Outlook: We All Want Longer, Healthier Lives. But It's Going to Cost Us.
The 'Malthusian Spectre' and American Health Care
Monday, January 12, 2009; 1:00 PM
"Over the next few months, this country will engage in the first serious national discussion on health care in 15 years. Most of the talk will be about ways to make medical insurance available to all U.S. citizens. There will be a fair amount, too, about the need to make the hodgepodge 'system' of American health care safer, better and more efficient. What we're unlikely to hear, though, is something like this:
"Arresting the growth of health care spending in the United States is impossible. The policies and programs we're suggesting will either accelerate the upward trend or slow it temporarily, but they won't stop it. Health care costs will go up year by year until you die, and probably until your children die, too."
David Brown, a physician and Washington Post health and science reporter, was online Monday, January 12 to discuss his Outlook article on why it's so difficult to bring down health care spending in the United States.
A transcript follows.
David Brown: Dear Chatters
This is the Live Online about the piece in yesterday's Outlook section on the reason for the relentless rise in health care costs over the last half century. So let's get started.
Bloomington, Indiana: I think we can have an impact on costs if we get away from the medical model of treating illnesses that are preventable to begin with. Our current "system" is set up to profit from the treatment (not the prevention) of disease. It is the most expensive kind of "health" care. We need to adopt a different model for looking at health promotion and disease prevention. We have to get the profit out of the system. We have to look at this in a more of a community health perspective, get "upstream" on some of these conditions.
David Brown: There is a lot of interest in disease prevention as a means of saving money that would otherwise go for health care. Prevention is certainly important and I do not want to suggest for a minute that it isn't. But prevention, when implemented as a population-wide strategy, costs money, too. Getting people to eat less, eat differently, exercise more, sleep better, etc. takes substantial investment in public education, changing laws about food labeling and content, putting in place incentives for individuals to lead healthier lifestyles and employers to make healthful behaviors easier to do (such as by subsidizing health club memberships or putting gyms in work places, etc.). Even when all those things are done, the "yield" in terms of behavior change and improved health can be relatively modest and take a long time. The biggest such change in the last half century is the reduction in smoking. It has taken 45 years since the Surgeon General's report of 1964 to cut smoking in half or more. So prevention is possible, but it is not cheap or fast.
Ashton, Md.: I read your article with interest. I work on health policy and I'm not as pessimistic as you seem to be. You quote Drew Altman as saying, "Americans want the latest and best in health care technology, and we want it down the street, and we want it now."
He's right, but only because Americans believe that the latest, most expensive technology is always the best. It's not. Shannon Brownlee's book "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer" is accurate. A lot of high tech, high cost treatments don't provide better value or better health. In fact, a lot of treatments leave the patient worse off than no treatments at all.
With that in mind, isn't it possible to ratchet down costs by doing actual research on what works and what doesn't AND (it's important) getting the information out to Americans that sometimes doing little or nothing is better for them than spending a lot of money on something that will reduce their quality of life?
David Brown: There is certainly in American medicine a predilection for treatment over non-treatment and often for the latest and higher-tech treatment over lower tech, cheaper. "Dont's just stand there, do something!" is what I have always thought is the slogan of American medicine. These are cultural values. That said, it is certainly possible to change those values over time through education, consciousness-raising, etc., as Shannon Brownlee's book does so well. It is also true that there are lots of treatments whose benefits are marginal or at worth thinking twice about before doing, and this should be make clearer to patients. There are also many interventions whose relative benefit to other treatments, and to doing nothing, is not known or well-established. Doing such studies--cost-effectiveness studies and comparative-effectiveness studies--is very important. I suspect they will get a lot of attention over the next year as the Obama administration tries to address numerous health-care issues. But those studies are quite expensive to do and they take time.
Washington, D.C.: You quote many medical costs in your article, ie $7,600 per person.
I am looking at a statement for a routine visit to my doctor. He billed $2,101. My BC/BS allowed $377.14 (17.9%) The remainder is written off.
What is the real cost here? How does this relate to costs I read in news articles? Are the numbers I read all inflated 5.5 times? I'm confused...
David Brown: The per capita cost for health care in the United States quoted in the article are actual amounts paid out, not billed costs. As you point out, there is a big difference.
San Jose, Calif.: I believe part of the problem with rising health care costs is that most people don't know in advance what the medical procedures they undergo will cost. Wouldn't it help to publish prices for treatments, and calculate (or estimate) insurance coverage and out-of-pocket costs before procedures are performed? With HSA's, in theory patients have more control over their health care expenditures, and knowing costs in advance would help us make smarter, and hopefully less expensive, health-care decisions. Your thoughts?
David Brown: Well this is one of the ideas for how to make the consumption of medical care more like the consumption of other products in the economy. The problem is that in most cases the consumer is not paying the full cost of the intervention (but more likely a fixed deductible), although that is changing to some extent. I think patients also feel they are facing enough choices without having to add economic variables to the decision-making process, even if it is just for educational value. Of course, if people have a fixed life-time amount that will be paid for their health care, then that might change. Plus it is very difficult to put off an optimal treatment now because of the belief that the money will be more useful later.
Nutmeg State: Ray Kurzweil, noted technological economist, is predicting we will live very very long in the coming future due to improvements in healthcare, the possibility of living hundreds of years may be feasable.
