Costs - The Health Care Cost Challenge

I have coffee each morning with a group of eight men of Medicare age. Each considers himself “healthy,” yet,

• one has had both knees replaced,
• another is scheduled soon for surgery for a bulging abdominal aneurysm,
• another has had open heart surgery ,
• another has had a stent placed to bypass an iliac aneurysm,
• another has had rotator cuff surgery,
• another has a vertebral column festooned with metallic devices,
• two have had surgery for intractable disc-induced sacroiliac pain,
• three have had cataracts extracted,
• four have had skin cancers excised,
• most of them are on statins or antihypertensive agents,
• all have had a CT or MRI scan during their medical episodes.

To the man, all thought doctors did the right thing for the right reasons at the right time. And I have not told their wives’ tales. All, and here is the kicker, are functioning, active members of the community.

You do the math. Now tell me – in human and politically feasible terms – how do you put the health care genie back in the bottle and close the lid?

When I think of my coffee mates, I’m bemused and sympathetic when federal officials talk of heading off the impending health care cost apocalypse. They would impress me more if they offered concrete solutions – such as overt rationing or high deductibles --to decrease demand by dampening routine expectations of my coffee friends.

The talk of those who would tamp down exploding costs generally seems to be: we could only rein in those greedy doctors with their expensive technologies; all would be well, to wit:

“The bulk of the spending growth appears not to result from increasing disease prevalence but from the development and diffusion of new medical technologies and therapies ( Orszag, Peter, and Ellis, Philip, “The Challenge of Rising Health Costs – A View from the Congressional Budget Office, November 1, 2007, NEJM). With full knowledge of my limited sample size, I challenge the notion about disease prevalence, especially in an aging population.

My small group would disagree with the cost critics’ secondary argument: those U.S. citizens don’t show any health or quality gains from these technologies,

“There might be less concern about increasing costs if they yielded commensurate gains in health. Instead substantial evidence exists that more expensive care doesn’t always mean higher quality care.” (Nov.1, NEJM).

What do federal budget officials mean by “quality” – adherence to guidelines, meeting quality standards, or disease outcomes? Or are they referring to longevity, which is beyond the reach or control of most doctors most of the time, since longevity

Depends mostly on social and cultural factors outside physician offices
Or hospital wards --genetics, personal behavior, and social factors, such as violence or other forms of mayhem.

The underlying implication is that American doctors are foisting technologies on Americans who don’t need high tech care. Mention is rarely made that the current system promotes such care by having third parties pay for it, that Americans expect and even demand such care because it enhances their life style and keeps them functional well into old age, and that many, including doctors, citizens, and lawyers, consider it indefensible to deny such care to Americans who consider it their God-given entitlement right to have access to such care (as long as someone else is paying for it).

Furthermore, no American politician has the guts to say that either overt or covert rationing will be necessary to stem this access to high tech care to cut costs. Neither will they say that if citizens have to pay more out of pocket, demand will decrease.

Besides, who is to say what percent of GNP, now 16%, should be devoted to health care in an aging population who wants to remain as young and healthy and fuctioning as as long as they can.