We’ve now set a record that should be a source of chagrin for all clinicians. We’ve exceeded spending over $10,000 per capita per year in the U.S. on healthcare. With this amount of annual spending, any reasonable observer would believe that the United States must have the best healthcare on the planet. But the facts are just way too obvious to those of us who practice medicine – this is not the case.
Our closest neighbor to the north spent something around $6,300 per person in 2016 (11.1% of its Gross Domestic Product). By comparison, we spend about 18% of our GDP on healthcare.
As President Trump has said, “Nobody knew medicine could be so complicated.” Duh! Why can’t we figure this out? Somehow many of us assume that capitalism, if just left to its normal course, will solve the problem. But the rules of capitalism don’t seem to apply to the provision of healthcare in the United States – at least not fee-for-service healthcare (the majority of patients). Normally in capitalism, the more providers of a service there are, the lower the prices go (supply and demand). So how is it that in Miami (where there are oodles of doctors) the cost to provide care for a Medicare patient is about $13,000 a year, while in Minneapolis it costs only about $8,000 a year to take care of the same problems?
The difference between Minneapolis and Miami might have something to do with our current payment system of fee-for-service healthcare. (In 2016, 69% of Medicare patients were in fee-for-service programs.) In this system, the more clinicians do, the more tests that are ordered, the more revisits that are scheduled, the more referrals that are made, the more money doctors make. In this system, there are no incentives for doctors to do less (except, perhaps, ethical reasons). Fee-for-service payers just keep on paying the same amount for office visits, colonoscopies, cataract surgery, CT scans, etc. Volume has no effect on the cost-per-service. Lots of services, lots of payments – no supply vs. demand at all.
There is another system in which the opposite incentives apply – the HMO system. Like fee-for-service payment systems, HMOs can also be nasty. In their worst iteration, the less clinicians do, the more they make (or actually the company who owns the HMO makes). As of January, 2016, about 92 million Americans belonged to HMO plans. Some of these plans are exceptionally good – the Kaiser and Mayo Clinic systems come to mind. But let’s face the brutal reality, if there was going to be an approach to dealing with the cost of our healthcare, it would seem that the HMO system would be much more likely to be successful than the fee-for-service system.
Seems we need to break our addiction to the fee-for-service payment model. This is not to say that the Kaiser and Mayo Clinic systems are not capitalism – they sure are. But the incentives are much more likely to result in lower costs (our biggest problem right now). Surely if we used the universal coverage model of all of the other advanced Westernized countries and spent the $3.2 trillion we are currently spending, we could provide terrific health care for everyone in our country – but we would have to pay less to providers than we do now per unit of service and we would have to expect more services to be performed.
Bottom line – one of the major problems with the U.S. healthcare system is that it is just not affordable.
There’s also a lack of access for all citizens, a focus on sickness versus wellness and excessive variability in quality. Consider the marked variation that exists in the admission rates for pneumonia, which I’ve written about in this column in the past. Although numerous studies point to huge variability in the ordering of tests and the diagnostic approach to various ED patient complaints, there probably is no costlier variation than that related to hospitalizations.
But variation in care certainly doesn’t stop at the ED. What happens once a patient is admitted? In the May, 2017, issue of JAMA Internal Medicine, Y. Tsugawa, et al, looked at spending and outcomes in non-electively admitted fee-for-service Medicare patients. Of 485,016 admissions treated by 21,963 hospitalists at 2,837 hospitals there was a 40% difference in average hospital spending between the highest ($1,055) and lowest ($743) quartiles of physicians while there was no statistically significant difference in 30-day readmissions and 30-day mortality rates. And, compound this variation with that of the sheer variability in Medicare admissions. In a nationwide study of Medicare admission rates (Caines, K., et al, Ann Emerg Med, October, 2016) it was found that the admission rate in the lowest quintile of U.S. counties was 19.3% versus 40.3% in the highest quintile of county admissions – a 50% difference in admission rates.
So there is a lot more work to do than fix the payment and access issues in our country. Physicians need to tackle the “3rd rail of medical leadership.” They have to accurately and fairly measure physician practice and compare it with an agreed upon, evidence-based reasonable standard. Physician variability in care is something we need to tackle. Will it be a popular endeavor? No way. I can hear the whining now. “My patients were sicker than hers.” “This is the way I was taught to practice in residency.” “I order lots of tests to avoid being sued.” “I don’t want to practice ‘cookbook medicine’.” And on and on. But it has to happen. If physicians don’t do it, CEOs and/or payers will (and it will be even less pleasant if they do so). Now that EMRs are ubiquitous the finest details of clinician variability are easily scrutinized. We need to own up to this problem and fix it – our patients deserve it and our healthcare system needs it badly.