(I hesitate to present this article because everything in it is so indisputable to those who work in health care that I might be accused of belaboring the obvious. With this in mind I ask for the indulgence of you, oh my regular readers, who may skip this article entirely as nothing new will be covered. I submit this article in the hope that random internet passers-by, people who have no idea how health care is delivered, will find something interesting in it and that it may give them a different perspective from their usual desire to pay as little as possible for a service that they think comes as easily as turning a tap provides water. I also want to give a hat-tip to the Happy Hospitalist for his excellent series of articles laying out some of the facts of life about health care and its cost.-PB)

Bread and Circuses

This is not a political blog and I like to avoid discussing politics as much as possible for not the least of which reasons that civil debate is impossible even with many who consider themselves well-informed and open-minded. You can, for example, have what you believe to be a reasonable conversation with what you take to be a rational person when something inside them snaps and they start foaming at the mouth about the CIA plot to topple the World Trade Towers, blame the Muslims, and allow President Bush to assume dictatorial powers. This sort of thing used to be confined to the lunatic fringe but now even otherwise respectable political candidates, sensing that kookery has become more prevalent, will cater to these kinds of impulses. This is not to say that we don’t have long history of colorful politics in our country but only that we have not advanced much in our political discourse in the last 231 years. The mob gets an idea in its head, placed there or at least reinforced by its political leaders, and the thing is obliged to run its course no matter how destructive or ridiculous.

The latest idee fixe of the mob is that Health Care is a right and sensing the political winds, even some of the Republican candidates in the impending presidential election, ostensibly from a party that traditionally serves as a check to some of the more destructive initiatives coming from the left, have embraced the notion. What the left means, of course, by declaring medical care to be a right is that someone else needs to provide it regardless of the effort required. The Holy Grail of the left, after all, is the quest to have someone else take care of all of their basic human needs leaving them free to work at some meaningless public service job from which they can never be fired and which shelters them from the productive sector. (College professors, who strive mightily for tenure and the shelter from the world that it provides, perfectly epitomize the desire of many to fall into the comforting bosom of the nanny state.) As it has never been hard to convince people that things should be free, in this particular lying season the race is on to see who can give away as much of other people’s time and effort as possible. Some political candidates will be more overt taking the more obvious socialistic route while others will be more circumspect, inventing ingenious formulas to prove that we can pay for all the health care everybody needs without spending every dollar of tax revenue doing it and without comprimising any of the other legitimate functions of government. We have but to fix the health care system and everything is going to fall into place.

The premise of the health care debate is wrong, however. The health care system in this country is not broken. It is a beautifully evolved creature, functioning perfectly, and exquisitely adpated to the political, legal, and economic environment in which it operates. In other words, every initiative to fix health care wil be useless, as ineffectual as rearranging the china while the bull still rampages, unless the underlying conditions that dictate the current system are addessed and there are very few political candidates with the political courage or even the understanding of the problem to do it.

Consider first the legal environment in which we operate. It has been correctly pointed out that awarded damages and even malpractice insurance costs account for a relatively small fraction of total health care expenses. This fact is used by plaintiff’s attorneys to justify their depredation on physicians and hospitals, tacitly admitting that while they may be somewhat overzealous as they chase ambulances, their activities amount to very minor parasitism and should be ignored. It cannot be denied, however, by anyone who has been less than a quarter of a mile from a real patient that a large portion of a physician’s work, and by extension the support staff’s and the hospital’s, is devoted to keeping the lawyers at bay. What is most paperwork, after all, but an attempt to cover oneself legally against every possible bad outcome, even those that are an inevitable result of either the patient’s own incredibly bad health or equally incredible irresponsibility. On the witness stand, unfortunately, every patient is a sympathetic figure who has been harmed by an incompetent doctor from whom not only absolute perfection but absloute omniscience is expected.

It is no wonder then that much of a physician’s time is spent wrestling increasingly detailed paperwork designed to automatically protect against legal jeopardy. Little of this time has anything to do with patient care and yet oppressive paperwork is so indispensable in modern medicine that it would be no exagerration to say that most of every physician’s time is spent typing at a computer or writing notes even though it is common knowledge that from a purely medical point of view, everything pertinent about most patients most of the time could be written in big letters on one side of an index card. Who is seeing patients, the real deluge of which is looming and has yet to hit the system as the baby-boomers discover that their coronary arteries are no different from their parent’s, when the doctor is trying to devise medicolegal documentation to dissuade the lawyers?

