Tuesday, June 11, 2013

Do All of Us Really Have to Change?

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.