Waste and the Cost of Care
Being against waste is one of those “no-brainer” positions. NPR recently ran a story based on a ProPublica publication outlining examples of waste and overuse of medical care. “Wasteful use of medical care has ‘become so normalized that I don’t think people in the system see it,’ said Dr. Vikas Saini, president of Lown Institute, a Boston think tank focused of making health care more effective, affordable, and just. ‘We need more serious study of what these practices are.’” The article then goes on to focus on what might best be described as the intensity of services, which is subtly different from waste.
As it happens, I have two recent “case studies” that illustrate the challenge of defining, much less reining in the intensity of services. The first patient is a 92 year old woman who has an incurable, painful chronic disease, and has made the decision with her family that she is to be treated palliatively. Recently she had a flare of symptoms and her daughter, an experienced RN, took her to the Emergency Room for relief. Despite telling everyone the goal of care was palliation, she had to “fight off” a couple of nurses and at least one ER doctor and one hospitalist, who kept insisting she needed tests to further define her problem. Now the tests they wanted to do were appropriate tests for the usual patient with her problem set—it wasn’t a case where they just wanted to do tests. Further, neither was going to profit from doing the tests. But they were anxious about not doing “standard” care. After three hours of argument, she was finally able to persuade them to leave things as they were. But what if she was not an RN and not a forceful advocate for her mother’s care? What if she succumbed to feelings of guilt about not doing “everything” for her mother?
The second case is a 75 year old man I first encountered more than 30 years ago. He was admitted with a myocardial infarction and underwent coronary artery bypass grafting. He seemed to be doing well, was extubated post-operatively, and then had a cardiac arrest with prolonged anoxia. This left him with a spastic paralysis, aphasia, and pituitary apoplexy. For more than three decades his atrial fibrillation was treated with digoxin, he was not anticoagulated, and he was on replacement hormones for his pituitary apoplexy. His wife has struggled to continue to care for him at home, to pay for his medications, and has managed to do so. Recently, his insurance situation stabilized, and he was able to acquire a new primary care doctor, who referred him to a new (young) cardiologist. The cardiologist stopped the digoxin and replaced it with amiodarone. Then he had hematuria and got a CT scan that showed a bladder tumor, and now he is being scheduled to have that resected. He still has a spastic paralysis, but can walk some, has great difficulty communicating, but is presently feeling okay. Here again, each of the actions was “correct” in the sense that he was getting current “standard” treatment. The fact that he had done well with the previous standard treatment, which is cheaper, was apparently not enough to override the decision to go with “standard” care. He has a drug plan, so the wife’s out of pocket costs are not a major issue, but what of the cost to the system?
These two cases illustrate some of the pressures that drive intensity of service, but neither case is an outlier where the problem can be labeled “waste.” The NPR story looked at this question more in examining variations in use of the intensive care unit and noted there is no good way to determine appropriate from “wasteful” use, despite headlines to the contrary.
A recent article in the medical literature, summarized by the New York Times, suggests even if we could tackle the intensity of service question it might not matter much. The authors reported on a study looking at personal health spending costs from 1996 to 2013 controlling for the size of the population, age, and co-morbidities. They also factored in utilization of care as well as the intensity of hospital services, combined with the price of care. They found personal health care spending rose at a 4% annual rate, compared to a 2.4% growth rate in the whole economy. Interestingly, change in health status over the years was associated with a 2.4% decrease in health spending, much of which was accounted for by improvements in cardiovascular care.
“Did we do more for patients at each health visit or inpatient stay? The JAMA study found that, together, these accounted for 63 percent of the increase in spending from 1996 to 2013. In other words, most of the explanation for American health care spending growth—and why it has pulled away from health spending in other countries—is that more is done for patients during hospital stays and doctor visits, they’re charged more per service, or both.
Though the JAMA study could not separate care intensity and price, other research blames prices more. For example, on study…found that spending growth for treating patients between 2003 and 2007 is almost entirely because of a growth in prices, with little contribution from growth in services…”
In my area, at least five hospitals have closed, and several more are barely functional, so demand for service continues to rise at my principal hospital, yet many of the patients are not able to pay for the care, even at government prices. Unfortunately, both hospital and physician resources are running low, and there is little resilience to cope with further increases in demand for services. One consequence is there is little time for thoughtful reflection on the best course of care for individual patients like the two I presented earlier. It is more “efficient,” to just do standard care. And if you are already two patients behind, there is not much incentive to linger. And while hospitals rely on fee-for-service payment, there really isn’t much incentive to limit demand. So, we have a perfect storm—care costs too much, a lot of it doesn’t help, and almost no one has an incentive to do anything about it unless they run out of people to provide the care. It is not clear what it will take to cut this Gordian knot—but current efforts haven’t made much a dent.
11 January 2018
 Allen, Marshall. Epidemic of Health Care Waste: From $1,887 Ear Piercing to ICU Overuse. 28 November 2017. Accessed 29 November 2017 at https://www.npr.org/sections/health-shots/2017/11/28/566782929/epidemic-of-health-care-waste.html.
 Frakt, Austin and Carroll, Aaron E. Why the U. S. Spends So Much More Than Other Nations on Health Care. NY Times, 2 Jan 2018. Accessed same day at https://www.nytimes.com/2018/01/02/upshot/us-health-care-expensive-country-comparison.html.
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