Where the Money Goes
American medical care is expensive and only getting more expensive. I blame the nurses. Think about it. Who is always at the hospital drawing their princely 25-to-40-dollar-an-hour salary? Who must provide continous coverage for the patients? Who are the most numerous employees of the hospital?
Nurses, that’s who.
Think about it. Doctors may make a lot of money but in most hospitals they are pretty thin on the ground. On the other hand you can’t swing a JCAHO-compliant dead cat without hitting four or five nurses. They’re everywhere. Thick as thieves, robbing the public blind with their salary demands. What gives them the right to make their ill-gotten five-figure salaries when the typical American struggles, yes struggles, to pay for all of those cool features on their cell phones?
It’s a scandal. Until we address nurse’s pay health care will continue to get more and more expensive.
And don’t even get me started on the respiratory therapists, pharmacists, and others who unfairly try to parlay their many years of education into the high wages thus forcing the sturdy peasantry to choose between their blood pressure medications and their personal watercraft.
Made of Money
On the subject of health care spending, it is fairly obvious to anybody who has spent any time in a hospital why our nation spends so much on health care. Just pick up a random chart from any nurse’s station and the chances are you could elucidate a medical history that reads like a pathology textbook. I used to be amazed that one person could have so many diseases and so many procedures. Now that I have grown used to Homo Polymorbidus I am more amazed at the rare patient who has no past medical history and takes no medications. Hell, even most kids are on something.
So it’s true that we spend a lot of money but keeping the typical ninety-year-old alive isn’t cheap and is only made possible by a stunning amount of medical care, the cumulative amount of which is probably in the millions of dollars. In one two-month stretch in the Emergency Department I saw the same nonagenarian three times for essentially the same complaint. The triage note said “Altered Mental Status” but it might just as well have said “The Nursing Home Panicked When the Patient Seemed a Little More Sluggish Than Usual.”
Folks, when you’re ninety you just start slowing down a tad, especially if you have been in a nursing home since the Reagan adminstration and sit at the pinnacle of the medical food chain as a top predator of medical services. That much medical care would wear anybody out. I am not advocating discarding the elderly. It’s just that somewhere in the feeding frenzy a point is passed where we need to step back and say, “What in the hell are we thinking?” We admitted the above-mentioned patient twice and as far as I know she has returned to her nursing home in the same mostly demented state that is her baseline and where she will lie, collecting bed sores, until the next time we save her life.
Now, one patient is not going to bankrupt the system. The infrastructure is in place after all, so what’s it going to hurt sending one frail little old lady up to the ICU? But that’s kind of the point. It’s the infrastructure that costs money, not the individual patient. Collectively, the ethos that requires us to keep everyone alive at all costs all the time requires that hospitals have a commensurate level of facilities and staff. It also requires an army of highly paid specialists to coax the last dregs of life out of the actively dying.
Is this a bad thing? I can’t say. When I was twenty I thought life was over at forty. Now that I have passed forty I can see that life is still worth living even if I can no longer run six-minute miles. Maybe despite being a doddering wreck at eighty I won’t be ready to shuffle unselfishly off of my mortal coil so as not inconvenience my children. But keeping me going will cost money. Everything that requires time and resources that belong to somebody else does. The expectation that it can be otherwise is ridiculous, as is the religious faith of the Single Payer zealots who believe that by adding an expensive layer of ineffectual free primary care somehow everything is going to be all right.
In no way is any socialized, quasi-socialized, or we-swear-it-aint-socialized scheme going to do a thing to lower the cost of medical care unless fundamental changes are made in the way we conduct health care business. As these fundamental changes mostly involve the rationing of care for people who expect limitless access, the voting public is never going to buy it unless they are tricked into it with promises of a shining all-you-can-eat medical buffet on a hill. This is a promise that cannot possibly be kept except by continuing to increase health care spending. After all, what politician has the guts to tell the people that they can’t have it all? To do so is counterproductive anyways, even for an honest politician of which there are many, because it is political suicide. No one is going to bell this cat.
What Are We Really Getting for Our Money, Anyways?
I’m not entirely convinced that a lot of what we do on a routine basis is really worth the money. Take a simple thing like Coumadin. Coumadin inhibits several of the factors in blood that makes it form clots. The lay people call it a blood thinner (although it doesn’t really make blood any thinner) and some even know that it was first used a rat poison.
Coumadin is widely prescribed for all manners of conditions, particularly for atrial fibrillation to prevent clots from forming in the dead spaces of the quivering left atria. Pieces can break off of these clots and travel to practically any organ in the body where they can abruptly shut off blood flow. In the brain this is called a stroke and is a particularly deadly complication of chronic atrial fibrillation.
