Rearranging Deck Chairs on the Titanic

It's a tired cliche for focusing on marginal details in the face of a major catastrophe, but it is oh-so applicable to the Obama Administration's "Health Care Reform" media event yesterday.

To summarize from the most recent blog posting:
1) US health care is extremely expensive - we spend about twice per capita what other developed countries spend
2) US health care is a relatively poor value - we aren't getting results commensurate with what we're spending
3) The combination of rising health care costs and the retirement of 78 million baby boomers will burden the US economy with crippling levels of debt. Health care costs are the most imminent threat to our future prosperity as a nation.

I will at least give credit to the Obama administration for recognizing that controlling health care costs should be a top priority. What came out of the vaunted meeting between health care industry leaders and administration officials, however, could only very optimistically be characterized as a drop in the bucket. The product of this high-level meeting was a pledge to reduce - not the actual cost of health care - but the rate of growth of health care costs - by a barely-detectable 1.5% over the next 10 years.

Obama is often compared to JFK these days. If JFK had the kind of audacity represented by this meeting, he would have set NASA the goal of sending a man up a flight of stairs, and returning him safely to Earth, before the end of the decade.

And how did the health industry leaders say they were going to achieve these underwhelming results? By coordinating care, reducing administrative costs, and focusing on effeciency, quality, and standardization; that's how!

Obviously, this [sacrasm] stunningly bold approach [/sacrasm] isn't going to get us anywhere near the savings we need to preserve the fiscal viability of our nation. Real solutions and meaningful cost control are going to involve real changes, not just re-arranging the deck chairs on a sinking ship. Based on my 13 years of experience in the health care system, here are some of my suggestions for where we're wasting real money, and where real money might be saved.

Inapporpriate Use of Emergency Services

The cost of health care changes depending on where it is delivered. A pregnant woman with a yeast infection can be treated for about $90 in an outpatient clinic. If she goes to a hospital ER or OB triage unit, that same yeast infection could easily cost $2500. People who favor universal health care like to pretend that their plans will drastically reduce such inappropriate use of emergency services. The only reason Ms Smith takes her yeast infection to the ER, they say, is because she has no insurance and therefore can't go to the clinic. If she has insurance, she'll go to the clinic and save the nation $2410.

It's a nice thought, but it totally contradicts my experience working in an OB triage unit. In Indiana we have Medicaid coverage for every pregnant woman and an extensive network of Medicaid clinics in the underserved neighborhoods of Indianapolis. And yet, I still see pregnant women - who have Medicaid coverage for their pregnancies and who are registered in clinics - come in to my OB triage unit with yeast infections every day. Obviously, this is not an issue of access to care.

What does motivate people to go to the clinic instead of the hospital? I'll tell you what motivates our family: multi-tiered copays. If we go to the ER, our copay is $120. If we go to the doctor's office, it's $20. Even more of a motivator: if we go to the ER for a trivial reason, our insurance may not cover it. I'll bet it wouldn't take too many times paying the full $2500 for a yeast infection to learn that lesson in health care economics.

Private insurance has applied similar incentives to encourage patients to choose generic medications instead of expensive new meds still under patent, to see their primary provider first instead of going to a brain surgeon every time they get a headache, and to discourage demanding a CT scan every time someone bumps his head getting out of the car.

Problem is, these motivators haven't been applied to the lower end of the income scale. The pregnant women who come to our OB triage unit don't have to pay any copays at all, and there's no chance of them getting stuck with the bill no matter what happens. They never even see the bill. When we can figure out how to apply cost based incentives to recipients of publicly funded health care (ie, Medicare and Medicaid), we stand to save some real money.

Inability to Cope Appropriately with Death

They say death and taxes are the only things in life that are certain, but we spend ridiculous amounts of money trying to pretend it's only taxes that are inevitable. Terminally ill patients routinely spend their last days in intensive care, where literally tens or hundreds of thousands of dollars are spent to delay death another few days. Right now, the decision to discontinue aggressive death-delaying care rests mostly with the patient's family. Essentially, we keep the patient alive until the family can come to terms with the fact that their loved one is going to die. Then we let him or her die.