No one. They tell me that we have a physician shortage and yet the paperwork burden on physicians keeps increasing as even the very hospitals which should be lobbying against this kind of thing invent even more complex paperwork systems to ensure that if anyone should step out of line, the trail of plausible deniability is intact and somebody else, the physician who never completed his JHACO certification in hand washing for example, is the culpable party. It is this lack of trust, this hopeless desire to avoid legal risk, that adds an incredibly expensive burden on our health care system.

In addition to the paperwork requirements, the wasteful and futile effort to prevent the legal profession from finding chinks in our professional armor, the threat of litigation forces the physician to ignore good medical practices and common sense in how health care resources are spent. There is, it seems, no complaint too trivial or no presentation of a chronic condition that does not require a physician, if he wishes to avoid placing his career and property in jeopardy, to order every test and study under the sun on a fishing expedition to avoid the possiblilty of a missed diagnosis. Thus do many patients with vague abdominal pain and unimpressive physical exam findings receive a healthy volley of testing and imaging, the exact extent of which is often dependent on how often or if the physician has ever been sued for a missed diagnosis.

The point here is that some conditions will be missed. If you want to minimize this probability, already vanishingly small just using the traditional skills of history and physical exam, it is going to cost money, a lot of money, as we are well within the realm of diminshing marginal returns and playing the zero-defect game, while it may pick up the rare silent presentation of a deadly disease, results in a huge number of expensive, low probability studies which only confirm what we already know, namely that the patient is not sick. You cannot have it both ways, on one hand opining that health care is expensive but on the other insisting that expensive technology should always trump medical judgement. The current system is adpated to allow physicians to survive both the onslaugt of the legal profession and the often unreasonable expectaions of patients who are conditioned to expect a test or a study and won’t believe a doctor unless they see the labs.

Things Cost What They Cost

I had a patient several months ago, a very pleasant, otherwise healthy middle-aged gentleman who looked fit and had obviously spent his life taking care of his health. He stated that he was an avid runner and he looked the part, several orders of magnitude fitter than most of my patients that day who were half his age. His presenting complaint was a vague, intermittant sensation of chest pressure which had started several months before and which he had been ignoring until his equally fit, highly intelligent wife had finally ordered him to come to the Emergency Department. He was without symptoms at presentation with a completely normal EKG and, other than his age, had absolutely no risk factors for coronary artery disease. As he had a very good cardiac story, we began our standard cardiac workup (that we actually do even if the story is not so good), fully expecting that all of his laboratory studies would be negative and he would be admitted for a routine exercise stress test which would probably be negative after which he would be easily discharged with the usual boiler-plate discharge instruction for chest pain of an unknown origin.

Twenty minutes after I first saw him he developed a mild, constant nagging ache in his chest which was initially relieved by subligual nitroglycerine. A repeat EKG showed what are known as ST-segment depressions (indicators of ongoing ischemia) in the lateral leads. This was followed shortly by an unequivocally positive Troponin, one of the standard cardiac markers. Clearly there was something going on and our disposition plans changed accordingly to an immediate cardiology consult for an as yet urgent (but non-emergent, you understand) coronary artery catheterization. He was definitely “ruling in” as we say.

Shortly after our call to cardiology the patient develop more severe chest pain which could only briefly be managed with a nitroglycerin drip and morphine before it became excruciating, doubling the patient over with pain and nausea. Another EKG now showed pronounced ST-segment elevations, the harbinger of ongoing myocardial infarction, in the inferior leads. The patient was now having a massive heart attack, all in the space of less than an hour from a standing start of a normal EKG and no symptoms. He was taken to the cath lab for an immediate catheterization which showed an almost complete occlusion of his entire right coronary artery, not quite as bad as an occulsion of the Left Anterior Descending Artery (also known as the widow-maker) but bad enough and certainly a life-threatening or life-ending event all the same.

He walked out of the hospital two days later “feeling great” with plans to contnue his healthy lifestyle.

Fifty years ago this gentleman would have either died in the Emergency Department or shortly thereafter. At the very least he would have left the hospital after a several week stay so debilitated that a normal life would have been impossible and probably would have continued to have heart attacks and arrythmias until one or the other finally killed him, probably fairly soon. Although he may have had an extensive hospital stay, he would not have received forty thousand dollars worth of life-saving medical interventions and the health care system would be spared the inevitable expense of the complications that would have developed as my patient aged and, despite his healthy lifestyle, reached and passed his pre-programmed genetic obsolescence.

