A very small percentage of the patients in the healthcare system use up the bulk of the available dollars. Since I’ve written about quality of life vs. quality of death before, let’s focus on what conditions are driving the costs so high and what, if anything, can be done about it.
According to the Agency for Healthcare Research and Quality, the five most expensive diseases/conditions in the U.S. are trauma, heart disease, cancer, mental disorders, and pulmonary disorders. While a trauma patient (car accident) is something almost impossible to manage, the others are very often either preventable or are manageable with care routines different than those currently practiced. Unfortunately, these latter disorders are problems that patients can act to increase the probability of occurance. To make matters worse, our cost plus reimbursement system encourags providers to spend a lot of money to solve both these problems and related additional health issues.
Let’s look at the expenses genereated by providers.
The Commonwealth Fund, in a study authored by David Squires, compared the U.S. to other OECD countries to see whether we spend more per medical incident than our worldwide colleagues. Here are a few fun facts.
- We use more than twice the number of MRI (magnetic response imaging) tests as the OECD median.
- We use about 90% more CT scans as our other worldwide peers. (These are both per 1000 population.)
- We pay about twice as much for drugs as our colleagues around the world on a per capita basis.
As far as quality goes, we are showing no signs of better outcomes given our expenses.
- While not tied directly to the above mentioned tests, our asthma mortality is 4 times worse than the OECD per capita.
- Our amputations due to diabetes is over 3 times worse. (Getting direct cost to outcome data is hard due to a lack of definition of outcome and patient populations that are very diverse.)
The U.S. does excel on the most complicated diseases and procedures but that is because we have the best technology and physicians in the world; they are simply expensive.
So, we know that our doctors use the latest and most expensive technology a lot to seemingly little patient benefit in the main. Are the patients responsible for some of these problem as well? Of course, although nobody wants to address this problem because they are afraid of the political fallout. Consider these facts.
- Obesity, a major driver of heart disease and type 2 diabetes, as well as many other nasty problems, accounts for 10% of all health care costs.
- Type 2 diabetes is a disease largely driven by lifestyle and has a cost , counting medical and indirect costs such as lost wages, of about $251,ooo for men and $180,ooo for women lifetime. (American Diabetic Association Scientific Sessions, X Zho,2010)
- The CDC has estimated that 40% of the U.S. population is diabetic or prediabetic and that number could be 50% by 2020.
While it is true that some of these diabetes patients became ill through no fault of their own, most became diabetic because of being overweight, having a poor diet, not exercising enough, etc. Again, the CDC estimates that 35.9 % of our population can be classified as obese. We lead the world in this statistic, and obesity contributes heavily to many of the previously discussed condition.
Can people control their weight better than they currently do? Of course, but that requires insurers and doctors to force the issue, and that requires courage. We also need to have more preventitave care and primary care providers at a time when primary care doctors are leaving the system, or thinking of it, in record numbers. Oh, we are about to drop 30 million new patients into the system, many with problems at least as dramatic as those just discussed.
Could we price health insurance to reflect the patient’s propensity to make themselves more expensive? We could – this is done by the life insurance industry. Yet health insurers are unwilling, with the exception of pre-existing conditions, to take on this practice. And, of course, the Affordable Care Act will make it impossible to deny insurance on the basis of pre-exisiting conditions.
There is plenty of blame to go around on this overly expensive patient problem. We need all parties to step up: doctors with more comprehensive preventitive care; insurers with real outcome based pricing to incent doctors and patients; and patients to take responsibility for their own health and not feel entitled treatment no matter how irresponsibly they act. We are a long way away from this, and the math is about to get dramatically worse, starting this year as we implement “Obamacare”.
Since the insurance industry is central to “Obamacare” implementation, we’ll take a look at that next.