Where the Money Goes

American medical care is expensive and only getting more expensive. I blame the nurses. Think about it. Who is always at the hospital drawing their princely 25-to-40-dollar-an-hour salary? Who must provide continous coverage for the patients? Who are the most numerous employees of the hospital?

Nurses, that’s who.

Think about it. Doctors may make a lot of money but in most hospitals they are pretty thin on the ground. On the other hand you can’t swing a JCAHO-compliant dead cat without hitting four or five nurses. They’re everywhere. Thick as thieves, robbing the public blind with their salary demands. What gives them the right to make their ill-gotten five-figure salaries when the typical American struggles, yes struggles, to pay for all of those cool features on their cell phones?

It’s a scandal. Until we address nurse’s pay health care will continue to get more and more expensive.

And don’t even get me started on the respiratory therapists, pharmacists, and others who unfairly try to parlay their many years of education into the high wages thus forcing the sturdy peasantry to choose between their blood pressure medications and their personal watercraft.

Made of Money

On the subject of health care spending, it is fairly obvious to anybody who has spent any time in a hospital why our nation spends so much on health care. Just pick up a random chart from any nurse’s station and the chances are you could elucidate a medical history that reads like a pathology textbook. I used to be amazed that one person could have so many diseases and so many procedures. Now that I have grown used to Homo Polymorbidus I am more amazed at the rare patient who has no past medical history and takes no medications. Hell, even most kids are on something.

So it’s true that we spend a lot of money but keeping the typical ninety-year-old alive isn’t cheap and is only made possible by a stunning amount of medical care, the cumulative amount of which is probably in the millions of dollars. In one two-month stretch in the Emergency Department I saw the same nonagenarian three times for essentially the same complaint. The triage note said “Altered Mental Status” but it might just as well have said “The Nursing Home Panicked When the Patient Seemed a Little More Sluggish Than Usual.”

Folks, when you’re ninety you just start slowing down a tad, especially if you have been in a nursing home since the Reagan adminstration and sit at the pinnacle of the medical food chain as a top predator of medical services. That much medical care would wear anybody out. I am not advocating discarding the elderly. It’s just that somewhere in the feeding frenzy a point is passed where we need to step back and say, “What in the hell are we thinking?” We admitted the above-mentioned patient twice and as far as I know she has returned to her nursing home in the same mostly demented state that is her baseline and where she will lie, collecting bed sores, until the next time we save her life.

Now, one patient is not going to bankrupt the system. The infrastructure is in place after all, so what’s it going to hurt sending one frail little old lady up to the ICU? But that’s kind of the point. It’s the infrastructure that costs money, not the individual patient. Collectively, the ethos that requires us to keep everyone alive at all costs all the time requires that hospitals have a commensurate level of facilities and staff. It also requires an army of highly paid specialists to coax the last dregs of life out of the actively dying.

Is this a bad thing? I can’t say. When I was twenty I thought life was over at forty. Now that I have passed forty I can see that life is still worth living even if I can no longer run six-minute miles. Maybe despite being a doddering wreck at eighty I won’t be ready to shuffle unselfishly off of my mortal coil so as not inconvenience my children. But keeping me going will cost money. Everything that requires time and resources that belong to somebody else does. The expectation that it can be otherwise is ridiculous, as is the religious faith of the Single Payer zealots who believe that by adding an expensive layer of ineffectual free primary care somehow everything is going to be all right.

In no way is any socialized, quasi-socialized, or we-swear-it-aint-socialized scheme going to do a thing to lower the cost of medical care unless fundamental changes are made in the way we conduct health care business. As these fundamental changes mostly involve the rationing of care for people who expect limitless access, the voting public is never going to buy it unless they are tricked into it with promises of a shining all-you-can-eat medical buffet on a hill. This is a promise that cannot possibly be kept except by continuing to increase health care spending. After all, what politician has the guts to tell the people that they can’t have it all? To do so is counterproductive anyways, even for an honest politician of which there are many, because it is political suicide. No one is going to bell this cat.

What Are We Really Getting for Our Money, Anyways?

I’m not entirely convinced that a lot of what we do on a routine basis is really worth the money. Take a simple thing like Coumadin. Coumadin inhibits several of the factors in blood that makes it form clots. The lay people call it a blood thinner (although it doesn’t really make blood any thinner) and some even know that it was first used a rat poison.

Coumadin is widely prescribed for all manners of conditions, particularly for atrial fibrillation to prevent clots from forming in the dead spaces of the quivering left atria. Pieces can break off of these clots and travel to practically any organ in the body where they can abruptly shut off blood flow. In the brain this is called a stroke and is a particularly deadly complication of chronic atrial fibrillation.

And yet coumadin is not a benign drug and can cause complications every bit as bad a stroke. The interesting thing is that without coumadin, the risk of forming an atrial clot a stroke is about six percent per year. Just taking aspirin, a relatively safe drug that “thins” the blood by preventing platelets from clumping together, lowers your risk to three percent per year. Using coumadin lowers the risk to one percent per year. So you see that not only is the risk of clot formation stroke in atrial fibrillation fairly low to begin with but to achieve an almost insignificant reduction in risk we habitually pick a dangerous drug that is likely responsible for billions of dollars worth of side effects over a the safer drug.

That’s kind of the gestalt of American medicine. The drive to spend whatever it takes to extract the last bit of life out of everybody even though we are already well into the realm of diminshing marginal returns for a large portion of what we spend.

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