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Sharing the Responsibility

By Dr. Sachin D. Shah

It’s no secret that health care expenditures in the U.S., accounting for over 17% of our nation’s GDP, threaten our nation’s economic solvency.  What’s worse is that our major health outcomes are no better than other industrialized countries that spend much less on health care, and in many cases significantly worse. 

Under the protective banner of capitalism and the free market, our health system is riddled with inefficiency, redundancy, and gross overspending.  Different parts of the country practice medicine in wildly disparate ways and at shockingly different costs despite well known, evidence based standards of care.  Procedures are incentivized over prevention, and expensive, unproven new technologies and pharmaceuticals are touted to -- and therefore demanded by -- consumers as miracle cures, regardless of what the data show.  Protocols are often shunned in the name of preserving ‘the art of medicine,’ which in reality is too often a euphemism for unnecessarily subjective and haphazard approaches to well studied medical conditions.

There is a lot of data in medicine that prove or disprove the value of certain approaches to common diseases.  This data has been analyzed extensively and repeatedly and distilled into easy to follow guidelines.  How should we treat heart failure?  When should we stop screening for colon cancer?  What medications should we use for asthma?  There’s clear evidence for how to manage so many of medicine’s most common illnesses, but too often we don’t follow them.

We get cardiac stress tests every year on asymptomatic patients.  We order colonoscopies on hospice patients.  We treat the mildest forms of asthma with the most expensive inhalers.  But yet we also leave diabetics uncontrolled for years until they need dialysis for their kidney failure and an amputation for their foot gangrene.  We let high blood pressure silently damage our patients until they abruptly present to the Emergency Department with a stroke.

What we are hearing increasingly in this era of debt defaults and budget crises is that we must make across the board cuts to programs like Medicaid and Medicare.  But beware: willful ignorance is no path to economic bliss.  Thoughtless, categorical spending cuts are a blunt instrument that will only exacerbate the problem of rising health care costs. 

Just because we eliminate medical coverage for a segment of the population doesn’t mean their medical conditions simply disappear.  It may mean they don’t seek medical care for it now, but it also means they will present to our Emergency Departments and hospitals much sicker with far fewer options.  And then what we will end up offering is often both expensive and futile, an unacceptable and unsustainable combination in this or any era of medicine.

There’s a way to be cost effective in medicine while improving patient care as opposed to eliminating it.  This requires a population based, public health approach.  We as physicians need to follow our established, evidence based guidelines.  These are protocols based on optimizing the most important outcomes, such as maximizing survival rates after heart attacks, minimizing the risk of missing curable cancers, and avoiding costly hospitalizations and unnecessary complications. 

There will obviously be unusual cases that will require more extensive and expensive care, but these are the exception in medicine.  We shouldn’t work up and treat every patient as if they might be the exception.  Common things are common, and the exceptions have a way of declaring themselves to those who are paying attention.

Let’s be honest when it comes to rising health care costs.  Our patients aren’t over utilizing medical care.  Their physicians are.  We could do a significant amount to control costs by simply practicing more in accordance with evidence-based guidelines and working to reduce the variations in regional practice.  The costs saved could be used to expand coverage to include millions without access instead of worsening our problems further with indiscriminate cuts.

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