And yet coumadin is not a benign drug and can cause complications every bit as bad a stroke. The interesting thing is that without coumadin, the risk of forming an atrial clot a stroke is about six percent per year. Just taking aspirin, a relatively safe drug that “thins” the blood by preventing platelets from clumping together, lowers your risk to three percent per year. Using coumadin lowers the risk to one percent per year. So you see that not only is the risk of clot formation stroke in atrial fibrillation fairly low to begin with but to achieve an almost insignificant reduction in risk we habitually pick a dangerous drug that is likely responsible for billions of dollars worth of side effects over a the safer drug.
That’s kind of the gestalt of American medicine. The drive to spend whatever it takes to extract the last bit of life out of everybody even though we are already well into the realm of diminshing marginal returns for a large portion of what we spend.
Very well said, very well said!
Totally agreed with two of the points you made.
First being the current trend of keeping patients alive despite them having a terribly poor (or even none) quality of life. I live half a world away from you, and yet the exact same thing is happening on my land.
Second being the fact that as you rightly point out, alot of physicians follow “standard” treatment blindly. Like you, I’ve always wondered if we were doing the correct thing by whacking every single asymptomatic patient with AF using warfarin. Some of these people are in their prime even!
Having known how much a hassle it is to keep someone on warfarin (the close monitoring, the regular labs, and how much trouble it takes to retitrate once the regimen is knocked out of balancec) as well as having witnessed the potential side effects of warfarin… sometimes I ask myself: “Why are we doing these to pple?”
And the worst comes when dealing with less educated folks who have no idea about their condition or treatment, and some pple just tell them “you have AF, therefore you need to take warfarin” without even explaining to them the alternatives or perhaps even the fact that they might rather take the risk of the disease over the risk from the treatment.
Panda, I enjoy reading your blogs because (though they are consistently brimming with controversy) they offer some points that we’re all thinking but dare not say. However, blaming the health care cost crisis on nurses is really unfair. Nurses deserve the $ they get – and we’d all be doomed without them. They keep a watchful eye on patients when we docs can’t be there, they have to do some of the most unpleasant but important patient care (wound care, manual disimpaction, handling disgruntled families) and they really are unsung heroes – often being treated as second class citizens by docs and patients alike. If we didn’t have enough nurses, our patients would be festering in their own feces, having heart attacks in the middle of the night with no one to notice, and us triaging family member pages 24/7. I for one, deeply respect and appreciate our nurses… cost cutting is not about decreasing nursing staff or paying them less than they deserve. Now, expensive and futile measures at end of life – that’s something we should really focus on.
Val he was being sarcastic…..
I know I am going to get slammed for this. You are a very intelligent man, why do you say “anyways” when the proper word is “anyway”? Love your writing, but that drives me INSANE!
(I’m not writing a thesis. And if you listen, people say “anyways,” not “anyway.” It may not be correct but it sounds right and since this is the common usage I’m going to use it.-PB)
Wow, just wow. You’ve obviously never done nursing school. Yes, I know you never claimed to do nursing school, but uhm, I have, and it’s not easy. Nor is being a nurse easy. Nor are we exactly without responsibility. Would you give Coumadin to a patient with an allergy to benzoyl peroxide? I’m guessing you don’t know off the top of your head that Warfarin shouldn’t be given to such patients, and would probably be willing to write such a prescription, since I’d be willing to wager anything that you don’t look up every drug you prescribe. I do know that there’s an interaction. It’s the nurses and pharmacists saving your (the collective “your” referring to all doctors)ass on occasions like this.
Oh, and ps, to those struggling with paying your cell phone bills, feel free to go to nursing school. They have job openings, I hear.
And by her third comment in a row…she’s catching the sarcasm. You got me so riled up I couldn’t wait to comment. Guess that was the point.
And my 4th comment, cause I already look like an idiot, so I might as well correct myself. It’s Lovenox that benzoyl peroxide hypersensitivity is a contraindication to, not warfarin.
“What gives them the right to make their ill-gotten five-figure salaries when the typical American struggles, yes struggles, to pay for all of those cool features on their cell phones?”
To everyone who is still angry on behalf of nurses, I’m pretty sure this is meant to be sarcastic. Enough people reflexively think of doctors as overpaid without really questioning that belief, despite their hard work and lengthy education. So by describing another group of hardworking and well-educated healthcare professionals as overpaid, he invites us to question our preconceived beliefs about doctors as well.
