In America We Get the Health Care, and Cost, We Deserve

I'm back in Denver again, working on a project regarding surgery in patients who have infection in their lungs. Interesting to me, and National Jewish, but not really a topic of general concern. I took a route from Seattle that went through Salt Lake City and Eastern Utah and Western Colorado. I won't do it again since I ran into dust storms, flat-flat-flat terrain, and billboards against abortion and for marriage through Utah. Two issues that I am in favor of, mostly, but not really familiar billboard fare to me. I prefer the nonreligious stuff on billboards like what kind of car to buy, real estate, and insurance products. Actually, I could do without billboards. I also didn't have XM radio this trip which made the ride less exciting. I resorted to listening to Spanish language tapes.

Well, health care legislation has passed and I am glad. Now there will be some sort of expectation that nearly all will have health insurance in our country and there will be fewer shenanigans by health insurers regarding limiting coverage for people who are actually sick.

But the real discussion in the future will be regarding cost of health care and I would like to propose that we must come to terms with this as a nation, outside of the doctor-patient sphere. As a representative democracy we essentially get what we want, or deserve, and this seems confusing to some. I am in favor of good health care for all but I am a doctor and this is in my blood. Some would also say that it is economically in my interest to see high health care costs since I reap the financial benefit. This is true but I would be a happier person if I made a little less money and saw everyone a little more settled about the issue. We must either accept some limitation in our expectations of the health care system, at lower cost, or accept a higher cost of care to continue our consumption practices. As a friend suggested, in the middle class, do we want two cars a piece or do we want one car and piece of mind that we can get the health care we want? I don't think we can have both. A you-can't-have-your-cake-and-eat-it-too argument.

I recently read a piece on the New York Times Health blog by David Leonhardt titled, In Medicine, the Power to Say No. His thesis seemed to be that until medical professionals can start to say no to patients we will continue to see elevated health care costs. I generally disagree since my experience has been that, as a doctor, I can sometimes direct a patient in their health care economically but often the patient directs me. I have had patients ask me for medically unwarranted tests and I often get them because it will avoid time-wasting hassle with the patient who knows what he wants, despite reasonable alternatives, or indeed will limit my worry about being sued, or at least berated, or late to see the next demanding, irritated patient. I have had patients of means ask me to admit their elderly, nonsick relatives to hospital so they could divert resources to medicare, thus not inconveniencing their time or pocketbook, and I have had a patient ask for my help to arrange a chest CT scan in Singapore, requiring disproportionate logistical and time expenditure, so her potential lung cancer would not inconvenience her Asian cruise. Anecdotes yes, but a tip of an iceberg that suggests something wrong is happening here. As individuals some Americans can't be denied, but this comes at a cost to others.

There is great disparity in expectations of the health care system across the nation. In a recent publication by the Dartmouth Atlas of Health Care they showed that patients receiving care through the UCLA hospital system were hospitalized 50% more than patient's receiving care through the Mayo Clinic system and the UCLA crowd had twice as many doctor visits, many specialists. UCLA spent an average of $52, 911 on each patient in the last six months of care before they died, where the Mayo Clinic spent $28, 763 over the same period with each dying patient. Since the outcome measured was death it is hard to argue that there were differing "severity" of illness scores in these groups. Other statistics show that health care expenditures are high in Miami and Manhattan as well. This is a complicated issue but maybe Denis Cortese, Chief Medical Officer at NYU Medical Center, was onto something when he suggested that their patient population has grown accustomed to an
" aggressive" level of care and the physicians at NYU have obliged. But maybe too passive or generous to the patients since, in my experience at NYU, for three years as a fellow there, I heard more than once about lawyers of patients calling medical residents to ask why a certain test was not being performed on their clients. I just got a lawyer and he just did my will.

It seems possible that expenditures at the Mayo Clinic are lower because those Minnesota farmers know when the jig is up at the end of life, and the patients at UCLA, or other large urban centers, have higher expectations of care that the medical system must oblige, or pay a price. Mortality comes to everyone but some are more or less accepting of it. This does not seem to be a problem of doctors, hospitals or insurers making more money, it's a problem that comes from the kind of people we are.

Medicare has now formed an Innovation Center to cull efficiencies that can be made in the system that will limit cost expenditures. There are many intelligent people working to discover how we can deliver care more efficiently but in America we will not be dictated to. It is the obligation of physicians and nurses to attend to the autonomy of each patient which means that paternalism is dead in our country, and perhaps for good reason. But this means that medical professionals are more at the mercy of the patients and the public. Previous attempts to "manage care", to create gate-keepers, or to encourage discussion of limiting care at the end of life among individuals and their families have all been castigated by some in our country as limiting choice.

There are many instances where physicians are accused of acting in their own financial interest but patients in America must accept some complicity. As in all professions there are those that want to maximize financial gain, but many physicians work with clear consciences in this regard. Some obstetricians may perform cesarean sections frequently for their convenience or financial gain but I think this is not the norm. They use technology to avoid being witness to babies with cerebral palsy, and to avoid being sued over this disastrous outcome. If as patients we want to accept responsibility for more babies with cerebral palsy we should argue for limiting cesarean sections but give the doctors a break and accept some of the risk, financial and emotional. This is a decision for society and not the doctors.

If we want cardiologists to do fewer cardiac catheterizations we must accept a higher risk for sudden death, albeit a less expensive choice.

And if we want to spend less on patients at the end of life we must accept limitations on who gets intensive care at the end of life. Until now the legislature, the courts and the American people have been unwilling to shoulder this burden. It is too much to ask doctors to just say "no".

Asking health care professionals to just say "no" seems to be a rather simplistic, and uncomfortable, answer to a difficult question that must be tackled by us, as Americans, through our press, legislatures and courts. Convincing the American people that limitations come with cost seems to be an imperative. We can have limitless care if it calms our emotions or we can have limitations in care if it makes our pocketbooks happy but we can't have both. It is an issue that extends beyond the doctor-patient relationship.