THE $20 ASPIRIN

People often ask, " Why is medicine so expensive in the United States?" This simple question requires a complicated series of answers.

As recently as 60 or 70 years ago, if you were sick, there was relatively little the medical profession could do to diagnose and treat your ailment.  Beyond some simple x-rays, a few antibiotics, and some rudimentary blood and urine tests, the armamentarium of the physician was relatively bare compared to what it is today.  Our science has developed noninvasive ways of looking inside your body such as ultrasound, CT scan, MRI scan, and PET scan.  The cost of each of these machines runs from $100,000 to several million dollars.  Each require technicians with specialized training to run them, and physicians with specialized training to interpret the results.  As expensive as these machines are, they quickly become obsolescent and require replacement due to the demands of the public as well as the newly minted doctors trained in their use.

While we are a long ways away from finding the cure for cancer, there are number of cancers today that actually can be cured with a combination of available treatments.  For many others, there are treatments which can slow down the progression of the disease.  Unfortunately, the cost of these therapies runs into the hundreds of thousands of dollars and more.

The public appears to have an insatiable appetite for news regarding health care.  Newspapers, magazines, television, books, and the Internet have combined to provide a prodigious amount of information regarding health and disease.  Unfortunately, the media approach is often sensationalistic, and designed more to generate fear leading to more media consumption than to the dissemination of the real facts.  For those without medical or scientific background it becomes difficult to separate the wheat from the chaff.  Nonetheless, most doctors will readily tell you that their offices routinely have to deal with the worried well.  These patients consume significant health care dollars in their recurring need for more tests to reassure them they are not suffering from an as yet undiscovered malady.

The ever-looming threat of malpractice motivates doctors to order more and more tests from an ever-growing armamentarium.  Because there are few studies that can be considered 100% conclusive, there is continued escalation of tests driven both by patient demand and malpractice worries.  The growing intrusion of both courts and legislatures into the practice of medicine fuel this process.

We have both a mobile society as well as an insurance system that forces patients to frequently change doctors.  Since we lack a system of readily available health records, and because patients are often ignorant of what tests they already had done nor the name of the facility which has performed them, there often results duplication of studies.

We as a society have done a very poor job of accepting the reality of death, and have failed to parse the distinction between the prolongation of life and the prolongation of death.  There's a poor understanding of the hospice movement not only by the general public but also by many physicians.  Despite the fact that it has been around for over 30 years, and that 98% of families have given high marks to hospice and would recommend it to their friends and family members, the program remains underutilized.  This is a topic that deserves its own discussion, and the one that I will address in a following piece.

People are justifiably outraged when they receive a hospital bill showing a $20.00 charge for an aspirin.  The fault, however, lies within the arcane system of charges forced upon hospitals by the bureaucracy of insurance companies and the government.  There are a large number of unfunded mandates such as laws requiring hospitals and doctors to provide care to any one walking through the doors regardless of their ability to pay; state mandated staffing ratios; state and federally mandated utilization review programs, infection control programs, quality control programs with increasing number and complexity of reporting requirements - all of which require significant expenditure of staff time and effort.  As there exists no direct means by which hospitals and physicians can bill for these services, the costs of these unfunded mandates get bundled into other allowable charges.  Hence, the $20.00 aspirin.  If grocery stores were required by law to provide food for any one who was hungry regardless of their ability to pay, if hotels were required by law to provide shelter to any one unable to afford it, then the cost of these services would rise exponentially, or it's providers would go bankrupt.  With 40% of the population having no health insurance, we are seeing evidence of both of these consequences.

If the picture I am painting looks bleak, indeed it is.  I sit on the financial committee of the board of a nonprofit three-hospital system in a reasonably affluent area.  For four years we have lost considerable amounts of money, and only in the last two years following staff and program cutbacks have we been able to eke out a 1% margin.  Unfortunately, while this is an improvement over our past performance, it does not allow us to even replace worn out equipment and infrastructure, much less build for the needs of the future.  Based on the experience of other facilities near us that have been forced into bankruptcy, there's no one in the public or private sector who will take over our operations should we fail.  If we close our doors, we can expect that 150 to 200,000 people in our geographic area will have to find healthcare much further away.  The domino effect of such an influx on the already strained resources of our neighbor hospitals is all too predictable.  While the crisis in our community is perhaps slightly greater than the rest of the country, we all face the same challenges.

In my next several offerings on this topic I will endeavor to give you a better insight into the physician side of this problem, as well as talk about some potential solutions we need to consider if we are to avert a total melt down of our healthcare system.

