Back in 2008, while the Obama administration was first evaluating healthcare reform, Peter Orszag, then the director of the Congressional Budget Office, estimated that 5% of the nation’s gross domestic product, or $700 billion per year, goes to medical tests and procedures that have no proven positive impact on outcomes.
Unaccounted for in this estimate are the billions more spent managing the often lifelong complications inherited from inappropriate tests and unproven procedures. MRIs that identify pseudo-lesions later biopsied or removed leading to surgical complications and turning previously healthy patients into diseased patients. Cardiac catheterizations with their subsequent stents and anticoagulants and myriad of complications all with unproven benefit over medical management and risk factor modification.
Much too could be said of medication overuse and abuse. Overuse of pain medications costs untold billions of dollars in lost productivity, not to mention the societal and psychological costs. Antibiotic overuse, while perhaps not directly responsible for a large share of the annual monetary waste, has certainly created a cesspool of multidrug-resistant bugs, and the downstream disasters, like MRSA and C. diff, contribute to billions more in health-related costs.
Most healthcare reform proposals addressing the overuse of high-cost tests and procedures have targeted the built-in incentive of fee-for-service payment systems as a key driver of unnecessary utilization. The more you do, the more you make. Reformers have suggested a “prospective payment” system that turns fee-for-service on its head and creates incentives to provide less care instead of more.
So where’s the rub? Well, prospective payment encourages cherry-picking of healthy patients and financial incentives to “underuse” what now could be necessary tests or procedures on a case by case basis. So health reform has taken a sick system of incentives to provide inappropriate care and proposed to replaced it with a sick system of disincentives … brilliant!
Unrealistic Patient Expectations
What all efforts at reform have failed to address to date is this: American society, and therefore healthcare recipients, has perhaps the most unrealistic expectations of the medical community of any country in the world. The perception is that active intervention and testing are almost universally better than medical wisdom, and therefore we have come to expect these active responses without regard to cost, risk, or benefit. It is this very expectation, I believe, that has given this country the notorious position of having the highest healthcare costs per capita alongside one of the worst outcomes-based ROI’s in the world.
Societal expectations represent the demand curve in healthcare economics 101. They drive payers, hospitals, and physicians to meet their demands or suffer the consequences. If you bite the hand that feeds you, even when it is deserved, you will lose. While healthcare reform is essentially driven by socialist goals of supporting the well-being of all through individual sacrifices, healthcare economics is still driven by free-market principles. Sorry, America, but you can’t have it both ways.
Two Options Moving Forward
We have only two choices: Embrace socialized medicine and let Big Brother decide who gets what, or embrace a new societal contract that empowers and pays physicians to choose the best course of care for their patients, free of the risk of lawsuits and free of the lopsided payment system that rewards utilization. If we want to cover all reasonable healthcare costs, for all reasonable healthcare needs, for all the people of this nation, then we must adequately incentivize and compensate physicians who agree to commit to the principles of proper utilization. We can then embark on a physician-led mission to re-educate the country one patient at a time and shift societal expectations to a more sustainable level.
Lee A. Resnick, MD
JUCM, The Journal of Urgent Care Medicine