12 REASONS HEALTH CARE IS IN CRISIS
Last year at about this time the New England Journal of Medicine published an article entitled “Options for slowing the growth of health care costs”. In table 1 there are listed 12 options for cost savings, ranked from highest to lowest potential. The NEJM is one of the most influential and respected medical journals in the world. If you Google the lead author, James J. Mongan, M.D., you get 736 entries. He is President and Chief Executive Officer of Partners HealthCare, the Medical Group Practice associated with Massachusetts General Hospital. He is also Professor of Health Care Policy and Professor of Social Medicine at Harvard Medical School. There is probably no more distinguished and respected doctor in the country. Yet not only did he not come up with any practical, doable solution to the Health Care Financial Crisis, he did not even correctly identify the real origins of the problem.
Rising Medical Care Costs are the consequence of:
Most adults, and now some children as young as 8 years of age, must visit their doctors regularly (every 6 months or more) to check for risk factors (such as high blood pressure, sugar and cholesterol) for developing illnesses such arteriosclerosis, heart disease and stroke. If present they usually must be treated with one or more medications. Direct to consumer ads encourage patients to “ask your Doctor” for the most expensive brand name drugs in preference to generics. This marketing works! There are screening tests of body fluids, X-rays, CAT scans and MRIs for early detection of various problems, including many cancers. This practice of preventive medicine began in the latter half of the 20th century and has added a huge and growing cost burden to the health care system. The insurance industry believes it is cost effective in terms of sickness prevention and so monitors doctors to make certain they follow “best practices” with respect to screening for and treating all risk factors with medications. They usually do not stress lifestyle and dietary factors and patients usually do not bring this subject up. Unlike medications for actual diseases such as infections, anemia or stomach ulcers, treating risk factors involves regular doctor visits and taking medication everyday for the rest of your life, even though you may have no symptoms and are not actually sick. Big Pharma has responded to this growing opportunity with many 100’s of new and expensive medications which they market extensively to the consumer on TV and in print media. Marketing is much more effective than most people realize. Marketing has made Lipitor, just one of several cholesterol lowering drugs, the best selling drug in history, with annual sales of $12 billion. Lipitor doesn’t cure anything and it doesn’t really help all that many people. An antibiotic for a bladder infection usually cures 98% of patients in 7-10 days. Lipitor taken for 5 years has been shown to benefit (ie prevent heart attacks or stroke) in only 1% of high risk patients. After 5 years they have no solid evidence that Lipitor is doing more good than harm. (Pfizer’s marketing division could give lessons to Nike, Wal-Mart, McDonalds, GM and Starbucks.) Taking these “preventive” medications does not actually prevent but only delays the onset of the multiple diseases associated with aging. Most people over 60 have one or more chronic medical problems for which they must see, not just their primary care doctor but one or more specialists as well. In the last 40 years we have developed an amazingly effective, complex and ever more expensive technology and expertise to deal with these complex medical problems. The availability of, the need for and the cost of this technology and expertise is rising rapidly. Kidney dialysis units are full 24/7 and they’re not being built fast enough to keep up with demand. A specialist in Memphis can manipulate a robot in Peoria via closed circuit TV to remove an adrenal gland tumor… well you get my point. Lung, heart, kidney, liver and bone marrow transplants are now commonplace, limited only by availability of healthy organs. (If you’re too ugly, they’re now doing face transplants!) With Bush gone, stem cell therapy is being developed aggressively. Recently ABC News reported success at regenerating an entire rat heart with stem cells, which then began beating to the wondering eyes of the media. (This is indeed good news for our ex-VP Dick Cheney!) This means that more elderly patients will primarily depend on specialist(s) care rather than primary care. This will drive up the costs more quickly. David Walker, former head of the GAO has predicted with great certainty that the United States of America will go bankrupt in approximately 2020 due to the expense of millions of baby boomers becoming eligible for Medicare. Adding the Medicare drug benefit brought the bankruptcy date back to 2017. (By bankruptcy he meant most of the Federal Government, including the Pentagon, would be forced to close its doors. During the current economic downturn, the expanding demands on Medicaid and SCHIP may bring that bankruptcy sooner.) Even if we could afford it, providing everyone from an early age with Health Insurance would not solve the problem. Two famous bad examples: Baby Boomer numero uno, Bill Clinton has already had his first heart attack before he even turned 60. You can only imagine how much his acute and now follow up care is costing the