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.
Why the Dutch Girl Cried
Half-way through the medical student seminar, the Dutch girl began to cry.
The seminar, a conversation among medical students and patients, was intended to teach aspects of chronic illness. A young patient advocate from the Netherlands was an invited guest. None of us in the room, including her, had anticipated her tears.
“I was startled,” she told me later. She had thought the American patients would describe personal courage, doctor-patient communication, and personal resource-finding. Instead, she heard an angry litany about roadblocks in our health care system. “I was very upset,” she said, “because ill people should not be spending their precious energy arguing with their health insurance companies, begging them for help. They need that energy to recover and feel as well as possible.” So this day’s lesson was not about chronic illness. It became instead a conversation about, to her, America’s incomprehensible approach to medical care.
She cried because she heard American patients protesting private insurers’ denial of diagnostic tests, of medications, and of rights to consult specific physicians. These, she thought, would have been trivial, uncontroversial, and easily-supported requests in her native land. She explained in a later e-mail: “I did not want to emphasize how happy I was, because I felt guilty as well. I also felt a little embarrassed. I didn't have to write a letter or make a phone call when I needed chemotherapy or a new experimental drug or a prosthetic hip. How lucky I am,” she continued, “that I was born in the Netherlands.” Hers is message Americans should be startled to hear.
I, a teacher, had been taught. I had presented to students what I considered to be common problems in chronic disease management—identifying resources, self-advocacy, maintaining optimism. I now saw that I had unquestioningly accepted the structure of our health care system. I had been oblivious to how crazy it looks to foreign eyes.
I asked her Dutch physician, who had worked for several years in the United States and is my friend, what features of American medicine he would like to import to his home? His answer: “Nothing. I feel that the Dutch health care system is very good… I do not miss many things.” I then thought about patients of mine who, travelling, had fallen ill in England, France, Germany, Italy, Korea, Hong Kong, and Japan. They had found unencumbered access to top flight care and no bankrupting hospital bills, the opposite of what ill foreigners experience here.
My Dutch colleague says, and his patient’s tears show, that the uniform (national) health care services of other lands work better than does our patchwork plan. Americans pay 62% more per capita for health care than do the Dutch. One of every 7 Americans, but not a single Dutch person, has no medical insurance at all. Dutch insurers do not waste resources on armies of functionaries hired to find reasons to deny. Dutch physicians’ offices are not peopled with administrative assistants whose job is to get requests approved or to contest refusals to pay.
In the United States, obtaining approvals from private insurers is an abstruse, argumentative, and unpredictable process—at least two cycles of application-refusal-appeal then a telephone conversation with an arbiter who may or may not be authorized to approve. In contrast, Medicare and Medicaid—our closest approximation to the European way—makes approvals for tests or medications straight-forward, reasonable, and predictable. Medicare offers fair rules, uniformly applied; private insurance does not.
The young Dutch woman saw, more easily than did I, the cruelty in our system. Patients should focus on getting well, she said. Doctors should spend their time with their patients, not arguing with insurers. I agree.
America can do better. The President’s Affordable Care Act (ObamaCare) is a start—a health care system that has uniform rules for all for those who qualify, perhaps for all at a future date. The Affordable Care Act promises to use our resources for direct patient care and not for private insurance bureaucracies. With it, perhaps, we will be able to offer care for every person, well or chronically ill, and not subject the ill and vulnerable to the vagaries of whether they can or cannot be insured.
We should do this now. We should not need a young Dutch woman’s tears to tell us what to do.