Lowering Health Care Costs

On March 20, 2010, Lesley Alderman published an article in the New York Times quoting the responses of several doctors to the question, How can we lower health care costs. Their answers were very narrow:  insure catastrophic but not minor illness, change malpractice law, counsel nutrition, rely on evidence (don’t order tests you don’t need), allow for expertise, use “integrative medicine”, pay to treat childhood obesity, stop overeating, restore the humanity of medicine.


These are all good ideas, but I find them limited. The doctors mostly responded to issues in their own fields, and did not think of big ideas that can have large impact on costs.


Like Ms. Alderman and others, I do worry about the cost of health care. My solutions would be broader than those listed above.


The first solution would be to reduce waste: I see waste in the administrative cost of complying with (or arguing against) a multiplicity of insurers that have different rules and different forms, all dedicated to refusing care. The new health care bill will reduce but not eliminate this cost.  A one-payer system, or uniform rules for all patients, would be a tremendous help.


I see waste in the cost of pharmaceuticals, in the United States, that can be purchased at half the cost in Europe or Canada—why cannot we regulate pricing, or profit margins, the way that other countries do? I am willing to let drug developers recoup their development costs, but are we subsidizing Europe, or does our lack of price controls permit manufacturers to charge the most they can and profit more than they should?


I see waste in overuse of technologies—the repeated CT scans and MRIs, when a recent one will do. Granted, sometimes one machine, or one laboratory, does a better job than another, but mostly not, so this is a training issue: training both doctors and patients in rational use. It is also an abundance issue—if the machines are available, why not use them, the argument goes, particularly when, having been purchased, they must be paid for by maximum use?


I have other proposals that some may find unpalatable. Some patients do not accept answers doctors give, and seek other opinions. I do not argue with that right; it is fair and appropriate. Doctors differ in personalities, skills, and judgment, so bureaucratically locking one patient to one doctor is bad policy. On the other hand, this past week I was the fifth academic, professorial rank, highly trained rheumatologist to see a patient who had not heard the answer she wanted overall (I agreed with three of the prior four). It was easy for her to see so many doctors—who, by the way, each repeated all of her tests (I did not)—because her insurance covered all costs, no questions asked. Perhaps requiring her to pay upfront some part of the cost after, say, the third opinion, would reduce the over-doctoring that is waste. Or, as the physician in Ms. Alderman’s article who recommended covering only catastrophic care suggested, perhaps routine items of care, or minor medical problems, could be paid out-of-pocket, a low initial cost reducing the demand for what is (for some) totally free care.


The other unpopular solution that I offer concerns the inequity in physician pay. There is a 10-fold difference in income between primary care, non-procedure-oriented medical specialties and the surgical or procedure-based medical specialties. The difference is not based on achieved skill, hours worked, or even physician’s personal responsibility. (Surgeons often turn care before and after the operating room over to physician’s assistants or to their medical colleagues.) The pay scale is based on perceived value and drama of care—fair enough in a capitalist world—but one can argue for a narrower differential among specialties, for salaried rather than fee-for-service payment, and for federal support for training costs so that physicians do not enter practice deeply in debt (and so choose lucrative specialties to recoup).

Saving money is a test of values. Do you want insurance companies to set the rules regarding what tests you can or cannot have? Do you value capitalism so much that you concede price-setting to the companies that make the drugs you take? Do you want to have access to as many exotic technologies, and as many physicians, as you (not your doctor, not medical need) wish, as often as you wish? Do you want your doctor to be an entrepreneur in a fee-for-service system, earning what he or she can charge, or would you prefer that her or his diagnostic and treatment decisions be made without concern about the doctor earning less or more depending on the choice?


While I don’t find these questions hard to answer, I know that different answers are equally legitimate. The debate has just begun.

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