Less expensive health care is a pipe dream

By LINDA SEEBACH
ROCKY MOUNTAIN NEWS
Would Americans rather limit health care or limit spending on health care?
It's easy to proclaim, in the abstract, that the amount of money spent on health care, currently around 14 percent of the gross national product, is already "too much" and if it rises to more than 20 percent as the population ages, which could happen, that the American economy could not survive.
But when it's your mother who needs a kidney transplant, or your baby who spends weeks fighting for his life in the neonatal intensive-care unit, no cost of health care is too high.
These views may be in conflict, but at the point where care decisions are made, it is usually the second one that prevails.
The result, say George Halvorson and George Isham, is an "Epidemic of Care," as they have titled their book on America's system, or lack thereof, of health care. Isham is medical director and chief health officer for HealthPartners in Minnesota, and Halvorson was president and CEO there before moving to Kaiser Permanente as chairman and CEO.
Their discussion of the economics of health care should be illuminating, especially for people who naively believe that if the government took over paying for it, health care would be both better and cheaper. But twiddling with the administration of care won't ever be an answer, even if you're naive enough to think government administrators are likely to be more efficient than private ones. A chief reason health care is becoming steadily more expensive is that there are so many new kinds of it -- better technology, new drugs, whole new forms of care.
Costly
Take heart transplants, for example. We used to spend nothing on heart transplants because we couldn't do them. Now each one costs from $150,000 to $500,000, plus $14,000 to $95,000 a year for the rest of the patient's life.
Is it worth it? If it were your heart in need of replacing, would you turn down the opportunity on the grounds of cost?
Of course, that's not a realistic question, but this is. Suppose you had a choice of insurance plans, and one covered transplants and cost a little more, and the other didn't but cost a little less. Would you decide to be safe or sorry?
And another realistic question: If you decided the risk was too small to worry about, but it turned out you were one of the unlucky few who would die without a transplant, would you take your insurance company to court to force it to pay for something you chose not to insure?
Halvorson and Isham hold out little hope of making health care less expensive, but they are far more optimistic about ways to make it safer and better -- and highly critical of the fact that it is now often unsafe and inadequate.
"Selecting caregivers," they write, "is simply a game of chance for far too many Americans. It's pure luck if you are diabetic and end up with a doctor or medical group that actually meets minimal American Diabetes Association care standards. (Two-thirds of America's doctors currently do not meet those standards.)" And a third of doctors don't know the best practices for preventing a second heart attack.
Professional qualifications
That's pretty scary when you think about how most people go about finding a doctor. It's also why I signed up for Kaiser when I moved to California in 1992; I figured they had a much better chance of assessing professional qualifications than I did.
The authors recommend systematic collection of information about performance, because they have discovered that many doctors who in fact are not giving good care are unaware of the fact. For instance, they cite a study done by Kaiser in Colorado of the skills of people reading mammograms.
The researchers looked back at earlier mammograms of women with more advanced stages of breast cancer to see whether the cancers could have been detected earlier. There was significant variation in how skillful doctors were in picking out cancerous lumps at a very early stage.
Some doctors were retrained, others were reassigned, and in a short time, the percentage of cancers detected only at a more advanced stage dropped from 14 percent to 6 percent.
The authors point out, moreover, that the doctors in this study were all trained radiologists, but in many cases mammograms are read by internists or family practitioners with much less training. "Wouldn't you like a system in place to track caregiver accuracy in that area?" they ask, rhetorically of course, because everyone would.
As it is, most insurance is bought by employers, who often buy primarily on price and service because they don't have information about quality of care.
But plans don't want to invest in measuring care quality unless buyers will use quality as a criterion for choosing plans.
Develop protocols for care. Track compliance with them. Measure outcomes.
Inform the public. The system will be better and more accountable.
It just won't be cheaper.
Scripps Howard News Service