The cost of healthcare is a major problem and getting worse, as demand for healthcare services grows relentlessly. Some believe that direct to consumer advertising of costly drugs and tests is the problem. Others think that containing demand by forcing people to pay more out of pocket for their health care expenses is the way to reduce costs. But to me, the real crux of the cost problem isn’t pharmaceutical advertising or recreational MRIs. The highest costs by far are generated by people with chronic illnesses who need lots of medical care. Kenneth Thorpe, a professor at Emory University, has created a great chart to illustrate this problem. Using data from the Medical Expenditure Panel Survey (MEPS), he has shown that 20 percent of the population account for 78 percent of health spending and 30 percent generate almost no costs at all.
That the sickest people consume a disproportionate share of our country’s health care resources leads to two important conclusions. First of all, it makes sense to concentrate on this group and try to do a better job of managing their care to avoid costly hospitalization. Many providers and insurers across the country are working on this approach. At MGH, we are part of a national demonstration project in which 2,500 chronically ill Medicare patients are receiving practice-based care management and other special efforts – education, family support, mental health services, and end-of-life services – to help better coordinate care and avoid hospitalization. Our early results are promising, but it is too soon to say we have found the answer. I am convinced, though, that care to the chronically ill is the right place to focus attention to make a sustainable difference on cost, for the simple reason that it is where we spend, by far, the most money.
The second conclusion is that for health insurance to work there needs to be universal participation. Having insurance coverage is essential for patients with chronic illness so that they get access to the resources, preventive services, and medications they need. The basic idea of insurance is that it distributes the burden of cost across a population so that coverage is available for all (even though it may not be used by all) in a given interval. This means that healthy people should pay for medical insurance too. That isn’t an infringement on personal liberty; it’s the way insurance works. Individuals and employers who don’t pay for insurance aren’t just avoiding cost for themselves, they’re increasing the cost for everyone else. Illness or accident can strike any one of us, at any time. It is our collective responsibility to share the expense.
David F. Torchiana, MD
Chairman and CEO
Massachusetts General Physicians Organization
We’re learning more about Clinical Disappointment–for instance, we’ve discovered that environmental factors (like undesirable events) can trigger Disappointment in persons that are predisposed to the disease.
The concern (not to be confused with Clinical Concern), is that Clinical Disappointment seems to be on the rise: 130 million Americans suffer–and I mean suffer–needlessly from it in any given year; and the numbers are rising. The good news is that effective treatments are available for Disappointment. Disappointment hurts. And we think serotonin may be involved. Or bad events.
Moreover, we’re now seeing frequent cases of Clinical Humiliation (we’re not sure what the cause is, but it seems to be concomitant in persons exposed to humiliating circumstances–but we’re working hard to find genes for Humiliation). We think it’s underdiagnosed.
But our worry (not to be confused with Clinical Worry–for which safe and effective treatments are available (serotonin may be involved)) is that we’ll need to staff up for a cure to these diseases–which are just as debilitating and more numerous than diabetes, heart disease, kidney disease, and pulmonary disease combined. Yes it’s true that these diseases are expensive to treat, and we’ll have to work hard to raise more money for research, but the outlook for Clinical Disappointment in the state is ominous. If more people lose jobs, or homes, they may suffer from Disappointment; it means more resources will have to be diverted to helping those stricken by the illness.
It’s called insurance if an underwriter creates a reasonably priced product that addresses a risk for which someone is willing to indemnify him/herself.
Willing only if the risk is reasonable.
Not willing if diseases are simply invented for the sole purpose of inflating the bottom lines of an industry. Not willing if the corporate world–abetted by professional liberal patients–creates a society of fragile hothouse flowers.
Not willing if every cheerleader mourning a rejection is given a BS clinical diagnosis because that’s what it says is available on subway and magazine adertisements.
Not willing if cardiac operations are the ticket to establishing a suburban front on the Health Care (TM) empire.
Not willing if they’re just going to schedule wellness check-up visits, months in advance, in order only to justify having several thousand dollars robbed from their savings (check ups involving the little more than stethoscope, bp, nose, and ear exams that were assailed as essentially-meaningless legacies of early 20th century medicine in published reports a few years ago). Money they could otherwise have used to pay for an allergy shot, or a dental bill, or an eye exam.
A few business leaders–other than those representing Health Care (TM)–are competing for that same elusive dollar from their 45 million countrymen, and counting, who don’t subscribe to the HC industry pitch. Their economies will see declines as a result of lost revenue. But some corporation has to come out on top–it might as well be HC (TM).