SKYROCKETING costs of medical care are worrying everybody, and how to control them is currently the subject of heated debates in many circles. This is as it should be. There are too many things we need to do to improve our society to let medical care gobble up more dollars than absolutely necessary.
But as is often the case when humans are worried about something which affects them quite personally, they tend to seek out vilains. Thus, many of the debates about cost containment are an emotional search for that villian -- and there are many candidates for title. For some, it is an intrusive government with its inflationary Medicare and Medicaid programs. For others, it is all those ill-managed, expensive hospitals. Some point to avaricious doctors or the pharmaceutical industry. Blue Cross and Blue Shield, which appear to encourage overuse of high-priced services, also get votes. So it would seem that we have more than enough potential culprits around to satisfy everybody.
Yet in recent discussions on this subject which I have attended, still another villain has been added. He is called the "consumer" or "user" -- current euphemisms for those who used to be called "patients." Perhaps this is appropriate -- it gets everybody into the act. But blaming patients for medical care costs has the hazard of letting those of us who are the "providers" off the hook, and the two main premises on which their inclusion is based deserve examination.
THE FIRST derives from some statements made by Enoch Powell, former health minister of Great Britain, during a period of frustration about the cost overruns of the British National Health Service. He made several observations which have been boiled down to the catchy statement: "Demands for health care are infinite and will always exceed the resources made available for it." This has become an accepted truism, gravely stated at most of the meetings on medical costs which I attend.
But unless I am peculiarly obtuse or my own experiences as a physician quite atypical, I don't find this to be the case. Most people seem to use medical care quite sparingly. I have personally found almost no one who views going to the doctor with anything like enthusiasm. Most people do not enjoy having to confess their sins like too much smoking or drinking and the like. I have never encountered people who have told me that they liked having their chests thumped or their bellies proded or their private orifices explored. Similarly, I have found almost no one who enjoyed undergoing surgery or even taking pills. To be sure, all physicians encounter occasional patients who overuse or misuse their services, but I think such people are really quite rare.
The experience of most prepaid medical care programs would also seem to bear me out. There is an initial expansion in people's desire to see the doctor when their visits do not result in additional out-of-pocket costs, but the number of visits does plateau at levels which seem acceptable.
One other striking trend of the last decade would also seem to refute Powell's dictum. Hospital occupancy rates in the United States have fallen steadily since the 1950s. Here is a "resource" which now significantly exceeds "demands," and we are struggling to get rid of excess hospital beds because people aren't filling them.
THE SECOND premise runs that if we could only educate our fellow man to use the medical care system appropriately, and call upon it simply to do what it knows how to do and not clutter it with trivial complaints, our problems of cost would be sharply reduced.
Again, I think the premise as stated is a fallacy. People go to doctors because they are frightened, or in pain, or both. Health education does little to eliminate those sensations from the human breast. Indeed, much health education helps people to recognize certain signals which should get them to the doctor. One of my colleagues has recently pointed out that "doctors are in the worry business," and I like that statement. We are, and we should be. But for each worry brought to the doctor that turns out to be a significant illness, there are many, thank goodness, that are not. Thus the majority of transactions between patients and doctors are sometimes dismissed as "simple reassurance."
But consider for a moment how precious and important this is and how difficult and expensive it may be to deliver this reassurance. To be able to tell the hard-driving 45-year-old executive that the pain in his chest experienced during a touchy negotiating session was not a heart attack is not a trivial interaction. It may require a whole battery of sophisticated electronic and biochemical studies to make that pronouncement. That the lump is not cancerous, that the headache's not a brain tumor, that a child's clumsiness is not cerebral palsy are all pretty important kinds of medical care even though the relief resulting from this information does not show up on anyone's scorecard. It takes time, scientific expertise, sophisticated technology and money to do this job, but that is what much of good medicine is all about.
Clearly, as a society we must develop sensible ways of controlling the escalating costs of medical care.We need to be more sparing in the use of some of our very expensive medical technologies. We need to develop better cooperative arrangements to avoid paying for too many CAT scanners or cobalt units or open heart surgeries. We need to eliminate unnecessary beds from our hospitals and try to make them as efficient as possible. We need to recast health insurance to encourage more out-of-hospital care, and we need to pay more attention to what medicine might be able to do to prevent more expensive medical care problems. And we must not only do this, but also pull into the system those citizens who continue to get less medical care than they need.
But at the same time, we should realize that many of our cost problems are a result of hard work to develop better services and trying to deliver them to a population which is growing both larger and older. We should recognize that public programs have given over 24 million more people financial access to those services, and that this has moved us clser to the more humane society we all strive for. We should be proud of these accomplishments.
So let's continue to work on the cost problem, but with less finger pointing. Patients have enough problems without being put down for being patients or for seeking medical care. I believe we can design an equitable system of care at costs that we can agree we can afford. We don't need scapegoats -- we need solutions. We have the capacity to develop those solutions if we can stop blaming patients for behaving like patients and get on with it.