Losing a loved one sucks, but losing a loved one on Friday isn't half a million dollars better than losing than losing him or her on Tuesday. This kind of end-of-life care will be completely unsustainable when multiplied by the 78 million baby boomers.

We're treating the wrong patient here: the real patients are the family and the correct diagnosis is anticipatory grief. Instead of spending ten or twenty thousand dollars a day on intensive care, how about bringing in a bereavement counselor?

Unrealistic Appraisal of Risks and the Expectation of Perfection

Imagine there's a story in the news today about a woman from Australia who was killed when a meteorite fell from the sky and hit her on the head. Now imagine that President Obama wants every American to go out and buy a $10,000 helmet to be worn on their heads at all times, as a way of addressing the Death by Meteorite problem.

Believe it or not, this is what we do in health care every day.

Whenever there is a maloccurrence somewhere in the health care world, we resolve to Do Whatever it Takes to Ensure This Never Happens Again. Even when the original event is a freak occurrence that's extremely unlikely to happen again anyway, we institute new routines and procedures to make sure It Never Happens Again. In fact, hospitals employ people whose job is entirely concerned with Never Happens Again issues. There's also a hospital accreditation agency that periodically inspects hospitals to ensure compliance with these routines and procedures, and suggest new and improved ones.

Some of these routines and procedures make sense. One good example is the "Pre-Operative Time Out." This started out as a simple verbal routine between the physician and the nurse, prior to beginning a procedure, to make sure everyone's on the same page about what procedure is being done to what body part of what patient. Makes sense so far, but with all these accreditation agencies and Never Happens Again busybodies running around, it never stops at the Makes Sense So Far point. If a simple verbal procedure is a good idea, then a three page form that has to be countersigned seven times by both the nurse and the physician is even better! If it makes sense to complete a three-page Time Out form before a major surgery, surely it also makes sense to do one every time we place an IV line or break a water bag, right? These Never Happens Again procedures keep growing, adding expense and complexity to everything we do. Never Happens Again has become so complex, in fact, that most health care organizations have entire staffs of "compliance officers" whose full time job it is to prepare for the next accreditation visit.

None of this is done with any sense of proportion, or balancing the expense and complexity of the new procedure versus the likelihood of the bad outcome we're supposedly trying to prevent.

Another great example is performing c-sections on large babies to prevent fetal injuries from stuck shoulders. Stuck shoulders is a complication that affects about 1/3000 deliveries. A small proportion of those cause injury to the baby, and a small proportion of those injuries result in lasting disability. So we're talking about a small proportion of a small proportion of a rare occurrence. Still, many obstetricians recommend cesearean delivery any time a large baby is suspected. The American College of OB-GYN recommends against this, noting that a policy of cesearean delivery for large babies would result in nearly 4,000 cesareans for every one baby saved from injury. Most private OBs ignore this recommendation, because in our health care culture, performing 3,999 unnecessary ceseareans for every one necessary one is a perfectly acceptable ratio.

A Common Thread

You'll notice a common thread running through all of these problems: they all relate to the separation of users from costs.

In every other service we buy, we make rational decisions about value versus cost. Nobody pays a mechanic $10,000 to make a car with a blown engine go around the block one more time. Given the choice between a quite-safe Honda and a slightly-safer Volvo for twice the price, I chose the Honda. Knowing groceries cost more at the all-night convenience store, I try to wait until daylight so I can shop at Costco. If my plumber said "let's go ahead and run a fudgippity test on your drains," I want to know what a fudgippity test is, how much it costs, and what the consequences are of not doing it.

When we purchase health care services, however, we don't ask any of these questions or make any of these evaluations of cost vs. value. One of the reasons we don't is that the costs are essentially invisible to us. A key component of health care reform, particularly if cost control is desired, is to make the patient feel the cost of his or her care. Higher costs have to have some effect on us if we're going to change our behavior to choose lower cost alternatives.

Back to the meeting between Obama and the health industry leaders, then. Why didn't they propose anything along these lines? From Obama's perspective, exposing patients to any kind of negative consequences for costly behavior is going to be very unpopular. Politicians don't like to propose things that won't be popular. And the last thing those health care industry leaders want is a bunch of cost-conscious consumers.