Annals of Medicine: The Cost Conundrum

[Beet]

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns

...

“Come on,” the general surgeon finally said. “We all know these arguments are bullsh**t. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”

Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.

The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.

Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.

I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?

Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.

And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization."

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

[Ban my account ffs!]

Sooo... the key to lowering the cost of medical care is to... ration it? hmmm...

In the end, the main question in health insurance will be this:

Who do you want to ration your care?  Your insurance company or the government?

[pbrower2a]

Sooo... the key to lowering the cost of medical care is to... ration it? hmmm...

In the end, the main question in health insurance will be this:

Who do you want to ration your care?  Your insurance company or the government?

We may have gone far past the point of diminishing returns for health-care spending. We give a blank check to Big Pharma on the ground that it needs the money for research (never mind that the government and the universities do the medical research) -- and Big Pharma does research, all right -- in marketing.

Much of our health care problem is of course  the usual effect of a plutocratic society: the poor get $crewed badly. If one doesn't work for a large corporation one gets bad health insurance or must pay exorbitant rates for it, and if one works for a giant corporation one is treated like livestock at best these days. (Note well that the solution to our economic mess might be lesser reliance on Big Business as employers, and a single-payer system would solve that).

Bad habits -- alcoholism, drug use, sedentary lives, and above all obesity -- play their roles. We probably do better than the rest of the world with cancerweed (tobacco) use... but we have a drug epidemic (meth today). Americans eat like ranch hands, farm laborers, stevedores, commercial fishermen, and lumberjacks -- even if they are office workers. Obesity has begun to reduce life expectancy in America -- and it is a physician's nightmare if the physician isn't a greedy SOB above all else. It's easy to blame fast food, but we need to remember that doubling or super-sizing an order of a sugary soft drink (or milkshake), a hamburger, and fries as a habit is a good preparation for a bad time at the coronary unit in one's fifties -- as a patient.         

[Beet]

Rationing? No. Rationing is a radical wartime strategy and it wouldn't be practical to estimate anyone's rations for health care needs. My personal takeaways from this article were (1) doctors' incentives need to be changed so that there is no benefit for them to overutilize, and (2) the root cause of the health care crisis is the same as the root cause of the housing crisis, the consumer spending crisis, the dervivatives crisis, and the emerging government spending crisis: greed, selfishness, shortsightedness, irresponsibility, and at a deeper level the idea that you can get something for nothing.