So everyone please chill. Except you, Val Jones. Your comments brought a tear to my eye.
Chris, it amzes me how quickly people’s knees jerk. I thought it was obvious that I was making a point about how little doctors, nurses, pharmacists, et al are valued by a public that will spend hundreds of dollars for cable TV but not a penny for their medical care.
Come on Val, I was pulling your leg.
Don’t you know that my blog lives on the edge?
(By the way, Val, you called me a “Fiesty Young Blogger” on your site. Judging from your picture, I am a good deal older than you. In fact, I am in my mid-forties. I just got a late start in medicine having spent almost eight years in the Marines and then seven as a Structural Engineer.)
Quote: “They keep a watchful eye on patients when we docs can’t be there, they have to do some of the most unpleasant but important patient care (wound care, manual disimpaction, handling disgruntled families) and they really are unsung heroes – often being treated as second class citizens by docs and patients alike.”
sounds a lot like the job description for a Junior Medical Student…..
Hey PandaMD,
I definitely don’t agree with a lot of the things you said in other posts–but this post is awesome nonetheless.
> That’s kind of the gestalt of American medicine. The drive to spend whatever it takes to extract the last bit of life out of everybody even though we are already well into the realm of diminshing marginal returns for a large portion of what we spend.
Very well said. Very well said. The same sort of thing is prevalent in the drug industry too. I wonder who’s shouldering the expenses in developing (yet another) statin that diminishes risk of CVD by (gasp) another 1% over Lipitor.
That is hilarious that some didn’t clue into the sarcasm. You mean it might take someone with a professional degree that should be worth something to take care of critically ill patients??
interesting points. i was waiting for a comment on the NICU and 24 weekers. what happened to the edge just picking on the ole’ folks 🙂 (just jokes)
the whole medical cost is just ridiculous. physicians take the blunt of most of the complaints. “physicians make too much” medicare cuts physicians fees and the public doesn’t bat an eye. the hospitals make a mint off of the patients physicians admit. for every illinios public aid patient i see, i come out in the negative but the hospital actually makes money (doesn’t seem right).
you speak about the large chart and multiple medical problems and procedures, should we decrease our medical care based on cost? “ah, no more care for you, you had your allotted 3 diseases and 2 procedures in 2 years.” may be that is how we could cut costs. (before i get blasted, this was just jokes folks)
Panda – you ARE fiesty, and 40’s IS young in medicine (and just because I’m slightly younger doesn’t mean I can’t call YOU young). I knew you were being sarcastic (“choosing between blood pressure meds and personal watercraft”), but erroneously believed that you were also trying to make a point in an exaggerated way. I guess it was late at night, I was reading quickly, and I love my nurses… so voila. I’ll do my best not to complain any more.
I’ve said it before and I will say it again. Medicare should put an age limit on ICU admissions. No one over 75 allowed and if you want grandma to go to one you are on your own.
You see, that’s the problem. I know a lot of 80-year-old-and-above who are as sharp as tacks, active, and leading pretty high quality lives who I’d like to think we could save for another five years if they needed an ICU stay. I’d hate to have a cut-off age.
Still, I may not know where to draw the line for every patient but for some it is more obvious than others. Certainly after your third stroke and your fourth intubation we are not really doing much.
My real point is that American medical care is expensive because it is unequivocally better than any other country’s. Maybe if all I needed was an annual physical I’d rather be in France but when I get really, really sick and my life clock has turned black I’d rather be here. So you can have it cheap or you can have it good, but you can’t have both.
And by good I mean how well we take care of people who are really sick, not how we posture and provide primary care that most people don’t need and and even if they did, wouldn’t take advantage of it. The connection between access to primary care and good health, as I have pointed out, is tenuous and is more political than medical.
Our society has such a long way to go in its capacity to accept the inevitability of death. Until such a thing ever happens, people are going to be willing to shell out (or have the taxpayers shellout) oodles of $$ to keep people alive for a time well beyond what is reasonable or natural, for that matter.
If we are doomed to ration an age limit is equal for everyone. If I am lucky enough to reach 75, I should have accompished everything I want to otherwise its my own fault.
dawg: based on that post i have to assume you are already demented and should therefore be allowed to die. er, do you actually know anyone who is 75? how many of them seem to have “accomplished everything”?
Panda, you are a literary genius. I’m thinking about putting a link to your blog in my SDN signature, but I’d probably catch hell over at the Duke waitlist thread…. oh, well….here goes nothing!
Quick question: How long does it take you to knock out an average post? Do you slowly revise your valid points and interesting themes into the flowing results? Or does it just fall from your pen that way ?
