakeholders in their own health and healthcare and stop direct marketing to patients. I can’t tell you how much time I’ve spent over the years explaining to patients why I won’t order a “screening” CEA for ovarian cancer on a 20 yr old healthy woman, prescribe Abilify first line for mild depression or refer for coronary calcium a middle-aged man who has no intention of stopping smoking, improving his diet or exercising to control his weight. Too much of our health care dollars are spent on preventable illness due to the deplorable gluttony and physical laziness of far too many of our citizens. I believe that patients should pay for PREVENTABLE existing conditions. Few people change their behavior if there is no immediate consequence for it. If I were the Queen, I would define a “non-nutritious” (e.g., candy) and “unhealthy” (e.g., high fat/sugar/salt) food and TAX THE SNOT OUT OF IT. This would accomplish several things. The tax dollars would pay for health care, people would consume less of these foods, and companies would have incentive to market healthier foods. I also believe patients should fork over copayments and pay for “no show” visits. This helps keep people responsible for accessing the healthcare system wisely. Ah, well, I have lots of other thoughts but I’m running out of steam.
Your existing thoughts are fantastic, Jan! Would you mind being bumped up to the front page? I wouldn’t edit your comment, except for formatting.
Thanks for the wise words! -PD