COST OF HEALTH CARE -- NAPA STYLE!

While the country seems fixated on the question of who is going to pay the bills for health care, we ignore the real question, which is addressed so brilliantly by Steven Brill in the March 5 edition of Time magazine:  Why are the bills so  #@%!* high to begin with?

 How about a perfect example of why, right here in the Napa Valley?  True story, but it needs to be “hypothetical” to avoid giving money to lawyers.

 Let’s say there is a young man, in his early twenties.  He has a bit of a tendency to hypochondria.  Nothing serious, but it’s there.  One night, let’s say he comes home late and reports a fainting spell.  No witnesses to this event, other than his drinking buddy.  On the basis of this claim, and others such as his heart “racing, then slowing”, he goes to see a cardiologist.

 He is told, based on an EKG and a stethoscope, that yes, indeed, he has an arrhythmia; more tests are required.  He does not get a simple stress test at that point—a treadmill and some electrodes—but instead what is called an electrophysiology study.  This is a minimally invasive procedure which runs a catheter through a vein or an artery into the heart, to look for electrical irregularities.  It takes place in a hospital, requires an anesthesiologist, and is much more expensive—and thorough--than a stress test.

 So let’s say at the conclusion of this “study”, no serious irregularities are found.  Everything looks great.  But let’s also hypothesize that, as the patient is coming out of the anesthetic, the doctor asks if the patient would allow him to implant a medical device under the skin on the left side of his chest, one that would measure any potential irregular heart activity and allow for the registry of that activity by another device.  That record could then be transmitted by telephone line, through a third device, to the doctor’s office. 

 The woozy patient is asked, Is that all right with you?  Let’s say that through the haze of anesthesia he agrees.  He sleeps a little, then wakes with pain in his chest—but the pain emanates from the place where the roughly 2-inch by 1-inch medical device has been inserted beneath his skin.

 So though the young man came through the test looking perfectly normal, he now has an implant which must be checked by the doctor at least every month or two.  And let’s say this “study” is meant to continue over a period of two or three years.   

 Imagine if they had, let’s say, actually found something critical.

 Ah, but let’s say we are not finished yet.  Let’s say: not by a long shot.  Though the doctors have finally decided that the young man’s condition is a very benign arrhythmia which will in no way impact his ability to work or exercise, they want to send him to UC Davis Hospital to undergo a cardiac MRI test.  These are among the most elaborate MRIs, and usually cost somewhere in the neighborhood of $3000, though that number can go as high as $5000.  All those involved acquiesce in this since, let’s say, they feel doctors know best.  When the young man gets to UC Davis on the day of his appointment, however, he finds they will not do the MRI, because such a recently-inserted implant will distort the results.  No coordination among the doctors and UC Davis Hospital was in evidence.  So the patient’s time, not to mention the time allotted on the machine, is wasted.

So let’s say then the doctors decide, why not do a stress test after all?  And the young man comes through that with flying colors, no problems.

 But the course has already been set.  The course that automatically consumes time and money. The young man is on a schedule to have his heart’s functioning monitored for the next several years.  He is scheduled for visits to the cardiologist every 30 to 60 days.  Oh, and the doctors have not given up on doing the cardiac MRI, either.  They continue to push for that, though there is now significant resistance from the young man’s parents, if not from him.  

 Because let’s say those involved are beginning to connect the dots.  There must be some explanation for the doctors’ illogical sequencing of tests, e.g., electrophysiology study and MRI before a simple stress test.  Not to mention their insistence on elaborate procedures based on little or no evidence of need.  Who is benefitting, after all?  The young man?  His situation seems clear, and luckily not dangerous.  The doctors?  Well—ahem—yes.  By ordering relatively complicated procedures which were not necessarily indicated, they provide themselves and the hospital with some handsome revenue, all at the expense of an insurance company, which is happy to tack on its margin and pass those costs on to the taxpayer and/or his employer in the form of higher and higher premiums.  Oh, and let’s not forget the giant corporations that make devices and equipment.  Medical device manufacturers are gold mines! They operate on huge profit margins, having successfully lobbied Congress to allow them to charge whatever they like for their devices.  The CEO of one of the largest among them made over $12 million last year.  Nice work.

 So, right here in Napa, perfect illustrations of what is so desperately wrong with our health care system.  Institutionalized corruption that has been in place for so long that no one questions it any longer—or if anyone does, influence and money silences them in a hurry. 

 Though some of our local curmudgeons would dearly love to make this travesty a partisan issue, with all virtue on one side, all vice on the other, the truth is that the way forward involves both sides giving ground.   For example, conservatives are correct that high malpractice insurance will motivate doctors to order insanely expensive tests which aren’t indicated.  Getting sued can ruin your day.  So tort reform is necessary, regardless of what advocates of trial lawyers say.  But progressives are also correct in debunking the idea that true “free markets” can exist in the world of health care.  Can we get it through our heads that American consumers of health care devices and services do not shop in a free marketplace?   The process is nothing like buying a car or a washing machine, when the public can compare features and prices.  Doctors and hospitals decide what devices, equipment, and services people will get, and those decisions rarely involve cost considerations.  The system is rigged to produce large margins, from the manufacturer on down, margins that finally end up as a fat balance on the consumer’s bill.  No one is responsible.  Rarely does anyone look at the bill until long after the fact; even then most patients cannot make sense out of the items on it.

 So the nation suffers from sticker shock, and looks for ways to alleviate the pain.  And what are the first remedies  voiced by our elected representatives?  You would think they would suggest ways to bring the cost of medical devices down, or to permit Medicare to negotiate volume-driven, lower prices for devices and equipment, as well as for prescription drugs.   No such luck.  Instead, to add insult to the injuries of America’s least healthy and wealthy populations, our representatives immediately begin talking about maybe raising the age for Medicare eligibility, or cutting back on benefits.  I mean, how could they look themselves in the mirror if they challenged the huge profit margins and the multi-million dollar executive salaries paid at Medtronics, or at Pfizer?

 The truth is, until our beloved Congress gets out from under the sway of the fabulously wealthy pharmaceutical and medical device companies, and allows for obvious, common-sense cost-saving policies, we will continue to see boxes of gauze pads billed at $77 each, $300 wheelchairs sell for thousands of dollars, and $2000-per-dose miracle cancer drugs show up on patient bills for $15,000.

 As usual, Americans will have to make plenty of noise to get their “representatives” to begin representing them.  Whatever we do, we will get exactly what we deserve.