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Do you want Quality or Quantity?

By Dr. Chris Lillis
. 1 Comment(s)

I know what I want.  I want quality.  If that means paying a little bit more, then so be it.  If I am going to buy a flat screen TV, I will choose the more expensive model with the warranty plan so that I will enjoy a better picture, hopefully for a longer period of time. 

This is not how healthcare works.  More is not better. Expensive does not automatically equal a longer life.  In fact, The United States spends more money on healthcare than any other nation in the world.    Yet, among industrialized nations, we rank nowhere near the apex of clinical performance.  We trail other nations in preventing disease, infant mortality, and life expectancy.

While the cost of each episode of care in the United States is high, it is not the primary driver of skyrocketing system costs.  There are some variations in how much an EKG costs, or how much a night in the hospital costs…but the real differences that exist are in utilization.

The irreplaceable Dr. Atul Gawande wrote this piece in June 2009 to help explain.   Did you know that the average Medicare expenditure per person in McAllen, Texas is close to $15,000 a year, while the same Medicare patient costs about $7,000 a year in Rochester, Minnesota – the home of the Mayo Clinic?  What is the difference? Profit motive – doctors and hospitals are paid by a fee-for-service model. The more service, the more fees.  Most people don’t realize a great deal of grey area exists in clinical medicine, and not all tests, procedures or pills are “necessary” to treat a given condition.

Dr. Gawande uses this example to illustrate:

“Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.”

Discussing issues like this has caused some to accuse policy makers of enforcing rationing – especially when someone like me suggests we use evidenced based medicine to decide what procedures we should inflict on patients and which ones we avoid.  But the example Gawande chose can be argued away – the surgeon deemed the procedure necessary in his/her judgment.  Sometimes, the profit motive along with the cloak of clinical judgment provides more egregious examples to point to.

A Maryland Cardiologist is currently in a pitched legal battle.  He has been accused of placing coronary artery stents in as many as 600 Medicare patients who DID NOT NEED THEM.  He did, however, take home $1.3 Million in compensation in 2009, so affording his legal bills shouldn’t be too difficult.

I do not wish to point the finger exclusively at doctors, however.  As a private practice primary care physician, I have faced the worried patient who demands an MRI for their back pain or headache, when I am confident it is not needed.  Sometimes, despite my best efforts, I am left with the choice to either order the useless $1000 MRI or lose a patient. 

But the worried well cost far less than the truly ill among us.  In our great nation, the 5 percent of people with the highest health expenses spent 49% of the overall US health care dollar.  End of life care is inordinately expensive.  Can we discuss the need for better primary care to help avoid expensive and potentially useless procedures without being accused of favoring rationing?  Can we begin a dialog about facilitating the inevitable process of dying with comfort and dignity without staying in the intensive care unit while still avoiding the hyperbolic allegation of setting up “Death Panels?”   Can we begin to reallocate our ever more scarce resources towards universal coverage to provide preventive services and proper health education/counseling to begin to bend the cost curve? 

For a truly eye opening experience, try reading “Worried Sick” and you will learn what Dr. Nortin Hadler, thinks about our bloated health care system.  Dr. Hadler seems unafraid of being accused of promoting rationing. 

Physicians can take the lead on these issues. We don’t need to “Supersize” health care to achieve a healthier, happier population.   We need to stop focusing on the financial bottom line, and return our focus back to the human beings sitting in our exam rooms.

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  1. Peter Cohen, MD


    Good analysis. I would suggest, however, that the unidentified two ton elephant (metaphor intended) in the room is the private health insurance industry. Medicare for All with single payer financing is the most potent solution for run-away health care costs. Much as I admire Pelosi, Reid and Obama's persistence in sheparding a health care bill through Congress, the one they passed is deeply flawed and has no clear mechanism for reigning in costs. They were too timid in dropping a public option. Spending 3 cents of the healthcarte dollar on overhead and administrative costs (as Medicare does) rather than the nearly 30 cents that goes to obscene insurance CEO salaries would go along way in redirecting health care expenditures to the provision of appropriate care.

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