By Michael Weitekamp, MD
The eminent Stanford economist Victor Fuchs recently posited that historians may someday look back at the period from 1950 to 2009 as the “golden era of U.S. medicine.” Those years bore witness to remarkable growth of the American health care enterprise, from 4 percent to 17 percent of our national economy. At least a portion of our expanded life expectancy, particularly at the extremes of age — prematurity, childhood infectious disease, and frail elderly — can be attributed directly to the tremendous societal investment in biomedical research, health care infrastructure, graduate medical education, and technological advances. Physician supply and specialization expanded enormously over this period and most citizens have access to modern facilities and limited waiting for arguably the finest advanced critical care in the world. Furthermore, we appear to be on the cusp of numerous breakthrough applications of “personalized medicine” as the human genome project begins to bear applicable fruit.
If the ultimate goal of this investment is to have a healthy and productive citizenry, one capable of participating in a vibrant and balanced economy, caring for itself, the elderly and disabled, and prepared to leave a proud legacy of robust fiscal strength, ecological and infrastructural stability to a healthy and well-educated next generation … Alas, Houston, we have a problem! With no apology needed to Al Gore, let’s review some “inconvenient truths” about the current fiscal and health care environment that place such a goal in jeopardy.
This is my list. I will own it. It will not include everything learned during my recent year in Washington, DC, and you might not agree with everything on it. You likely know other inconvenient truths that have not made this list and I would like to hear them. The only rule is, as so eloquently stated by the late Daniel Patrick Moynihan, “Everyone is entitled to his own opinion, but not his own facts.” Let’s begin.
1) With our national debt at $15 trillion, and our GDP at $15 trillion, we have no responsible recourse but to spend less — much less, immediately and for the foreseeable future. There are few historical happy endings when a nation’s debt/GDP ratio exceeds 100 percent. While economic growth and tax reforms could help, the persistent and pervasive magical thinking in Washington that we can grow, inflate, or tax our way out of this hole is preposterous and dangerous.
2) Unfunded structural liabilities for Medicare, Medicaid, Social Security, and pensions in both the public and private sector make the $15 trillion of “on the books debt” look like chump change. Real numbers, if you can find them, may approach $100 trillion. Health care costs are the single largest factor in all these underfunded liabilities. Public/governmental funds now account for more than 50 percent of what is spent on health care, once you sum up all public programs and tax expenditures for employer-based private insurance.
3) Physician salaries per se are not the problem. If we all worked for free, we might cut the health care spend by 10 to 15 percent. However, our collective decisions made under prevailing incentives, systems, culture, and public expectations drive 80 percent of the $2.6 trillion spent on health care services this past year.
4) The major determinants of societal health are socioeconomic and educational status, personal behavioral choices, genetics, and the environment. Yet public spending on health care and interest payments on accumulated debt increasingly diminish the potential of directing resources toward these other, more important priorities.
5) Health care spending is remarkably skewed; 10 percent of the population accounts for 65 percent of the costs, with modest predictability over time and fueled largely by chronic diseases. The bottom 50 percent spend less than 3 percent. This offers a target-rich environment to aggressively manage the 10 percent, while working on holistic wellness for all to move more folks into the bottom category.
6) We have no actual health care system in the United States. We are stunningly inefficient and duplicative in infrastructure and administrative costs, and tolerate way too much unwarranted variation in price, volume, and intensity of services. Patients and providers are largely disconnected from the actual value (quality/cost) of their decisions. Additionally, direct-to-consumer advertising for products that are ultimately paid for by someone else creates moral hazard we can no longer afford.
7) The cavalry is not coming. Whatever you call the federal health legislation signed into law in March of 2010, the Patient Protection and Affordable Care Act (PPACA) or “Obamacare,” these inconvenient truths transcend any particular judicial, political, legislative, or regulatory flavor of the month. They will still be there after the November election and they will still be there the election after that.
8) “Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the US health care system, but without it, the health care enterprise is lost.” This quote from Cara S. Lesser, MPP, and colleagues resonates with me as I hope it does with you. Only physicians can fix this mess and no, they cannot do it alone, but they can lead.
Let me end the list here and move to potential action items which, as the title suggests, will challenge our profession and professionalism.
1) We all must attack the clinical and administrative waste that may account for 20 to 30 percent of the cost of health care. This is one task where the “we cannot do it alone” part comes in.
2) Fee-for-service will survive, and should, for certain complex and specialized services. These payments will need to more accurately reflect resources consumed — time, training, supplies, etc. — but must also be sensitive to market and budget realities.
3) We should be open to, lead, and participate in creating alternative payment, incentive, and employment models that better align the financing and delivery of services. Management of chronic disease and a holistic approach to population wellness is a true team sport that must involve other health professionals, social workers, public health officials, governments, insurers, and employers.
4) Campaigns such as “Choosing Wisely” are necessary, but will not be sufficient to the task at hand. We not only need to champion evidence-based care, educate the public, and train the next generation of health care professionals, but we must also be the go-to source to inform rationing of health care services once we have maximized the rationalization of what we do. We must not stand idly by while our educational system, environment, and infrastructure are sacrificed at the altar of unrestrained health care costs.
I don’t want to have to apologize to my children and potential grandchildren that we had a window to act and we did nothing. The “fiscal cliff” at the end of this year is real, unprecedented, and terrifying. The time to act is now. Perhaps then history may yet mark the past 60 years as the golden age of medicine, rather than a catalyst to our national decline.
—Michael R. Weitekamp M.D., M.H.A., F.A.C.P. is an internist and Professor of Medicine at Penn State College of Medicine and the Milton S. Hershey Medical Center, Hershey, PA. He served as a Robert G. Petersdorf Scholar in Residence at the AAMC from 2011 to 2012. He can be reached at firstname.lastname@example.org.