Annals of Medicine: The Cost Conundrum: newyorker.com

Annals of Medicine: The Cost Conundrum: newyorker.com

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Atul Gawande, author of the very popular medical books Better and Complications, has just published an article in the New Yorker that explores the rising costs in US health care. Dr. Gawande suggests that the culture of a local medical community can cause a dramatic difference in the cost of care for each patient per year. This article stated some strong facts supporting an inverse relationship between the money spent per patient and the quality of care one receives. This idea makes sense when considering the risks associated with the medical procedures that cause higher costs.

It was surprising that Dr. Gawande's hosts in the various hospitals he visited were mostly unaware of the per patient expenditure of their hospital as compared to that of the national average. Why is Medicare and Medicaid, two government sponsored agencies, not monitoring this more closely?

The article emphasizes the role of the entrepreneurial spirit that is nurtured in some locations, such as McAllen, Texas and is discouraged in others, such as the Mayo Clinic, Minnesota. It seems that doctors should be salaried, so that in no way do their procedures correlate with total income.

Various clinics in the country show that there is a better model to guide doctors. The leaders need to focus the physicians in the community on patient well being and remove per procedure monetary return. However, this concept of care over finance should start in the formative years of a physicians life: Medical School. The application process for medical school is simply too expensive for a college student ($3000-$5000 per application cycle when considering AMCAS, secondary fees and school visits). Most medical students graduate with $200k in loans. Therefore, it is very difficult for professors to instill a disconnect between clinical care and monetary incentive when the student is burdened severely by their monetary obligations.

The government spends almost $400 billion on Medicare and $275 billion on Medicaid per year. There are about 130 accredited medical schools in the US with on average 140 students in each class (560 total at each school). It would cost the US (130 x 560 x 40,000) just under 3 billion dollars (assuming each school costs 40 thousand per year) to offer every accepted student a free medical school education. This is 0.3% of the cost of government provided health care. If the country wants to make a real investment to have cost conscious physicians in the 21st century, removing the monetary pressure from graduating students is an interesting place to start.

Separately, there are other issues that should be considered when discussing health care. Many private physicians outsource their billing services to private companies that have expertise in diagnostic and billing codes. These billing companies receive payment as a percentage of money received from the insurance companies. They, therefore, have an incentive to encourage billing for the highest possible amounts. Therefore, even a well meaning doctor looses some autonomy over costs when utilizing a service that is so focused on maximizing the profit per patient visit.

Health care dialogue is confusing and often convoluted with biased statistics. Insurance companies tend to be demonized as greedy corporations that often refuse to cover vital services to save costs whenever possible. Yet Dr. Gawande moves the dialogue towards the role physicians have in health care's rising costs. The hardest part for physicians, I think, is connecting the check received from Medicare or Blue Cross Blue Shield with the national economy.

The idea of creating an ethical clinical community is an excellent one. We should address the attitudes of practicing doctors, but maybe an investment in the consciousness of medical students would be the wisest change of all.

A joke at every end:

A guy walks into a doctors office with pain in his leg.
The doctor performs some tests and tells the man that he
has a fracture and will need a cast for three months.
The man freaks out and starts yelling,
"oh no this can't be, I want a second opinion!"
"Ok," says the doctor. "You're ugly too!"

Unexpected skaters and sharpies

Some interesting things come out when one looks closely. Recently the BBC world news podcast had a story about Fresno, California. The foreclosure rates in Fresno are extremely high. One of the overlooked side effects of the recession is the growth of unused pools in the nation's warmer cities. Stagnant water leads to a mosquito paradise which lead to scratching and can cause an increasing rate of west nile virus transmission. The causative virion, a strain in the Flaviridae family, relies on mosquitoes to be transported from birds to humans.

Punk rock skateboarders are providing a temporary solution. In fact, there is a growing movement of young boarders who are rolling around Fresno looking for For Sale signs. With an empty house, they break in, drain and clean the pool and skate until they get kicked out by police. While there is no question that these cats are trespassing, they might be doing all of us a favor by getting rid of all the stagnant water overlooked by a failing economy.

Health care reform is a polarizing issue that has an impact on all of us. President Obama's success as a leader will be intimately tied to the revitalization of affordable medical coverage. Medicare is implementing an electronic prescribing incentive program that provides a 2% refund on medicare billing for all physicians that have an accredited electronic prescribing system in place and in use for their medicare covered patients. The refund will turn into a penalty within two years in the hopes of increasing efficiency, decreasing prescription errors, and ultimately lowering costs for government funded coverage.

So wouldn't be nice if there was an easier way to save money? Proto, an excellent quarterly magazine published by the Massacusets General Hospital (sign up for free delivery), noted a study that questioned whether surgeons should be throwing out their sharpies. As per protocol, surgeons mark the site of the incision with a marker and then toss the markers to avoid contamination of one patient with the other's troublesome bacteria. A couple of doctors at the University of Alberta decided to look into this. Considering a sharpie uses alcohol based ink, the study showed that a quick alcohol swipe is all that is needed to disinfect this 2$ per writing tool. On a big scale, this can make a financial difference.

Can the knowledge that alcohol based ink is easier to disinfect be applied to other disciplines? Should we encourage skaters to drain our pools in exchange for a little noise and fun? Let's look around, maybe there are more unexpected opportunities.

A joke at every end:

A newly married man asks his wife, "Would you have married me if my father hadn't left me a fortune?"
"Honey," the woman replied sweetly, "I'd have married you no matter who left you a fortune."