This is one patient. A guy who is doing everything he’s supposed to and yet I have no doubt that the cost of his health care will eventually run into the millions of dollars as greater and greater efforts are made to save his life. Now consider that most of my chronically sick patients are in no way making even the slightest effort to take care of their health and, where my otherwise healthy patient had an isolated cardiac event which should be relatively easy to manage, these patients each have several to a dozen deadly medical problems which are only prevented from killing them by the expenditure of vast sums of health care dollars. Fifty years ago they would not have survived the intial heart attack or the the failure of their kidneys. Their kindly country doctor would have arrived at the house with his well-worn doctor’s bag, examined the patient, looked appropriately grave and directed the family to call their priest and the funeral home. The total cost to the health care system would have been whatever the doctor charged for his visit and the patient’s family themselves would have paid the bill.

It is therefore senseless to complain about the cost of health care and long for the fairly recent days when providing medical care did not suck up a fifth of our gross domestic product. Times have changed. Medical care today is expensive because it is a sophisticated enterprise employing some of the highest-skilled and most intelligent people in our society. Fifty years ago, while doctors were equally intelligent and trained to be superlative diagnosticians, the treatment options for serious medical conditions were severely limited and the deteriorating course of a cancer patient, for example, was followed more for the intellectual exercise than for the ability to intervene. There was no Golden Age of medicine when doctors were more caring and provided effective and economical treatments. Doctors may have been more caring fifty years ago but thats’ all they had to offer. It was just play-acting which is not very expensive.

You then, who complain about the cost of medical care should look to yourselves and your own families. Keeping your aged grandmother alive is expensive. The majority of all health care expenditures for a typical pateint are incurred towards the end of their life. As their medical problems accumulate their care becomes a constant battle, waged with expensive specialists and procedures, to briefly stave off the inevitable and ends up costing the health care system thousands of dollars for every month added to the life of the elderly and multiply comorbid. Whether this is a good or a bad use of resources is the subject for another debate. But you can’t have it both ways, on one hand expecting that no expense will be spared squeezing the last dregs of life out of you and your family while at the same time acting shocked, yes shocked, that your health insurance premiums are so high. As the Happy Hospitalist notes, you can’t insure a burning house. The amount of money required to keep your aged gandmother alive at the twiglight of her life far exceeds any health insurance premiums, either to private insurance of Medicare, that she has paid in her life. The money has to come from somewhere. To demand that expenses be reduced is the same as asking that care be withdrawn from somebody else’s grandmother, something that sounds reasonable as long as it is done to somebody else.

Throwing Good Money After Bad

I see the same patient, it seems, several times a day: An octogenerian, severely demented nursing home resident who spends their day laying in their own feces and urine except when they are sent to the Emergency Department by the nervous staff for an exacerabation of one of their many comorbidities. The EMS report usually states that the patient, a person who has not stood upright or talked to anyone since the Clinton administration, has had an alteration in their mental status, a brief interval of decreased oxygen saturation in the setting of severe emphysema, or an irregular heart rate which did not resove under the automatic ministrations of their second Automated Implantable Cardioverter Defibrillator. They are usually found to be septic from one source or another and are often admitted to the ICU for a week or two of highly expensive critical care to stabilize them enough so they may be returned to their warehouse until the next time. This little drama is repeated many times until finally we reach the limit of our ability to cheat the reaper and the patient finally dies in the ICU, usually after one more round of expensive interventions demanded by the family who want no expense spared in the effort to squeeze out one more week of life for the patient..

For perspective, maintaining an ICU bed costs a hospital several thousand dollars per day which someone, somehow, has to pay. Medicare and insurance companies can low-ball doctors with impunity but as the cost of a physician’s services are a relatively small portion of the total cost of running the ICU, an enterprise that involves many highly trained nurses and the latest equipment, there is no way to realistically decrease the expense of taking care of a critical patient.

My European friends, some of them physicians, are amazed at the measures we take to keep patients alive who have absoutely no quality of life and no chance of recovery. The Europeans may have cradle-to-grave socialism but they have a fairly well-defined idea of when to let the patient go to their grave. In the United States it seems sometimes that we want to follow the patient into the mausoleum, trying to the very last to get one more day or even one more hour of life for the patient regardless of cost. This is a mindset that is built into our system, evolving as it has from the egalitarian and extremely misguided notion that the patient or their family should be an equal partner in medical decision making. I say misguided because putting the patient or their family in charge of health care without at the same time making them responsible for their decisions is a formula guaranteed to lead to excessive spending. It is easy to say, “We want everything done,” if someone else is footing the bill. If we but required families of terminally ill patients for whom all care is futile to pay even a fraction of the cost for their care there would be a mad scramble for the proverbial plug.

Whether it is good or bad that patient’s families have so much say in the decision to continue futile care is also the subject for another debate. But as long as there is no disincentive for the families and no ability for the physician to finally throw in the towel, our system is going to be ridiculously expensive at the terminal end and there is no way this will ever change until a political candidate has the guts to say, clearly, that to save money it may be necessary to put your granny down.

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