Thursday, July 9, 2009

Have Doctors Been Complicit in Driving Healthcare Cost?

“Doctors have been complicit in driving up health care costs. They need to become part of the solution.” ~ Editorial: Doctors & the Cost of Care, New York Times, 13 June, 2009

“The greatest threat to America’s fiscal health is not Social Security. It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.” ~ President Barack Obama, in a March 2009 speech at the White House.

“Medicine has become a pig trough here. We took a wrong turn when doctors stopped being doctors and became businessmen.” ~ Dr Lester Dyke, Cardiac Surgeon, McAllen, Texas

Healthcare Cost has Escalated
Last night, while I was having dinner with some friends, I was once again reminded that perhaps health care cost in Malaysia has escalated beyond the pale of inflation or affordability.

A close friend whose brother was suddenly taken ill with haemorrhagic fever was admitted into a Klang Valley hospital, where he developed complications one after another. He bled into the gut, and also into the brain, went into shock which also led to kidney failure. He was transfused profusely, had intensive critical care, required haemodialysis, and was consulted by at least 4 specialists including an internist, a nephrologist, a gastroenterologist and a neurosurgeon. Sadly, after 9 days of deteriorating multi-organ function, he died. And the bill exceeded an unexpected RM45,000.

That was the crux of the complaint—why was the bill so high, and was there any overcharging, and if not, were our doctors' billings too excessive, if not too exorbitant?

There was a suggestion that perhaps under such complex illness requiring multiple physician input and management, there could perhaps be more coordination, and perhaps an attenuated billing system of professional fees. The aggrieved family lamented that almost all the doctors charged the maximum complex fee for each visit, although, most of these visits appear cursory and lasted just a few minutes per time. The gentleman noted that some of the physicians did not simply consult with this one patient, but attended to a few others in the ICU at the same visit, so why had he charged so much?

To add fuel to the fire, when he complained to one of the hospital directors, he was told that nearly all the doctors had begun charging the highest rates ever since the new regulations came into being—putting squarely the blame on the Ministry of Health for including the fee schedule in the Private Healthcare Facilities and Services Regulations, in 2006. He further added that when the physicians first started practice at that hospital, they were all driving Protons, but now all have upgraded to expensive imported models!

Such fatuous unthinking comments can only contribute to unhappiness and feelings of possible overcharging in the minds of grieving relatives. These also underline the unspoken or misspoken envy that many hospital administrators harbour against many of our professional doctors, whom they perceive as perhaps earning too much!

This recent anecdote demonstrates the complex nature of the healthcare cost conundrum, not just in the USA, but closer home, in our own backyard as well.

Modern Medical Care is NOT Free Lunch

One sad fact which is misunderstood, is that healthcare is or should be readily affordable to everyone, including the least endowed. There is that public expectation that while life-saving care should be universally available, it should never be too costly, because this can potentially cause severe hardship to, or even bankrupt the victims of such unforeseen medical disasters.

But it is precisely these forms of catastrophic illnesses which are frightfully expensive; particularly when many high-tech measures have been engaged to try reverse or even to ameliorate deteriorating bodily functions.

Intensive care therapies with multiple organ support measures, including close monitoring and mechanical ventilation support, are very costly. Actual costs of using mechanical ventilation, oxygen therapy and supporting medications and close scrupulous monitoring, can easily rake up to RM3000 - RM5000 per day (excluding physician fees)!

Unfortunately again, this has not been made known to the public at large, because either some third party payer had been reimbursing thus far, or that many continue to assume that these therapies would be charged at rates equal to those at public hospitals.

Here is the conundrum: our public hospital charges are massively subsidised through our tax dollars! These are not free lunches, and cannot be transposed so easily into private settings, where every penny has to be counted and balanced!

Here too lies the failure of our government to address and expose the real cost of healthcare. We have been cross-subsidising healthcare costs for so long and offering our citizens' healthcare cost at such ludicrously low rates, that they have grown accustomed to these unrealistic levels.

Of the 12.9 billion ringgit government spending on health care, the public had paid only a miserly 2%, according to Health Minister Dato' Sri Liow. Thus, the public healthcare sector is 98% subsidised by our tax dollars!

Unfortunately too, our health insurance (private prepaid plans) take up is still notoriously low, with less than 15% (11.9 to 14.4%) of the private health care expenses being paid for by such means. Most private health care expenditure (73-75%) is still paid out of pocket!

