As the nation debates competing plans to overhaul our health care system, critics from President Barack Obama on down seem to see the growing proportion of the gross national product spent on health care as an apocalyptic, unsustainable trend. Their suggestions for fixes range from electronic medical records and reduced pay for specialists to a single-payer national health insurance.
But none of those things will solve the problem of ever-increasing health care costs.
It is not that the current clamor to resolve the health care crisis is ill-timed or ill-motivated. It is not that the current debate tries to address too many problems and attempts to kill too many birds with one stone. Rather, it is that the debate is aimed at the wrong birds – the focus is on the wrong issues.
As a specialist in pulmonary and critical-care medicine with 30 years of experience, I have my opinions (some would say biases) on these health care issues.
The electronic medical record slows me down and diverts my attention from the patient to the computer. The record may contain all of the patient's medical history, but it is rare that I really need to read every note anyone has ever charted.
Any hospital-based nurse, recently hospitalized patient or the patient's family members can attest that the electronic charting takes nurses away from the bedside with increasing demands for digital documentation. These computer records may improve accounting, but not health care.
Similarly, the idea of shifting dollars away from specialty care to primary care as a way to drive down costs is naive. It is also a somewhat insulting suggestion. Primary-care physicians are already motivated to try to keep patients healthy. All physicians are. We get paid when patients get sick and need treatment, but we want to keep our patients healthy.
When a patient needs surgery for colon cancer or breast cancer, when she gets pneumonia or has a heart attack, will paying less to the specialist for treatment improve health care? I may wish there were fewer fires, but reducing the number of firefighters won't make it so. We could do more, perhaps, to prevent fires (and illness), but when prevention fails, we still need people trained and ready to respond.
Finally, creating a national health insurance to cover everyone will probably increase costs, not decrease them, just as feeding the world's hungry three full meals a day would not reduce our grocery bill. Personally, I think instituting universal health care is the humane thing to do, but let's be honest: Somebody will have to pay for it.
So impose an electronic medical record, "incentivize" physicians differently, cover everyone in the country with medical care, be it single-payer or private insurance. This still does not address the root problem causing our health care costs to climb. These are the wrong birds.
No matter how well a physician treats hypertension and cholesterol, or electronically charts, or avoids specialty referrals, the human body wears out with age. And when it wears out, it needs medical care to keep going. Providing that care – and increasing amounts of it – costs money.
Recently I had a 92-year-old patient with renal failure. She had had a stroke and was mildly demented. Despite her caregivers' best attention, her thin, frail skin had some pressure sores. Her legs were swollen, the inevitable consequence of an old, weakening heart. She no longer gasped for air because her costly oxygen temporarily relieved that symptom. With her family – educated and caring people – saying that they wanted "everything done," we consulted a nephrologist about dialysis. He strongly recommended against it but assented to the family wishes. And so the patient was transferred to the intensive care unit, or should I cynically say to the "expensive care unit."
The patient got great care from the nurses, aides and physicians – as I hope all my patients do – and she was discharged back to the nursing home. This is a typical scenario, not an exception. It illustrates how a lot of the health care dollar is spent.
No amount of vaccinations or lowering of lipids or anti-hypertensive medication would have prevented that episode. If you wanted to eliminate the costs associated with that patient's treatment, you would have to empower somebody to deny the care she and her family desired.
To borrow a popular expression, the elephant in the room that nobody addresses is the "R word": rationing. Without limiting access to expensive procedures, we are not going to make much more than a dent in the increasing cost of health care.
Personally, I don't want some bureaucrat making arbitrary decisions with life-and-death health care issues. To be honest, I'm glad we have people who fight fires, and I'm willing to pay for their services.
Dr. Tom Shragg, a medical doctor and Sacramento resident, has practiced in the fields of pulmonary and critical-care medicine for more than 30 years.
