As someone who professionally closely tracks the debate over
the transformation of the American health care clinical delivery system, I did
not learn much new from the June 2nd New York Times article titled
“The 2.7 Trillion Medical Bill.” I
did find the article’s approach useful in explaining how the wide variations in
price for procedures contribute to the unnecessary high cost of American health
care. (http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?pagewanted=all)
Although the article did document many procedures are more
expensive in the United States than in the rest of the world, it concentrated
on how colonoscopies average $1,185 in America and $655 in Switzerland. They could have just as easily focused
on MRIs where the American average cost is $1,121 vs. the Dutch average cost of
$319 or hip replacement surgery where it costs on average $40,363 in the United
States vs. $7,731 in Spain.
I did make several power point slides from the article for
future presentations, but then I did not think much about the impact of the
article until days later when I read the letters to the editor. The article and the response to
it provide fascinating and powerful insights into the whole health care debate.
In typical guild based medicine fashion, there are letters
from the leaders of the American Society of Anesthesiologists, the American
College of Radiology, and the American College of Gastroenterology. John M. Zerwas, the President of the
American Society of Anesthesiologists, offers no evidence-based medical reason
for his carefully worded concluding sentence: “Whether a procedure takes place in an office, a surgical
center or a hospital, we believe that sedation is best delivered with physician
anesthesiologists involved.” Dr.
Zerwas does not answer the challenge of experts who in the article question the
need for physician anesthesiologists to monitor office-based sedatives that are
safely administered by a wide range of doctors and nurses in other
countries. Dr. Zerwas does not
explain why less expensive nurse anesthetists could not be used. Dr. Zerwas does not explain why the
charges for the sedation are so much more expensive than the charges for the
physician performing the colonoscopy.
Dr. Zerwas does not explain that one reason for his society’s rigid
stand is that it makes money for his members. (http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html)
Judy Yee, the chairwoman of the Colorectal Cancer Committee
of the American College of Radiology, is quick to point out in her letter to
the editor that “Medicare coverage of virtual colonoscopy would make this less
expensive test more widely available, attract many more people to be screened
and ultimately save lives.” She
does not, of course, point out that this method has the downsides of missing
some small lesions and exposing the patient to radiation. She also does not comment on the
financial gains that would be made by her society’s members if virtual colonoscopy
replaced standard colonoscopy. (http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html)
Ronald J. Vender, President of the American College of
Gastroenterology, “is disappointed that [the article] unfairly casts outsized
blame for high medical costs on colonoscopy and by extension on
gastroenterologists.” In the last
sentence of his letter he does provide a nod to shared decision making which
could lower costs and improve care: “It is correct that there are screening
strategies other than colonoscopy and likewise there are varied patient
preferences, so while colonoscopy is our preferred screening strategy, we agree
that the best test is one that actually gets taken.” Dr. Vender does not explain that some of the other screening
strategies are less expensive and that his members make a lot of money doing
colonoscopies. (http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all)
Sara Hartley in her letter advocates for “Medicare for all,
a national health insurance that eliminates needless profiteering and stealth
subsidies” and addresses “another major reason for price inflation: cost shifting from the uninsured and
inadequately covered.” I think she
means cost shifting from the insured to the uninsured, but cost shifting
certainly does occur and it makes the whole issue hard to understand and
control. ( http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all)
Dr. Kenneth Prager, a New Jersey surgeon, does write about
financial incentives in his letter to the editor in response to the original
article:
“I suspect that if physicians were
salaried there would be a substantial decrease in the number of medical
procedures performed, including colonoscopies. Money has an insidious way of
biasing medical judgment. When
physicians profit from every procedure, it is too easy for some to justify it
as in the patient’s best interest even when sound clinical judgment argues the
contrary.”( http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all)
I imagine if Dr. Prager bumped into Dr. Scott Ingber, Chief
Medical Officer at Mount Sinai North Shore Medical Group, at a conference or
cocktail party a lively debate might ensue. Dr. Ingber, with presumably a straight face, states in his
letter that “portraying doctors as overly concerned with financial advancement
plants seeds of skepticism in patients when a successful physician-patient
relationship rests upon unwavering trust.” One can just hear Dr. Prager quoting Reagan “to trust, but
verify.” It does not take too much
imagination to conjure up that Dr. Prager will refer Dr. Ingber to the
ProPublica website that exposes pharmaceutical payments to physicians (http://www.propublica.org/series/dollars-for-docs)
or to articles about medical device companies paying orthopaedic surgeons to
use their implants even if the patient is unaware of the cozy financial
relationship. (http://www.drugwatch.com/2012/01/18/orthopedic-surgeons-and-medical-device-companies-cosey-bed-fellows/) If Claire Burson of New Milford
Conneticiut happened to overhear the discussion, she might interrupt to point
out the quote from the patient in the article who says, “If a doctor says you
need it, you don’t ask.” Ms. Burson contends that:
“Attitudes like that need to
change. Of course you ask. You ask
why. You ask if there are other
options. You ask how the results
will affect your treatment. And
you should be able to ask what it will cost.” (http://www.nytimes.com/2013/06/04/opinion/why-health-care-costs-are-so-high.html?pagewanted=all)
You knew someone from an insurance company would write in to
defend that industry, and Sam Ho, Chief Medical Officer of UnitedHealthcare
does not disappoint us. He writes:
“Several health care organizations,
including UnitedHealthcare, have introduced online and mobile tools that put
relevant medical price information at people’s fingertips, enabling them to
comparison shop for health care as they would with other consumer products and services.”
((http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html)
Dr. Ho does not explain that health care is not like other
consumer products. I want to buy
an iPhone; I don’t want to see a doctor or go to the hospital. And it is hardly true that we have the
tools to comparison shop for medical care. Didn’t Dr. Ho read about the summer project by Jaime
Rosenthal? The Washington University student documented that only 10 percent of hospitals could quote a
complete price for hip replacement and the ones that did ranged in price from
$11,000 to $125,000? (http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/12/how-much-does-hip-surgery-cost-somewhere-between-10000-and-125000/)
Perhaps the last word should go to Lane Rosenthal of
Minneapolis:
“As your thoughtful case study
reported, we are all collectively at fault – from providers, hospitals,
pharmaceutical companies, device makers and insurers, to every one of us who
demands state-of-the-art technology for everything from a hangnail to a
headache, wants antibiotics for a cold, or threatens litigation. I don’t have the answer for how to
untangle the hydra-headed health care mess, but I do know it won’t be solved
until across the board we all stop finger-pointing and accept responsibility.” (http://www.nytimes.com/2013/06/07/opinion/the-continuing-debate-over-health-costs.html)
Alas, I guess we all have to change and accept
accountability. And humans are
good at neither change nor accountability.
