No one can deny the heavy price tag of health care in the United States — in fact, we have the priciest health care in the world. Some might jump to the conclusion that this would mean we also have the best health care, since increased spending means increased capacity to provide a higher quality of care, right? But according to the World Health Organization (WHO), we consistently fall short when compared to other nations in areas like life expectancy or speed of health services. While there are criticisms regarding exactly how organizations like the WHO or the Commonwealth Fund rank health care systems, it is no secret that we are consistently underperforming compared to other developed nations. So why do we spend so much and why does this fail to translate to quality care?
It’s easy to attribute rising costs to administrative overhead costs or the complicated private insurance system, and there are legitimate arguments to support these rationales. But a more interesting perspective is presented by Atul Gawande, a surgeon and widely recognized best-selling public health journalist. According to Gawande, our increased health care spending is less about the structure of our current health care system, and more about key social features that affect how doctors practice medicine today — specifically, our mentality that “more is better.” I appreciate his one example, where he presents a case to a group of physicians and asks how they would care for this patient 15 years ago versus today. The case is a 40-year old woman who presents with chest pain (that subsides on its own) following a fight with her husband, with workup that shows a normal EKG in a patient with no known history of heart disease. Unlike in the past, when she would be sent home with nothing more than a stress test, today she would be treated with the works — stress test plus an echocardiogram, mobile holter monitor, and cardiac catheterization. This trend is obvious at higher spending centers, which have increased rates of diagnostic testing, hospital treatment, surgeries and home care.
Disturbingly, the trend of more care also seems to be associated with lower health quality rankings — Louisiana, Texas, California and Florida have some of the highest spending rates but rank near bottom in terms of the quality of patient care. In fact, patients in higher spending regions receive more care but fare no better in terms of survival, function or satisfaction with care compared to lower-spending areas.
So why do we order more tests now than in the past when there is no obvious health benefit for our patients? Initially I thought it could be due to increasing malpractice insurance costs and the need to evade any kind of liability, but Gawande presents a view that seems almost sinister — that we are treating health care as a business, essentially a revenue stream for physicians. Since we currently compensate physicians not based on patient outcome but on services provided, there are financial incentives for physicians to provide more procedures, even if they may not be indicated. Some hospitals even provide physicians with a share of hospital profits from tests, surgery or other care if those same physicians provide patient referrals. If financial considerations drive a doctor’s decision for treatment, then health care really has become a for-profit business — the patient is no longer the priority.
This is not necessarily the fault of the physicians or hospitals, since no one is teaching us in medical school or residency how to think about money (for instance, which procedures are covered for a patient, how to deal with insurance rejections, government-reimbursement rules, or how to finance malpractice insurance). Similarly, not all physicians may be spending more on care simply to create a revenue stream; others may just be oblivious of the financial implications of their decisions or want to use extra finances to improve the quality of care they deliver (such as spending money on upgrading their EMR or offering expanded clinic hours). Hospitals only recognize whether or not they are balancing the books, not necessarily the impact they are having on the health of the community or whether or not they are more effective than similar hospitals in the area. But clearly, we need to work towards a healthcare model that not only considers the health of the community, but also the cost of care delivered.
Moving towards a more cost-effective approach is the Mayo Clinic, which prides itself as a high-quality low-cost system that does what it can to reduce waste, even if it means sacrificing revenue for the hospital. How does this model get around financial incentives that steer decisions away from what is best for the patient? They pool the money the doctors and hospital system receive and divvy it out as a salary, encouraging collaboration, shared expertise, more thinking and less (unnecessary) doing. Here, doctors are not paid for the quantity of services they provide but for the quality of care they deliver; they are paid not as individuals but as members of the team.
Now, the structure of the Mayo Clinic may not be flawless, but it does seem to reflect the ideal — a team approach that spends less while still doing what is best for the patient. Free from the cost-for-service system, the physician doesn’t order test after test willy-nilly, but instead has a guided approach that is based off of a solid history-taking and physical exam. Isn’t that what we are striving for as physicians? Maybe if we started to use our brains more before jumping to action, we could save more lives and money in the long-term. What I know for sure is that health care does not fit the typical business model, and we need to stop treating it like one; otherwise we are not only compromising our patients, but also our competitiveness in health care on a global stage.