This is the last of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 1 and Part 2.
I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input. We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works. But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws. In post, I look at the last of three central ideas that would lead to better and more affordable care.
3. Health Savings Accounts.
The third solution highlights increasing patients’ roles in their own health, which would lead to more patient satisfaction, and actually lower costs. This could be accomplished with health savings accounts. These accounts would be funded by patients with pre-tax dollars and contributions made by employers and/or government subsidy stratified based on the individual’s income and job status. With actual money in these accounts, patients would be able to discern costs better and use this money as if they were consuming any other good or service, such as handyman services. This money could grow each year like an investment account and even be passed on to heirs at the time of death, keeping that sense of ownership with loved ones.
In order for these accounts to work well though, hospitals’ and doctors’ prices need to be more transparent and reflect true costs so patients know what they are buying. Currently, that is impossible. Hospital and doctor bills make little sense, are falsely inflated (as described in Part 1 of this series), and do not reflect true costs, leaving patients confused about real costs to their health. When a patient hurts his or her knee, goes to the doctor, and the doctor orders an expensive MRI, there is no mention of costs. The patient’s insurance “covers” the MRI, making the costs a non-issue for that patient. There is no incentive to try ice, physical therapy, and rest before delving into an expensive MRI.
If the actual price was known for that MRI, patients could know what they are “buying.” This price would be significantly less than the inflated charges because prices would be required to be transparent. True prices would be published and patients could shop for MRI scanners just as they would for any other service. This would thus allow patients control over how they spend their health care dollars.
In the same light, during the last six months of our lives, we spend up to 50% of our own total lifetime health care dollars. In America, when patients are extremely sick and brought into the hospital, everything in our medical repertoire is used to keep them alive. Costs can be up to $10,000 per day of ICU care not including other aggressive measures.
Unfortunately, patients may not know these costs. With patient funded health savings accounts, patients would have more of a role in their own care, and could decide based on a doctor’s recommendation the best course of action, considering the patient’s prognosis, benefits, risks, and costs. Of course, families always have input into their loved ones health near the end of his or her life and can decide how aggressive they wish to be while talking with their team of doctors.
However, the way it is being done is likely wrong. Doctors are not bringing up hospice to patients early enough. Instead, many families with their loved ones are faced spending their last months in an ICU, hooked up to breathing tubes, only prolonging the inevitable. Patients’ and their families are being deprived of spending that time at home in a more comfortable setting. Quality of life is not being brought up, only quantity. An article in the Washington Post addresses these end of life issues extremely well, entitled “An unrealistic view of death, through a doctor’s eyes.”
It states that modern medicine may be doing more to complicate end of life issues, rather than improve it. The article also states that people think death is a failure of modern medicine rather than simply life’s natural conclusion. I am not saying that every patient in an ICU needs hospice brought up. Each patient is unique and families should decide based on their values and wishes. A previously healthy 28 year old involved in a car wreck who remains in an ICU may need months in an ICU to recover and would benefit from this long hospitalization.
However, a 90-year-old patient with other medical problems such as heart failure and kidney disease in the ICU with a new diagnosis of a terminal cancer may benefit from a talk with hospice. Every human being is unique in their health needs and I feel families and doctors need to be more open about goals of care at the end of life An interesting article details some of these issues, entitled “How Doctors Die.”
It basically points out that most doctors choose less, not more, care at the end of their life because they personally witness the limits to human medicine action. It illustrates that there is not always an answer or a cure and that doing nothing is sometimes the best care available. All in all, more patient ownership of end of life costs utilizing their health savings accounts combined with frank discussions with their doctors about these end of life issues would definitely lower health care costs and even help families cope with difficult illnesses.
The final suggestion involves preventing chronic illnesses that end up costing Americans a lot as they age. We are very good at treating complex medical problems with patients who are very sick, but not very good at reducing medical costs through preventative medicine. We are very good at bringing a new state of the art drug used to thin the blood to the market, but bad at actually preventing the reason for needing that drug in the first place!
In fact, 50% of our health care dollars ($623 billion) are spent on the sickest 5% of patients (30 million) in America. Interestingly, the top 1% of health care “spenders” accounted for 20% of the total health care expenditures in America. These are usually patients with multiple chronic medical conditions such as obesity, diabetes, kidney and heart disease. Studies often quote Americans as spending a lot on health care, yet being ranked lower than most other countries on health care outcomes. This is the reason these stats make sense. We spend a lot on patients who are very sick and can prolong their life, but do little to prevent them from getting sick.
Recently, Sanjay Gupta summed up the solution to this paradox very well in a CNN article. He basically states that increased access to health care with Obamacare would not improve our health outcomes. Rather, patients taking ownership of their own health and holding themselves accountable will promote a healthier America. Eating better, exercising more, and reducing stress can go a long way. It would also reduce the likelihood of developing these expensive chronic medical conditions, which drive costs higher.
In conclusion, I feel that Capitol Hill needs input from doctors working in the front lines to discuss our issues so that the best reform possible can be made. Doctors experience all of the above issues on a daily basis and have insight that politicians cannot observe since they do not spend time in doctor’s offices or hospitals. These are a few issues that would help our deserving patients get the best care and restore that critical relationship we need with our patients.
I believe that by empowering patients more in the health care system through health savings accounts, reforming our tort laws, making costs more transparent, being more realistic about end of life issues, and living healthier, we can come a long way. I hope we can work together with lawmakers to create a system that can benefit everyone.
-Matthew Moeller is a practicing Gastroenterologist. He can be reached on twitter (@DrMMoeller).