American Health Care – A System in Crisis

Anyone who has dealt with the healthcare system of our country realizes we are faced with a crisis.  The problem has been a long time in making, and is now being accelerated by a number of factors.  The aging of the baby boomers will continue to put an increasing burden on the system.  The increased numbers of uninsured patients for whom doctors and hospitals have to provide uncompensated care is placing an increasing financial burden on the providers.  The availability of new drugs and technologies, while providing a boon to the recipients, also significantly increase both the demand for, as well as the cost of health care.

Reform of our tort system remains quagmired in attorney-dominated legislatures beholding to the Trial Lawyers Association.  Increasingly rising expectations for perfect results combined with jackpot payouts continue to fuel new litigation.  The rising dominance of HMOs and a frequent alteration of employer contracts continue to shuffle patients between doctors, destroying the trust that comes from long established relationships.  Fueled by restrictive bureaucratic hoops designed to save insurance companies money, along with a sensationalist press, patients are coming to doctors' offices already angry and expecting bad treatment even before being seen.  The threat of malpractice leads to the practice of defensive medicine, which in turn is harmful both to the patient as well as the system.  Each day, more and more doctors are choosing either early retirement or a change of careers.  This trend is leading to both the critical shortage of physicians in some areas as well as potentially negatively affecting those who are considering entering the field.

Doctors and hospitals that have attempted to police their own ranks have been stymied by charges of harassment, discrimination, and restraint of trade.  The time and exorbitant cost burdens to defend against these charges have made the system of self-policing dysfunctional.  External agencies such as state boards are also limited in their effectiveness.  There needs to be better mechanisms than suspension or revocation of a physician's license as tools to ensure better quality care.

Morality and common sense are not items that can be legislated.  We cannot expect to supplement the healthcare manpower shortage by importing doctors and nurses from countries that have different cultural and ethical values from ours without resulting problems.  We cannot ignore the decline of honesty and ethical behavior in our own culture and schools without expecting a similar decline among the graduates we produce.  We need to take responsibility for our own abuses of our bodies with tobacco, alcohol, drugs, and food.  We also have to accept the consequences of ignoring the medical advice we have received.

The profits of public utilities are regulated, as we have no choice regarding the use of water, electricity or telephone. The companies that are involved in our healthcare from the pharmaceutical to the insurance industry may require similar controls.

Ultimately, what any patient wants, and has a right to expect, is access to a physician who is well trained, and who cares about their well being.  In addition to soliciting your ideas and comments regarding this topic, over the next few weeks I will be offering you my own observations and thoughts about the impediments that have been placed on the doctor-patient relationship, and what we can do to improve this relationship which we all at some time will need.

LOVE IN PARIS

I’m still recovering from jetlag, but want to take a few minutes to thank all you well wishers who have posted messages in response to my last post. Your good wishes came true.

If I were a movie director orchestrating the setting for a romantic wedding scene, I could not have chosen better than circumstances provided for us. French law requires couples to get married in the arrondissement (district) where they live. Accordingly, my favorite poet and his bride held their nuptials at the Mairie du XVI^eme  Arrondissement, a stately building of marble staircases, 30 foot ceilings, and frescoed walls. It was a fitting place for these two representatives of the United States of America and France to formally sign their mutual non-aggression pact, pledging their desire to cement good relationships with each other, and bring the best of each culture to this union.

It’s said that all brides are beautiful, but this one was breath-taking. Wearing a simple, elegant, two piece white strapless satin gown with a slightly flared skirt, her hair pulled back in a tight bun ornamented with pearls and decorative small, clear bubbles, she wore a matching choker. The tall, elegant groom’s tuxedo was accented with a light pink tie, matching the pink rose bouquet carried by the bride. Befitting the groom’s journalistic avocation, the sides of the room were filled with photographer friends firing salvos of flashes to document this magic moment.

After the ceremony, the newlyweds descended the long staircase, made their way through the portal, and were greeted by all thirty of the highly selected witnesses to their promises of eternal love. The wedding party wound its way down the tree shaded Parisian boulevard to the Trocadero, the large plaza with fountains overlooking the Eiffel Tower, where more photos were taken, and tourists from around the world had the opportunity to include the new royal couple in their souvenir photos of their French vacation. Electric blue skies filled with scattered fluffy white clouds framing the Eiffel Tower provided the perfect backdrop for the young couples wedding pictures.

The reception was held at the Press Club de France, which provided food and wine in a setting of crystal chandeliers and gilt edged rooms fitting for this happiest of celebrations. We all felt most fortunate to have been a witness this wonderful event, to have shared it with our families, and to have made the acquaintance my son’s charming, intelligent, and kind Parisian friends.

Though the photos of the wedding party are not for general publication, I’m posting a few shots taken at the time, as well as around Paris, to help give you a flavor of the city, and the setting of our recent celebration. Be well, and enjoy your weekend.