I'm worried that the "quality of life" curve will not rise as quickly as the "length of life" we will spend our later years hooked up to machines with no decent quality of life.
David Brown: This of course is an extremely important subject, and one that I obviously didn't touch on (although the story about end-of-life care by the Minnesota physician that was twinned with mine in the newspaper did). The amount of money it takes to add a year of life to an old person tends on average to be more than is required to add a year of life to a younger person. On top of that at some point the quality of that time often becomes substantially less, and in some cases actually not worth the investment. In many cases, the two curves you speak of are definitely not parallel.
Silver Spring, Md.: D. Brown -- I thought the most interesting part of your article was your example about cholesterol-lowering drugs.
When you point out that the drugs cost approx. $228,000 (1,200 x 95 x 2) to save one life, that puts the risks and benefits of the drug into a stark perspective.
What is the political path to assigning dollars to benefits and then sticking to the standards?
David Brown: At the moment there is no political path in this country for that. In England there is a committee whose acronym is NICE (I believe it is National Institute for Cost-Effectiveness) that review therapies and ultimately decides that some of them are not worth doing because the clinical benefit doesn't justify the expense. I believe at least one biological therapy for cancer that is in use here is not used in England (or with substantial limitations) because the clinical benefit is often measured in months of extra life, and the expense may be $20,000-$40,000.
Colorado: Hi Mr. Brown,
Why does innovation in health care cost so much? I wonder if there isn't a bit of slop in the system. For instance, a doctor gets paid higher than others with similar education, doctors have way higher insurance than most, med schools do a lot of research with soft money positions rather than hard money folks like in many other sciences, drug companies seem to devote most of their resources to marketing, companies that make medical equipment seem to be making pretty good profits. Am I wrong?
David Brown: Whether there is "slop" in the system depends, I suppose, on whether one thinks capitalism and entrepreneurialism is a self-purifying system that tends always toward optimizing efficiency. Certainly the huge profits of drug companies over the last century have been a major engine for innovation. The great investment by the taxpayer in medical education, and in medical research funded through entities such as the National Institutes of Health, has fuel that engine probably even more. Could this machine be run more efficiently? I don't know, but I suspect there are a lot of people who say that if you start trying to manage more directly there could be problems. I don't know enough economics to comment on this with any competence.
Medical Education: Doctors need to be educated to concern themselves with the fact that treatment costs money, and to consider those costs in their practice. One young doctor looked at me like I was from another planet when I declined a routine test, on the grounds that in my case it was unnecessary and it would cost my self-insuring employer money.
David Brown: I believe young doctors are being taught to think of costs, or at least be aware that there are trade-offs that will ultimately be made on the national or population-wide level, as a result of clinical decisions. But it is very tricky and problematical to bring a lot of economic thinking to the interaction with individual patients, unless (for example) the person has to pay for their own prescriptions and the choice is between an expensive drug and a cheap alternative. Indeed, there are situations where a doctor knows that the patient is going to get a huge bill for a procedure he or she can't pay for and the procedure is ordered anyway because the doctor knows it may greatly benefit the patient (could even save a life) and society will eventually absorb the cost of it one way or another.
Buffalo, New York: It seems to me that the contingencies of reinforcement are all wrong. Right now we have an illness care industry and not a health care industry. Doctors only get paid when people are sick. Where is the incentive to help people become healthier (for example, via lifestyle improvements) and thus need less health care?
David Brown: There has been a fair amount of effort to turn attention to disease prevention, both at the public health department level and at the level of the clinical encounter (such as at many HMOs). This is of course all to the good. But the question still is, when a person shows up with the disease, what do you do? And then the ultimate effect of prevention on a person's lifetime health-care expenses is uncertain. Studies have shown that the state of a person's health when he or she enters the Medicare system at 65 (or thereabouts) does not predict the amount of medical costs that person will incur over the rest of their lifetimes. People who enter Medicare in very good health often live a very long time, and incur medical expenses that are cumulatively equal to that of people who enter Medicare with lots of illness.
Chesterfield, Va.: Everyone please note this chat is being led by a Medical Doctor, so he won't post comments critical of his profession. This is a very one-sided PR session for the Medical Lobby.
David Brown: I do happen to be a physician, and physicians do certainly bear some responsibility for the amount of money we (our society and economy) spend on medical care. But the main drivers, as I tried to say in the article, are our desires and the amazing capability to address those desires that we now have.
Washington, D.C.: Your article seems to discount the possibility of rationing of care (I know rationing is a pejorative, but I view it is as an eventual reality). If the U.S. moves to government-guaranteed universal coverage, do you expect consumption patterns to remain the same? Also, the U.S. currently underwrites a significant share (perhaps of majority) of medical (especially drug) R and D, if payments to drug companies and providers are curtailed won't this slow technological advancement and thus lower the upward trajectory in costs?
David Brown: It is interesting that the word "rationing" has not come up earlier in this discussion. It is perhaps a good idea, then, that we end with the word. I think most people who have studied the problem of rising health care costs realize that there must eventually be some sort of rationing, perhaps not under that name. But some way of saying "We will do this, but we won't do that even though it's possible to do that." How we get to the point where we can do that with something of national consensus and a belief that we haven't violated the core American value of fairness---that is the question.
Thank you all for listening in and for the great questions. I am sorry I have had to leave so many unanswered. I enjoyed it.
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