Sunday, August 21, 2011

Steve Schroeder on Why We Can't Contain Medical Care Costs

Steve Schroeder, a friend and medical school classmate I've admired since our first day in anatomy class together, recently published his "Personal Reflections on the High Cost of Medical Care" in the Archives of Internal Medicine. Steve knows medical care and the health system inside out. He's a wise person who we should listen to.

Steve reviews a series of cost-increasing areas and efforts to change them that he and his colleagues have studied: unexplained variation in the use of medical services; protechnology payment bias; increased use of medical technologies; escalating hospital expenditures; expansion of the use and numbers of special care units and more intensive care at the end of life; overreliance on expensive medical specialists; medical malpractice; and, patient/family/public expectations.

Steve's conclusion doesn't support optimism about current efforts to "bend the cost curve":
During my professional lifetime I have witnessed a succession of individual cost containment strategies, each theoretically legitimate but each doomed to failure because they were either insufficient as a single intervention or ran up against political opposition to vigorous implementation...Implementing these strategies has been like squeezing a balloon—the desired specific change (eg, lower hospital length of stay) may occur, but compensatory adjustments (eg, growth of hospital intensive care units [ICUs] and outpatient imaging centers) negate overall savings.

...given our past performance, it seems naïve to assume that these latest efforts [electronic medical records, curbing fraud and abuse, paying for performance, and comparative effectiveness research - all part of the Patient Protection and Affordable Care Act] will be any more successful than their predecessors. In the long run, reining in costs will require mobilizing political forces that can withstand the inevitable claims of rationing sure to come from the industries currently benefiting from the 17% of the economy spent on health care, and from consumers who have come to expect unlimited access to what they feel they need. Until there exist sufficient countervailing forces so that a comprehensive, multipronged strategy could be implemented, politicians and health policy experts will continue to embrace tepid and ultimately ineffective solutions that may sound good in theory but will fall short in practice. (emphasis added)
If we needed any more evidence for U.S. paralysis about controlling costs, the politics of Medicare provides it. When Democrats proposed Medicare savings as part of the health reform process, the Republicans trounced them in the 2010 elections. When Paul Ryan proposed Medicare savings, Democrats won the 2011 special election in a traditionally Republican district in New York state.

As I see it, we won't "bend the curve" nationally until (1) the public demands it and (2) we establish an overall national budget for health care. It will take more of a crisis and better political leadership than we've yet experienced for this to happen. As Steve points out, we've been calling the health care cost curve "unsustainable" since he and I finished our training. Since then we've gone from spending 7.5% of GDP on medical care to our current level of 17%.

If Winston Churchill were alive he would remind us of his prediction - that Americans will always do the right thing, but only after we've exhausted all other options. Steve Schroeder suggests that we've not finished exhausting our capacity for wishful thinking yet.

As I wrote the previous sentence, which I intended as the end of this post, I thought of a teaching session during my psychiatry residency. A psychiatrist who specialized in alcohol treatment urged us to approach chronic alcoholics who made recurrent visits to the emergency room with respect. "You'll say the same thing about recovery and AA the first fifty times you see him - but on the fifty first visit he may be ready to hear you."

Our national capacity for denial and well-intentioned pseudo solutions to runaway healthcare costs is like the cognitive distortion folks with alcoholism suffers from. But if "hopeless alcoholics" can bottom out and recover, so can our country, drunk as we are on healthcare fantasies!

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