taxpayers. Tim Russert from “Meet the Press” on TV, had fine insurance and treatable risk factors, went to his doctor faithfully and took his pills. Yet he dropped dead of a heart attack at age 58. (His dying saved his health insurance company a bundle.) It should be apparent that with respect to Health Insurance and care we Americans are grossly over using the system. The doctors and all their magic technology can barely keep up. And the “not keeping up” problem is going to get much worse as the 78 million Baby Boomers become eligible for Medicare. Health Insurance for Americans is so costly for the same reasons that flood insurance is so expensive in New Orleans and hurricane insurance in South Florida. Cost is based on risk and Blue Cross, Blue Shield, Aetna, Humana, Unicare, Cigna, Anthem, Carefirst and Kaiser are very good at calculating risk. In fact they are so good it’s giving them a giant headache of miserable public relations. Let’s look at the problem of pre-existing medical conditions. The public and the politicians all want them covered, with no exclusions. Hey that’s only fair. People who are already sick need their health care expenses paid for now! But think about it for a minute and apply some common sense. Say you own a nice home, cost you 300 grand, well furnished in a nice neighborhood. The mortgage is pretty steep, you’ve got a couple of teenagers, and you and the wife have nice cars. So to cut expenses you didn’t buy home owners insurance. One day there is a grease fire in the kitchen, it spreads to the curtains, then the wooden cabinets and throwing pans of water is not working. Thinking quickly you call State Farm. Hello! Do you really think they are going to sell you fire insurance on the spot when the Fire Department is already on the way? Well, that is what many are expecting from the Blues and all the rest of them. That is turning healthcare “insurance” into a healthcare entitlement. Unless you are on a public program such as Medicare or Medicaid that is just not going to happen. Payment levels from Medicare, Medicaid and SCHIP (state children’s health insurance program) are not acceptable to many doctors. If you are a new Medicare enrollee with several chronic medical problems, good luck in finding a doctor who will take on your case. Medicaid payments to doctors are even worse. The large doctor group in LA of which I was a partner did not accept any Medicaid or SCHIP patients. Brave New World: many doctors don’t take care of old people or poor people any longer. Hippocrates and my grandfather are rolling over in their graves.
10. One more important point: just as the demand is rising exponentially, the resources are shrinking. There is a critical shortage of nurses. (2 large groups of Americans don’t go into nursing: men and white people). We are importing nurses from all over the world with higher salaries, thus exporting our healthcare crisis to other countries. Many emergency rooms and trauma centers are closing down because too many patients without insurance go there, leading to hospital bankruptcies. (http://www.emreportcard.org/) At City and County Hospital ERs (which can’t close by law) unless you are having a cardiac arrest, the wait to see a doctor may be several days. Bring along a lot of change because the only food you’re likely to get is out of vending machines. (Be warned, it sure ain’t health food.)
11. Finally, let’s get real about just what legislation is possible given the power of medical lobbyists. Big Pharma for starters. They managed to get Medicare Part D (the drug benefit) passed with no provision for bargaining for best prices. Medicare pays retail and most of the newest (thus most expensive) drugs are covered. Do you really think that Big Pharma, Big AMA (and all the other doctor groups) big Health Insurance (Blue Cross, Aetna, Humana, Cigna, PacifiCare, etc) and Big Hospitals are going to go along with making the whole healthcare system non-profit? Keep in mind: these guys own Congress.
12. Okay, let’s dream for a minute. The year is 2012. Congress and the Obama administration have passed comprehensive health care reform legislation. Every single citizen and legal immigrant in America is now covered by health insurance. Liberals are ecstatic and conservatives are cowed or grudgingly accepting of the new reality. You live in Los Angeles. One morning you awake with a splitting headache, and a fever of 103. Your urine is cloudy and bloody and painful to pass. You call your doctor and after a 25 minute wait listening to ghastly Musak, the recorded voice of the receptionist advises you to go the St Edwards Hospital emergency room. Reality sets in. The line to see their ER doctor starts in Bakersfield.
Remember when a McDonald’s hamburger was 25 cents and you could hold it in one hand? Now McDonalds has a burger, introduced in Tokyo, Japan that has 4 patties – one for each chamber of your heart!
I have been a medical doctor for 50 years. First third research and teaching at UCLA. Middle third created and directed a healthy living program in downtown Los Angeles. Wrote “Control Your High Blood Pressure Without Drugs” and a companion healthy cookbook. Updated versions are available at nomoremedicines.com. Last third as a hospital based doctor. This essay is based on that experience. Now I promote healthy diets and lifestyles. I am 75 years old because I do walk the talk.
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