When the Big Guys Don't Follow the Rules

By Stephen Christensen, MD

It's no secret that American health care is outrageously expensive-in 2006, we spent more than $7,000 for each man, woman, and child in the US. Within 7 to 10 years, health care expenditures are projected to consume 20% of our gross domestic product. We spend more per capita for health care than any other nation on earth, yet we consistently fall short of enjoying the same quality of life that citizens in other countries do (World Health Organization data for healthy life expectancy, infant mortality, and other important benchmarks show the US system to be surprisingly lacking). We could debate the reasons behind this dichotomy all day- indeed, the topic would be at the top of everyone's list if it weren't for the sub-prime meltdown, Iraq, and the presidential campaign- but when all the chaff is sifted from the argument, the problem can really be stated quite simply: American health care is so expensive because we have packaged it and advertised it for sale.

We cannot contain medical costs because the very people we have charged with this responsibility are the ones who stand to profit from ever-increasing costs. According to Robert Kuttner (The New England Journal of Medicine, Feb. 7, 2008), "...profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent." Furthermore, research indicates that between one-fifth and one-third of all medical outlays do nothing to improve health.

What are we to expect when we allow insurance companies, the pharmaceutical industry, and conglomerates of investor-owned hospital corporations to set up their own incentive structures, establish rules that govern all the other players on the field, and then play by an entirely different set of rules themselves? How have we come to believe that, on the one hand, incentives will lead to cost containment when, on the opposite hand, those incentives are by nature designed to drain more money from the market?

The usual market forces (supply, demand, competition, productivity, and quality) that control costs in other sectors don't seem to apply to this commodity we call "health care." One telling problem- and here I paraphrase a statement made by Victor Fuchs many years ago- is that we perceive health care to be a privilege that all can enjoy, but we market it as though it is a right for the chosen few. Due to a truly discriminatory insurance system, many citizens who most need medical services can least afford them. And we continue to sidestep those measures that could control costs, such as offering universal screening programs or standard treatment protocols for those conditions that have been shown to improve with widespread application of such programs. Instead, because standardized protocols, screening programs, and other public health measures aren't as lucrative as specialty treatments, we allow the "rule-makers" to promote those modalities that bring in the most profit (simply by offering to pay for these services while excluding those that offer lower profit!).

The following serves as an example of how perverse this "managed economy" has become: In order to divert attention from the real causes of escalating medical costs, the private insurance industry has, in the main, shifted the burden of cost containment to primary care doctors (family physicians, general internists, pediatricians, etc.). Thinking that doctors are motivated by salary, the insurance companies reduce the amount they pay the physicians for each visit, believing that doctors will simply increase the number of patients they'll see in a given day. So, the insurers appear to be "cutting the costs of medical care" while the providers of that care run harder to keep up with repeated cuts in their reimbursement per visit...inevitably, the real losers in this scenario (if you don't count the physicians, whose quality of life is abysmal and whose overhead costs per patient often exceed reimbursement) are the patients.

The truth of the matter is, any physician trained in any accredited institution this side of Mars will tell you that the time we spend with each patient is the single most important factor in determining a proper diagnosis and treatment plan. When our time is squeezed, patients tend to fare more poorly, and we know it. So, in order to compensate for the lack of time spent with each patient, we order more tests or arrange more specialty consultations to ensure our people get the kind of care they've come to expect. Thus, the cost per patient rises...but now it's the physicians' fault.

In closing, I once again turn to Robert Kuttner, whose eloquent treatment of this matter far surpasses my strident emotionalism:

"Despite our crisis of escalating costs, dwindling insurance coverage, and deteriorating conditions of medical practice, true national health insurance that would not rely on private insurers remains at the fringes of the national debate. This reality reflects the immense power of the insurance and pharmaceutical industries, the political fragmentation and ambivalence of the medical profession, the intimidation of politicians, and the erroneous media images of dissatisfied patients in universal systems."

Enough said.

Stephen Christensen, MD, a board-certified Family Physician, practiced rural medicine and emergency medicine for nearly two decades before retiring in 2003 due to visual impairment. He continues to advocate for responsible and effective health care policy, and he believes that not all is well with American health care. His interests include not only conventional Western medicine, but encompass such topics as Ayurvedic medicine, herbalism, homeopathy, and energy healing. Visit his blog at http://www.naturallyimmunemd.com