As Expensive As We Want It to Be

There are a number of factors that contribute to health care being so prohibitively expensive in this country. There’s plenty of blame to go around, from administrative costs for insurers, to waste, fraud and abuse, from a pharmaceutical industry focused on profits over outcomes, to a whole host of issues surrounding physician compensation and economic pressures. But if we’re going to point the finger, we also need to point it at ourselves. Health care is expensive because that’s the way we want it.

Not that, if given the choice, people would actually intentionally choose for the most expensive care in the world because it’s expensive. But the way we’ve gotten used to consuming health care and the way we feel like we’re entitled to receive care is directly tied to make it more expensive. Think of the big scary tactics advocated by Frank Luntz in his infamous memo: “Healthcare quality = “getting the treatment you need, when you need it”… Nothing will anger Americans more than the chance that they will be denied the healthcare they need for whatever reason.” Getting the treatment you need when you need it isn’t a bad thing. But getting the treatment you want when you want it can be… particularly if that care isn’t necessary, and isn’t likely to give you a better outcome. But none of our health care proposals dares scratch the surface of how we not only change our economic incentives but change our minds.

Dr. Atul Gawande has a truly excellent article in The New Yorker which is worth reading in full. He takes a trip down to McAllen, Texas which, despite every expectation, has the highest medical costs per person in the entire country. Even more bizarre, McAllen has nearly double the costs of nearby El Paso [edited based on reader feedback -- El Paso is 800 miles away, but a relatively good demographic comparison], but more or less the same demographics, population and public-health statistics. More to the point, for all of its cost, McAllen isn’t any healthier than El Paso – in fact, its five largest hospitals perform worse than El Paso’s. There’s no appreciable difference in the technologies and services offered. Gawande asks some of the local doctors why McAllen’s costs are off the charts, and someone claims medical malpractice, even though Texas has one of the most stringent malpractice caps and lawsuits have fallen “Practically to zero.” Ultimately there’s one major reason: over-utilizations. They get the care they want when they want it, sometimes even if they don’t need it.

Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.

The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

As they say, one man’s waste is another man’s profit, and money speaks for money. But our habits and our expectations share some measure of responsibility. We have a health care system that doesn’t value getting the health care you need when you need it so much as getting the health care you want or need when you can afford it. That’s how we can have 50 million Americans completely uninsured and without access to primary care or preventative medicine outside the Emergency Room on the one hand, yet on the other get indignant or scared when any enemy of reform suggests I might have to wait a couple of weeks for some non-emergency surgery.

There’s a cost for that--not just in terms of money, but in terms of quality.

(Photo credit:  Brooks Elliot on Flickr.)