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Tuesday Jan 02, 2018

New Year, Same Issues. Why Does Health Care Cost So Much?

As the new year begins, we asked our new physician bloggers what issues concern them for their practices and patients in 2018.

[blocks of 2017 turning into 2018]

The Exorbitant Cost of Care

According to CMS, the United States spends more than $10,000 per person each year on health care, more than any other country in the world. Way more. Also, the cost of health care continues to rise at a rate that handily outpaces inflation(fredblog.stlouisfed.org) in the rest of the economy. With that level of investment, we must be the healthiest nation, right?


In fact, we have some of the poorest indicators of overall health(www.cdc.gov) among developed nations, including lower life expectancy, higher infant mortality, higher rates of obesity and chronic illness. More than one out of three U.S. adults is obese, roughly half of adults are physically inactive and half of all adults have at least one chronic illness.

Much of the excess price tag goes to pay for pharmaceuticals and overuse of technology. Only the United States and New Zealand allow advertising for prescription drugs, and we have higher use of pharmaceuticals than any other developed nation.

The United States is the only country that does not cap, or in other ways limit, health care pricing. We also use technology such as CT scans at much higher rates than do other countries, and because there are no pricing controls, it is many times more expensive.

So, what are we getting for our health care dollar in 2018? That's a question we should all be asking. And unfortunately, the answer too often is, "Not much."

Peter Rippey, M.D., Bluffton, S.C.

High Deductibles Are Barrier to Care

My biggest concern for 2018 is patients struggling with high deductibles.

Increasingly, insured Americans are expected to pay for a larger part of their medical care before full coverage kicks in. This is particularly painful for people with chronic diseases who need labs, medication and diagnostic testing. An opaque pricing system often leads to these patients avoiding necessary care altogether.

There are some promising developments to help secure transparency and affordability for these patients, including the direct primary care model, but we should be conscious of this struggle regardless of our practice setting.

Ryan Neuhofel, D.O., M.P.H., Lawrence, Kan.

The Meddling Middle Man

I believe that the future of health care has the potential to be incredibly bright. Medical and technological advances are proceeding at breakneck speeds. To borrow the title of a book by Conrad Fischer, M.D., as physicians, we perform "routine miracles" every day.

In theory, we have endless storehouses of medical knowledge and countless resources at our disposal to save lives and reduce morbidity. However, we are not always able to use the most effective tools of our trade because of the prohibitive cost burden to the patient and the restrictions this places on us. It seems absurd to clinicians and is maddening to patients that we can't simply choose the treatments or tests that are most effective, but rather must settle on the best option for the most affordable price.

Cost-driven health care is one of the biggest problems we will continue to face until we deal with health care inflation and the exorbitant costs it generates. A big part of the problem is that we have a middle man, the insurer, arbitrating between the physician and the patient. Although I work for a hospital-owned practice and take most insurance, I am a big supporter of direct primary care, in which the doctor and patient work out rates and payment schedules directly. Although I'll concede that there is a necessary place for health insurance entities as facilitators in our diverse health care marketplace, an insurer (commercial or government-based) should not have a significant say in directing medical care. Clinicians should be free to make decisions in our offices in concert with the patient without a second thought about whether they might face a denial or require prior authorization.

Although a single-payer system would make things more straightforward in the sense that we wouldn't have to guess what is covered and what is not by each insurance company, I worry that such a system would further restrict care. In the end, I am for anything that results in optimal health care delivery while reducing counterproductive burdens for the physician and prohibitive costs for the patient.

Kurt Bravata, M.D., Bolivar, Mo.

Finding Needed Help

Payers frequently hound physicians about what they perceive as gaps in health care. For example, a 94-year-old woman who hasn't had a bone densitometry scan to screen for osteoporosis remains on one insurance company's list of patients I'm not properly caring for. Never mind the fact that she is homebound with metastatic breast cancer and is only interested in comfort care.

Payers look at patient data rather than at patients as individuals with poverty, food insecurity and the autonomy to make their own decisions. Sometimes people can't afford the gas money to get to a facility that does bone densitometry scans, or perhaps they have no interest in having a particular test or treatment.

What patients often do want and need is someone to help them navigate health care; help them learn how to keep a log of glucometer readings; help make a grocery list that fits their diabetes and their impossibly inadequate budget; and help find solutions to challenges they are embarrassed to admit they face, such as no access to running water or refrigeration.

Community health workers have become a vital part of my practice and my patients' lives. My hope for 2018 is that I don't lose the traction I have to prove their worth in a payer system that fails to focus on the patient.

Kimberly Becher, M.D., Clay County, W.Va.

Addressing Social Determinants of Health

There is much discussion these days regarding the identification of factors outside of traditional medicine that impact health. The development of social determinants of health screening tools has become more prominent in practice. However, the creation of an infrastructure to support answering these questions has seemingly been less well thought out.

I believe when we fully realize social determinants of health are not merely individual issues, but structural ones, we will then be able to reverse the epidemics of obesity, hypertension, diabetes, heart disease and cancer. It will depend less on family docs writing individual prescriptions and referrals to exercise, nutrition and housing programs, and more on us advocating for and creating environments where viable options are accessible, affordable and understood to be of importance in our communities.

This requires us to be more involved in creating policy that directly influences and impacts health at the local, national and global levels.

Venis Wilder, M.D., New York

Fill the Family Medicine Pipeline

I recently met a patient who hadn't seen a doctor in 10 years. He had insurance the entire time through his work. However, getting to a doctor was a cumbersome process while he was living in rural Arizona. Appointment times were all booked by others far ahead of his published work schedule, so an annual wellness visit wasn't worth the barriers to him.

Despite advances with insurance coverage through the Patient Protection and Affordable Care Act, millions of Americans still do not have true access to primary care because of the shortage of family physicians. The problem is only expected to get worse, with a predicted shortfall of up to 43,000 primary care physicians by 2030.(aamc-black.global.ssl.fastly.net) Unfortunately, only 11.7 percent of medical students chose family medicine as a specialty in 2017, a figure that has climbed only incrementally for years.

Luckily, growing the primary care workforce is being addressed from many angles: medical education, practice transformation, payment reform, physician wellness, workforce diversity, and so on. Family Medicine for America's Health,(fmahealth.org) a coalition of the eight leading family medicine organizations, has made student choice of family medicine a priority. Although the issue won't immediately get better in 2018, I'm hopeful we will see aggressive improvements in future years through a strategic and collaborative approach.

Natasha Bhuyan, M.D., Phoenix

Posted at 05:31PM Jan 02, 2018 by Peter Rippey, M.D.

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