Here’s to hoping I will find colleagues who don’t shoot themselves in their medicine-practing feet.
Nicely done as usual – I wanted to bitch and scream about the nurse comment for all of about 0.423 seconds until I realized that it wasn’t quite serious.
And also as usual, I don’t quite agree with Graham above… semantic mountains and molehills and all that.
Or we could just not have the taxpayers pay for everyone’s medical care anyway, and the value of an ICU stay could be debated with the patient and his family the old fashioned way, whether he’s 20 or 90.
Panda,
Don’t forget the gobs of money going into overtreatment of low risk conditions. Every cardiology note that I see recommends overtreatment of LDL based on the ATPIII standards. And now we’re supposed to consider treatment of PRE-hypertension?? What’s the NNT on that one? You can bet your Glaxo-Bridges-to-Access card that the published studies on prehypertension treatment will all be with new ARBs, not HCTZ.
We need to focus our prevention efforts where they’ll make a difference – on high risk individuals.
Dr. Smak
Samual, If you have a finite amount of dollars to spend and you have to ration care, how do you come up with a way that is fair for everyone involved?
To answer your question
1)Yes
2)All of them
Do you honestly think Levophed should ever be used on someone over 75? 9 times out of 10 is it is nothing more than a colossal waste of time, effort and money. Don’t you think the money saved by disallowing ICU stays and cutting futile end of life care would be better spent taking care of every child under 18 in this country?
On the subject of those over 75 who might be deserving of a stay in the ICU, I’m with Panda here. While I think there are a lot of husked shells that used to be humans lying around the ICU, I would hate to think of my husbands grandparents being subject to a cutoff age. They are in their mid-80’s, still living on their own, still in full control of their faculties, with minimal mobility issues. Grandma needs eye drops for cataracts and doesn’t do stairs too well (but that’s ok because they had the foresight in their 60’s to buy a 1-level house). The house is cleaner than mine and she’s a better cook too. Grandpa still grows a garden of both veggies and miscellaneous flowers every year – and he knows them all by name. He had a stroke recently but Grandma caught it; drove him to the emergency room herself, and the docs there got some clot busters into him in plenty of time. He was in the ICU 2 days, in the regular hospital another 2, and walked out of the hospital. He has some trouble with word recall on occasion now, but that is it. He’s the same as he was before. They have 1 great-grandchild and another on the way (not mine at this point, thank God) and even if they have “accomplished everything” in terms of career goals, etc, they are very much enjoying their golden years and their family – and their family is very much enjoying them. ICU cutoffs based on age would be a terrible thing in this case.
And Dawg, as someone who grew up on welfare and was the child of a card-carrying member of the dependocracy (so aptly named by Panda on a number of occasions) and has experienced that side of the coin, I say I’d rather save the money spent on the treating the indigent adults who refuse to take responsibility for their personal well-being and use THAT to take care of those under 18.
We often debate single payor on PB’s blog, so here is some fuel for the fire. Michael Moore will be on Oprah today promoting his new film “Sicko.”
Apparently, universal healthcare is on Oprah’s agenda which means it will be on the soccer mom’s agenda. Should be an interesting show.
As usual, good (and funny) post.
When I interview for med school and they begin questioning me on healthcare, I’m just going to quote excerpts from your blog, ok?
🙂
The point I was trying to make it that it is equal for everyone across the board. I too have seen 80 year olds that need an ICU stay and come out of it no worse. Unfortunately that is an extremely infrequent occurence. We have all seen the incredible wastes of resources and money trying everything to keep the Pods in the Matrix of the ICU functioning properly. I’d like to hear any other suggestion is fair to all involved. A physician is not going to make that decision in the legal climate we have now, so you can forget anything that has to do with the physician making the decision. The only way to eliminate these costs is hard and fast rules that are equal to the entire population. The healthcare system is not the fabled perpetual motion machine. It has its limits and we will have to ration care eventually. Spending 100,000 on a ICU stay for a 95 year old nursing home patient seems not the way to conserve resources and we all know that all too well.
I can’t believe I’m actually disagreeing with you, but a good nurse/therapist is worth their weight in gold. Especially when it comes to preventative medicine. Oh, wait, you were kidding!
LOL – more people (especially those on SDN) need to realize you write out of sarcasm 😉
I don’t know, all the nurses I’ve met seem like medical school rejects to me. Not too many Greg Fockers in the group.
😉
I just wanted to add a note to this discussion.
I work in organized labor and I must say that your point about nurses is somewhat right.
