The Unsustainable Cost of Health Care

By Dr. Molly McMullen-Laird

 

One of the biggest economic issues facing our nation is the funding of government programs for health care, Medicare and Medicaid, and the payments of private health insurance, either by the individual or the employer. It is well known that we pay twice as much as other countries for our health care needs, and most developed nations (and many developing) surpass our actual health ranking. What are we doing with these resources? Why do we tolerate such inefficiencies in health care and such exorbitant costs for mediocre results?

In my experience over the past 25 years in medicine, there has been an increase in the demands on physicians to focus on administrative tasks unrelated to the actual care of the patient. Our society places a high value on security and safety. We have created a standard of regulations that require a cadre of employees to understand and implement compliance. In order to keep the “business” of medicine working, the focus is on how to get reimbursement rather than on the patient and the problem the patient is presenting.

From electronic medical records to new, more specific diagnosis codes, the burden of our regulatory policies is onerous. The next strategy in health care administration is to create large entities called Accountable Care Organizations. Through efficiencies created by centralized information access and flow, these organizations will supposedly become the answer to our nation’s exorbitant health care expenditures and the answer to duplication in services and procedures. However, my concern is that we are looking at just more of the same approach — only this time it’s ramped up to a level that no small practice will survive, the quality of health care will diminish, the patients will be shuttled through the system and the costs and waste will not decrease.

Another direction toward which our regulatory advances are headed is to require electronic prescriptions to the pharmacy. The idea is to reduce mistakes and to make it easier for the physician and the pharmacist to monitor medication use with the help of the electronic prescription. While this approach has its advantages, the other side is that the pharmacy has a program that automatically generates a refill on prescriptions without the trigger of the patient or the doctor requesting the refill. As you can imagine, the over-dispensing of drugs is the result.

A nationwide study done in 1999 and 2000 by the United States Geological Survey (USGS) found low levels of drugs such as antibiotics, hormones, contraceptives, and steroids in 80% of the rivers and streams tested, which means active chemicals are likely ending up in our drinking water. The Environmental Protection Agency (EPA) mandates the filtering of contaminants and other harmful substances from our drinking water, but there are no standards for pharmaceuticals and not much funding available for even studying this potential public health issue. Should we not be spending some of the millions raised for cancer research on studying the potential effects of such contaminants rather than on continuing to search for the drug that will cure cancer?

We expect the government or the insurance companies to fix the skyrocketing costs of health care, but their approach — increasing standardization of medicine in order to increase compliance and safety and decrease duplication of services — is going to be more expensive in the long run. Why? Because the actual societal expectations of health care delivery are unsustainable, and no one wants to talk about that issue. We demand health care to be top notch, the best treatment for everyone. We allow the overprescribing of medications, lab tests, home care, and imaging procedures. We, as Americans, are trained to over-consume in the pursuit of happiness, and we apply that orientation to our health care as well. More testing must be better; free pills or devices provided by our insurance companies might be useful — they don’t cost anything, so why not?

To serve these basic attitudes we have developed actually costs a lot of money, which we all complain about regularly. What we don’t think about is the incredible waste of resources incurred with the increased treatments, testing, pill prescriptions, and medical devices. Imagine the whole footprint of a medical intervention. This is an area where we are using lots of energy, materials, and person power while creating lots of waste.

The amount of materials discarded daily in hospitals makes them a prime target for a massive overhaul in resource allocation and disposal. Patients are not conscientious of this because they have no incentive to decrease the waste. Again, patients rarely refuse the services of the home care agency or the extra supplies hospitals provide even when they know the items aren’t really necessary. Since it is free, they agree to receive whatever the system will provide. With a similar mindset, a patient hardly ever says, “I just had blood drawn last month at another doctor’s office. Perhaps we should look at that first.” We naively believe that the more times we are tested, the safer we are.

In medicine, physicians are very keen to find out what every abnormal value might reveal, and we go to great lengths to be sure that it doesn’t show anything pathological. We all have been taught that if you order 12 lab tests in a healthy subject, statistically one will fall out of the normal range. The results must be interpreted with a clinical understanding of the patient. Physicians would like to diagnose disease early and treat it when it is easily treated. We also have a litigious society, and all physicians are trained that it is better to over treat by a great measure than to face a lawsuit over missing a diagnosis. We do not tolerate mistakes in medicine.

It is past the time that our society should be looking at everything we do with an understanding of its environmental impact. We talk about climate change a lot, but we rarely get to the “Reduce” part of the three Rs (Reduce, Reuse, Recycle). What if everyone made a conscious effort to reduce what they eat? Again we are not in the mindset that it might benefit the planet if everyone ate less food! And consider the effect on diabetes, kidney failure, and heart disease. More and more discussion is happening about food waste in schools and restaurants, and they are starting to find ways to reduce it. The next step should be to look at medicine, analyze waste on all levels, and reduce the obvious redundancies.

It would also be very helpful to incentivize health care by having a co-pay associated with services, drugs, and medical supplies. Many times I have heard a patient defer a medication they felt they didn’t need because it had a co-pay of $10. Had it been free of charge, the patient would have simply filled it and not used it! A patient can also request smaller prescription amounts, such as 10 pills rather than 30. A standard prescription for patients leaving the hospital is 30 pills. Most of my patients do not need all those pills.

So what can we do right now?  If every one of us just had the mindset to remember that everything we consume, even medical care, has its carbon footprint.  If we don’t need it we can voice that.  In the event that the patient declines the intervention the system can document “patient refused Vicodin prescription, will use ibuprofen instead”  and then the health care practitioners are safely relieved of their mandate to offer each and every patient strong pain killers, for example.  You can refuse the unnecessary refill on the drug you are no longer taking if you know that it is a computer that generated that refill.  You can ask your physician whether you really need to have a pill and ask for the minimum amount at that time.  You can treat the health care resources like you would your own household resources and reduce the use of those resources responsibly knowing that the system is rewarded for overuse and over-treatment.   If the patient takes a part in this equation it will change.

Dr. Molly McMullen Laird is active in the community as an holistic physician at Community Supported Anthroposophical Medicine.  She and her husband have founded a direct primary care model at their practice which operates under a monthly subscription contract with patients who want to be involved in their health care choices and use the anthroposophical approach to medicine.  The fees in this model have increased annually between 2 and 3% rather than the double digit increases in conventional health insurance.  She is also the Medical Director of the Rudolf Steiner Health Center, a holistic inpatient center for patients with chronic illnesses and cancer.