Cost of Healthcare

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Cost of Healthcare

Columns - From the Addiction Physician

Monday, 29 March 2010 14:41

In the 1960s, media was quite inexpensive. One could watch any television channel or listen to the radio without charge. Once you bought your television and radio, the cost per hour of viewing or listening was zero. Nothing stops you from doing precisely that today. If you wish to watch high definition television using an antenna, you can. If you want HD Radio, that’s free each month as well. However, the average digital cable customer pays $75 each month, with even higher monthly expenses if the consumer wants a digital recorder or high definition pay channels.

Satellite radio for the car adds another monthly bill, and let’s not forget about the cost each month for Internet access, both at home and on the cell phone. A Netflix subscription adds more. By the time we’re done, what used to be free easily closes in on $2,400/year. Why do people spend so much on something which not only used to be free, but which still can be free? Because they want more than what they had, and more than they can have today for free, even though that alone is significantly better than what they had.

Healthcare was less costly 50 years ago than it is today. Not as much was available. Many illnesses which led to a quick and certain death in the 1960s can be held off at significant expense today. Costly diagnostic procedures are available to ensure that such illness will not develop, or if it does, it can be stopped in a timely manner. Patients are also far more educated today regarding their healthcare choices. Rather than simply going to their doctor and accepting an offered treatment or care plan, they research their options and go to the doctor requesting a specific diagnostic workup. A generation ago, people largely avoided going to the doctor at all. I imagine many of you, as with me, recall parents or grandparents who prided themselves on never having gone to the doctor. They didn’t need to, so they didn’t go. Healthcare can be just as inexpensive as it was a generation ago. Don’t go to the doctor. Don’t get the expensive diagnostic workup. When you find that you have a fatal illness, refuse treatment and make sure your affairs are in order. But we all have a choice. We can decide to spend more money and get better healthcare. That’s what we’ve done. And that’s the most important reason as to why a greater percentage of our economy goes to healthcare. As improvements arrive, healthcare is perceived as being of such importance that we all wish to take advantage of the improvements. Just as we’ve decided as a nation that we will spend more on media given greater media availability, we have decided to spend more on healthcare given greater healthcare availability.

The argument that we have a problem because we are spending an ever increasing percentage of our dollars on healthcare therefore does not hold water. All things considered, we would all spend 100 percent of our money on healthcare if it ensured that we would live forever and in excellent health. That is, of all possible decisions as to how to spend money, the most important of the possibilities.

So if the goal is to spend more on healthcare because such spending results in improvements over what was available before, we as a people must embrace such spending and ensure that the spending is rational. That is, we want to get the most healthcare for our expenditure. But there has been another change since the 1960s—the rise of an enormous for-profit industry that sits between clinician and patient. In 2008, the CEO of Aetna received $24 million; the CEO of Cigna received $12 million; Wellpoint’s CEO received almost $10 million; and the CEO of Coventry got $9 million. I could go on, but how many patient contacts could these funds have paid for? And that’s only a single employee of each company. What about all the expenses necessary for each of the company employees, buildings, advertising, mailings, review processes, regulatory oversight, legal counsel and furniture? All of those expenses come from funds that, once upon a time, would have paid for a patient visit.

An additional change that has taken place since the 1960s is the enormous regulatory burden on each of us. Where we used to have a simple office with perhaps one full-time employee, we are now forced into having multiple personnel in order to follow all the regulations. We spend hours of our time looking at clinically useless treatment plans, making sure that our offices meet HIPAA guidelines, sitting in on audits and reviews, following CLIA regulations, not to mention making sure that our office computer systems remain up to date, secure, confidential and operational. And of course another employee is necessary to learn various codes for billing purposes—an entire person dedicated to doing what we used to do in a minute at the end of each appointment when patients paid for their visit. We attend far more trainings, take far more frequent recertification examinations, and always make certain to avoid risk by documenting ever increasing amounts of information.

Mr. Smith was informed of all appropriate alternative treatment modalities, their risks, benefits and side effects, and made his decision as to which treatment to follow based upon his competent and well reasoned understanding as to the issues involved. Well, of course he did; that’s why he saw me in the first place. And how is it that my writing down my standard procedure makes it so that that’s what I did? The fact that I wasted time writing it down decreased the time I could actually spend with the patient in the first place. But I stray from my point.

Reducing the cost of healthcare is an achievable goal. But taking the least efficient part of the current system and attempting to mandate its use by the entire population is not the right way of reducing cost. The right way to reduce cost is to eliminate aspects of the system that are costly but that do not directly provide necessary care to the patient. Or, of course, we could simply refuse medical treatment. But I suppose that’s about as likely as our deciding not to have a cable box on the TV.

Stuart Gitlow, MD MPH MBA is a member of the American Medical Association’s Council on Science & Public Health, and an officer of the American Society of Addiction Medicine. This column represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

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