What bothers me the most in California is to watch the “patients advocates” nurses union turn their back on capping increasing health insurance premiums. Right now the nurses union supports increasing the monthly health insurance premiums that their members pay. They state that since their members (the nurses) make good salaries they should pay the higher premiums. Funny how self serving that is. They take that position not because the belive it but because they make their lively hood off it. They must support this to ensure that everyone else in the US pays higher premiums (even if those individuals can not afford it). They need those premiums to go up every year if they are going to be able to keep getting 25% pay increases for their members like they recently got from Kaiser.
So I guess they are only the patients advocates as long as those patients are able to pay for the increasing health insurance premiums.
Ways to save money on health care.
1) Shoot all retiree in the head- they had long and productive lives, time to move on grandma and give someone else a chance (btw this would also lower the cost of real estate)
2) get rid of all health insurance companies – by cutting out the middlemen we make savings! then only pepole who really need that hip/knee replacement/cardiac cath (meanning people who can pony up the dough) will get those treatments!
3)install credit card readers /atm machines in the icu – i think the going rate now is about $100/hour or $1.60 a minute – if you dont “recharge” your icu bed the bed can be made to automatically tip you out to make room for the next pt.
4) who needs a ventilator when you can hire a couple of mexican dudes to bag and mask grandma for $2.50 per hour at home – this will also improve her quality of life by letting her spend her last days inthe company of her loved ones
5) expenisive medications – cancer, aids, etc. – all are bad diseasess! why do we need expensive meds to pay fur when we can just give everyone a cheap morphine / ativan drip to comfort them and relieve pain – everyone knows we dont actually cure anything anyway. besides LIFe is aterminal disease!
6) nurses – can easily be replaced in most hospitals by nuns who make way less. also nusing assistant can be replaced with retards and insane asylum dwellers, putting thses good ppl to work.
-etc
Hey Panda, I have a question. Why don’t doctors and hospitals make incoming patients sign an agreement that all disputes will be handled by arbitration and not lawsuits? I know this is becoming a widespread practice in the construction industry and I don’t see anything illegal about it from my inexperienced viewpoint. I imagine that nearly all doctors and hospitals could then save money and practice more freely as the threat of lawsuit would be greatly diminished. I guess the only place this wouldn’t work would be the ED, and then only for those real emergencies where someone is unable to sign an agreement like that.
Basically, I have come to trust you with all things medical, legal, financial, and political, so I would love to hear your thoughts on the future of such agreements or why they are unfeasible. Thanks for listening.
Legally, you can’t sign away your rights including the right to sue. Such an agreement wouldn’t be worth the paper it was printed on because courts will negate exculpatory clauses that are unreasonable in nature.
Remember, frivolous or not, the plaintiff alleges that he was harmed by the negligance of the defendant. Exculpatory clauses only hold the defendant harmless if reasonable care was taken to prevent harm which is the point of bringing a suit, that is, to prove the opposite.
“Health Courts” are the medical equivalent of arbitration and would go a long way to curbing the current abuses in our legal system…but watch for the Lawyers to fight their implementation tooth and nail because they rely on medically ignorant, emotional juries.
I actually do think nurses are overpaid. In my hospital, their 2 year associates degree gets them $26.25/hr as a new grad, plus $5/hr shift diff at night, plus time and a half if they ever have to be in the hospital longer than 12 hours in a 24 hour period or come in on a holiday or put in more than 40hrs/week. So a 21yo new grad that works nights would be making ~63K/year WITHOUT any overtime. And dont tell me that new grad nurses aren’t still trainees, because they very much are. The hospital also gives them $5000/year to pay back their school loans… which is a mystery to me since the local CCs are only $900/year.
As for responisbility, they pass meds to 4 patients, hang bags of saline, and page the doc if anything semi-abnormal comes up. They have CNAs to do the dirty work, yet they nver stop complaining about how hard they have it…. God, I can only imagine what they would say if only they had gone to college, then 5 years of grad school in genetics or biochem or something similar then 3-4 years of post-docing for $35K/year and then became a college prof making $50K if they were lucky.
So why not become a nurse, you might ask? Where I live, nursing school admissions is done by a lottery system…. everyone with a 3.0GPA on the pre-reqs or better (~about 500 applicants) has their name put into a hat. 40 names are selected and those are the nursing students (no clinical experience required, no LORs, no interviews, etc). But there is 50% attrition and hence a nursing shortage. If someone wants to alleviate the nursing shortage, don’t let nurses be in charge of nursing schools.
I work with ER nurses and ICU nurses so I am heavily biased in favor of paying nurses well.
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