Yet, most citizen and consumer groups are still clamouring for the continuity of such practices, believing that our poorer segments of society must never lose out to every 'reasonable' medical care whenever they need these. Just what is defined as 'reasonable' medical care remains to be agreed upon! Laudable as these social affirmative aspirations may be, they are seriously flawed, when we have an unapologetic proclivity to an undisguised market-driven economic model.

Until and unless this economic model changes, there is little hope for some semblance of balance in health care considerations. Hence, the reality bites are such that some form of rationing and queuing must accompany every possible healthcare system where we have finite resources, but infinite needs!

We simply cannot afford to offer every possible technologically-advanced therapy to everyone on demand! Or even on need! Someone has to pay for this, and even though most nations in the world claim to have some form of universal access to healthcare, none can ever offer every possible medical care to anyone, everyone, on demand, every time!

We simply have to understand that while we can strive toward some form of universal access to healthcare, we also have to accept that some degree of delay, queuing, even rationing based on cost-effectiveness and affordability will have to be made by some medical authority or health economist.

Our public must be made to understand that that is the social contract for cheaper or hugely subsidised healthcare—that some form of delay is inevitable and that everyone needs to be patient and trust that the system would be fair in its distribution of the healthcare largesse.

Others who choose to deviate from the common pool will invariably have to pay more, and perhaps in an unfair manner, may demand some quicker access, some queue jumping or even some more heroic therapeutic measures, which on economic grounds might not have been justifiable, without the extra infusion of cold hard cash!

Fair for some isn't fair for all. But such is the power of capital and greater funding... It does not pretend to be socialist or utopian in equitable distribution.

Modern Advances demand Greater Utilisation, hence Higher Costs
Modern advances in measures to keep patients alive or support their recovery, are often accompanied by extremely expensive techniques and medications. Sadly, the availability of these new advances have led to increased demand and utilisation, rightly or wrongly!

There has always been this tendency by health workers and doctors to use more devices, more tests, more new therapies simply because these are available. Increasingly, informed IT-savvy patients are now also demanding more that should be done, even with fringe or outside chance benefits!

Thus, inadvertently, doctors and demanding patients alike contribute toward this increased cost by utilising more resources.

Do these necessarily improve survival or save lives? Often this is difficult to calculate with certainty, although on the individual basis, most doctors would swear by their efficacy and cost-efficiencies—each life saved or improved, is nevertheless one more life salvaged—whatever the costs!

The reality is that we cannot afford this on a universal scale! So we will have to re-look into this system gone awry. We have to re-tweak the system to ensure that it does not self-destruct from institutional collapse!

With regards to the above unfortunate patient though, it is regrettable that he did not survive despite the heroic measures that were attempted to sustain him. But, were the costs justified? That is another question, which many doctors have to consider and contemplate more and more. We have to decide how much to do, to refer, to test, to treat, or to let go, on some of these difficult professional actions.

Should we now have to consider the economic angle early, even as we struggle our level best to salvage a critically-ill, even terminally-ill or futile patient, without being accused of despondent incompetence?

How much do we need to temper our increasing dependence on and utilisation of newer and newfangled devices and measures to artificially support failing bodily functions? Is the cost of terminal or futile care justifiable even if there was just that very slim glimmer of hope?

And finally, do we as physicians need to charge at our extreme limits just because these patients are difficult and complex to manage, although our actual consulting moments with our patients appear so transient, sometimes cursory, sometimes callous, to their loved ones looking in?

Do we need to educate our patients and their relatives that the medical consult is not simply that few minutes of coming by the patient, that cursory examining of their pulse, or BP, or a quick scan of the charts?

Should we inform them that deep within our buzzing minds, we are always contemplating, making algorithmic decisions and choices, interrogating test results and assimilating previously learnt knowledge, past training experiences and newer information, even as we just sidle past our bed-ridden patients and auscultate their chest, or palpate their abdomen, out of dispassionate automatism rather than unfeigned examination?

Must we indeed demand and earn our professional fee that we feel we are entitled to, rather than out of duty and compassion...? Are we guilty of contributing toward the skyrocketing healthcare costs, and shouldn't we perhaps learn to temper this relentless trend?

How much can we value our professional skills in terms of monetary equivalence—how much do we cost our services, and to which level are we willing to take this inchoate economic appraisal as an increasingly specific service commodity?

How can we temper our economic worth vis-a-vis our vaunted altruistic benevolent vocation, our professionalism in a consumerist market-driven economy? When is enough, enough?


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