(Medical care is expensive, no doubt about it, but the remedies proposed by the usual suspects who hope to leverage the problem into political power don’t address the real factors driving up the cost. Maybe I’m just not an excitable fellow but I like to keep a cool head and not get swept up in the hysteria, especially as it is being lead by people who are themselves part of the problem-PB)
You get what you pay for.
Consider the space shuttle, a technological marvel conceived in the 1970s to revolutionize space transportation by using a reusable space vehicle to drastically decrease the cost-per-pound of lifting payloads into orbit. First flown in 1981, the fleet of incredibly complex and expensive orbiters have yet to achieve their stated purpose of making launches economical and have instead become something of a boondoggle to NASA, sucking vast amounts of money out of less glamorous but probably more important space endeavors. It turns out that disposable rockets are significantly cheaper on a cost-per-pound-to-orbit basis because they are less complex, unmanned, and do not have to be refurbished between flights. The cost of the shuttle program has been almost $150 billion dollars or a little more than one billion dollars per flight for each of the 117 missions. Unmanned rockets, even big ones, aren’t nearly that expensive.
The shuttle is more expensive than was hoped largely due to a rigid zero-defect mentality on the part of NASA. Even a minor malfunction can result in the complete loss of the crew and a two billion dollar vehicle. Consequently, NASA takes an already legendary obsession with perfection to a new level to ensure the absolute reliability of the orbiter before each launch. This obsession is built into the vehicle through redundant systems and meticulous quality control, carries on to the launch where the smallest anamoly can scrub the mission (leading to costly defueling and reinspection), and finishes with an exhaustive post-flight check where the engines and most major sub-systems are disassembled and inspected.
At every stage of the process a small army of engineers and technicians orchestrate a clumsy bureaucratic exercise to document contractually stipulated compliance with procedures and specification. And yet, despite their best efforts, to date there have been two catastrophic losses of crews and vehicles for a failure rate of about two percent.
It wasn’t supposed to be this way but perfection isn’t cheap. If you adopt a zero-defect mentality, you are going to have to pay for it and you will rapidly reach a point where large amounts of money need to be spent for infinitessimal increments of improvement.
Consider modern American medicine which, because it operates in a predatory legal environment, is also expected to be zero defect. It is hard for some people to believe but a physician can be sued by a patient who he treated many years before for a condition that may of may not have been the presenting complaint but which was not discovered at the time even though a reasonable standard of care was used. The patient may even have been told to return if the symptoms did not resolve but for whatever reason was “lost to follow-up” or whichever creepy, politically correct phrase is selected to divorce the patient from his responsibilities, in this case the responsibility to be concerned enough about his health to be more than a passive observer or some kind of oblivious passenger.
The physican’s records will be scrutinized by a rapacious attorney and any mistake or ommission, no matter how slight, will be used to construct a case which, while perhaps not the multi-million dollar jackpot of which all indigent patients dream, may likely be settled out of court to avoid the expense of a trial. It’s a living for many attorneys.
This zero defect mentality costs money and very little of it improves patient care. Mostly it goes to cover the massive cost of defensive medicine which is what, I would dare say from personal experience, most of American medicine comes down to. We know better of course, but it is a lot easier to obtain the CT or order the test than to defend your perfectly reasonable, evidence-based rationale for not obtaining it. We also probably admit many more people than need to be admitted out of the fear of allowing patients to be responsible for their own outpatient follow-up.
A healthy respect for the possibility of error is part of medicine and cannot be discounted. On the other hand, what we have today is an abject terror of making a mistake. Unfortunately, unlike NASA, we are not working with professionals who have contractual obligations that they must honor, at least none that are enforceable. The trendier hospitals make a big deal about their carefully crafted Statements of Patient Rights and Responsibilities but it’s all just fluff to keep Press Ganey, the insatiable God of the Bureaucracy, happy. In our medical system, patients have no responsibilites and therefore the physicians must play a constant game of chess with opponents who moves their pieces at random and out of turn.
The public has to decided what it wants. They can have a reasonable level of relatively inexpensive medical care that relies as much as possible on the clinical judgement of physicians and their own high level of personal accountability with the understanding that occasionally something is going to be missed or they can have a hugely expensive system of medical care where everybody gets the million-dollar workup on the rare chance that something is caught that would otherwise not have been.
But being zero defect costs money and you pay for what you get.