A visit to medicine’s past, present and future

In that popular holiday fable called, A Christmas Carol, by Charles Dickens a curmudgeonly old miser named Ebenezer Scrooge is haunted by three ghosts on Christmas eve, named the Ghost of Christmas Past, The Ghost of Christmas Present and The Ghost of Christmas Yet to Come. As a result of these spectral encounters, Scrooge is given a second chance at life. Fortunately for him, this new life doesn’t happen in modern day America.

In the United States these days, living well and charitably requires much more than ready cash and a renewed outlook. With more than half of the U.S. population suffering from chronic diseases like heart disease, diabetes, depression, and obesity not to mention millions more suffering still from untreatable diseases like cancer and AIDS, simple rehabilitation may not be enough to turn one’s life around. Instead, with consumer directed healthcare looming on the horizon, modern day Scrooge may need all the money he has and more to keep himself healthy let alone Tiny Tim.

In keeping with the holiday spirit,however, I wanted to bring you my own version of A Christmas Carol with a healthcare bent. Perhaps, by reflecting on our healthcare past, present and future we can, like Scrooge, gain insight on what’s needed to improve our current state of healthcare. As one English writer, Thomas Hood put it, "If Christmas, with its ancient and hospitable customs, its social and charitable observances, were in danger of decay, this is the book (A Christmas Carol) that would give them a new lease." Consider the following as my gift to you this holiday season to bring you good tidings about healthcare.

Those Good Old Days of Healthcare Past
According to the U.S. Department of Health’s Agency for Healthcare Research and Quality (AHRQ), America currently spends nearly triple on healthcare than what it did in the 1960’s. Back then healthcare spending was only 5 percent of the gross domestic product (GDP). Currently, our healthcare expenditures are nearly triple that or make up 13 percent of our GDP. Yet, put into the right perspective and given the right frame of reference, this exorbitant hike may not be the main source of our problems.

Compare physician salaries for instance. Robert Edsall in the journal for Family Practice Management, quotes a survey published in General Practice Journal (GP) which showed how the average doctor working in 1950’s fared. The survey showed that physicians back then worked “11-hour(s) (a) day, 300 days a year, and (saw) 25 patients each working day.” Compared to this, general practitioners in 2004 worked an average of 922 less hours, and saw about 1,840 fewer patients a year and still made 7 times more in salary than they would have in 1950, or $143,600 a year. Even though the $20,800 annual salary of the average GP in the 1950’s is worth about $163,034 in today’s dollars (this is about $20,000 higher than what 2004 doctors received) they had to work longer and see more patients to make this higher pay. According to Edsall’s calculations, doctor’s salaries have gone up only 21% during the last 57 years. Compared to the salary rises in the banking industry, that rise in physician pay is miniscule considering that doctors have 4 more years in school and train another 3-7 years as residents before they can make anywhere close to their expected pay. Also, most doctors by the time they go into practice have amassed approximately $200,000 in educational debt. The cost impinging on healthcare then may not be the doctors so much as the institutions that produce them.

Many would also argue that in the “good old days” of medicine, patients paid less and got more for what they paid, but then again, this all depends on how you define care. Up until the mid 1960’s, many general practitioners or primary care physicians (PCP’s) as they’re now called, took on more of their patients “care” than they do now. Back then, approximately 86 % of general practitioners provided obstetrics care and 68% performed surgery. Now only 28% of PCP’s handle obstetrics, and the majority, or approximately 70% refer patients out to other specialists or surgeons. So now, there are a lot more physicians, including specialists, caring for patients than ever before and much better still, those who have insurance pay only a $10-$30 co-pay to see each physician, which compared with the cost of seeing one doctor in 1950 probably works out to be about the same. In a sense, patients aren’t paying that much more to see a doctor than they did in 1950. They’re just spending more.

Of course, for those without insurance this is not the case. But even though many patients paying for their own medical care can pay anywhere from $65 to $420 depending on the level of service they needed, more of the elderly and disabled, a population that traditionally require more healthcare, receive government insurance coverage. In fact, prior to 1965 when Congress enacted the Medicare social insurance coverage, many of the elderly and disabled who couldn’t afford medical care simply went without. Although it’s been said that 47 million Americans lack insurance coverage even now, this number alone simply does not tell the whole scope of our current healthcare problems. Although with the advent of Medicare, the number of people who qualified for government insurance actually went up, the level of care has actually gone down. At the same time, the number of middle income families who don’t qualify for Medicare and for Medicaid are now being left out of the healthcare equation. As such, that 47 million uninsured figure that the media often points to may be skewed considering the inadequacies found in the insured patient populations as well.

Ghost of Healthcare Present
So where does the exorbitant $2 trillion dollar annual health bill that everyone is talking about these days coming from if doctors are not getting paid much more and patients who are financially covered are not actually getting better? If there were a Ghost of Healthcare Present he would most likely point to the rise in insurance premiums.

According to the Kaiser Family Foundation, the “latest rise in health insurance premiums” account for “twice the overall inflation rate of 2.6% and far ahead of the 3.7% increase in wages”. This is a significant rise considering that as these rates increase, “fewer workers can afford to pay premiums and medium and small-size firms give up offering coverage.” According to their figures, the number of companies with less than 200 employees offering health benefits declined from 68% in 2001 down to 59% currently.

Similarly, malpractice insurance premiums for physicians have risen exponentially as more and more hospitals and private insurance companies are dumping more of their financial burdens on their participants.  Currently, with uncapped premium hikes in many New England states, what used to be a minor expense of 3 to 5% of your gross wages has gone up as high as the combined salaries of two to three medical assistants. It’s not surprising then those physicians with the highest malpractice premiums to salary ratios like obstetricians (OB) are leaving their profession in droves. Many OB’s in private practice just don’t see the logic of paying out $125,000 or more to take home only a fraction of that in pay after other expenses like credentialing and licensing fees are factored in.

Similarly, in states like Massachusettes where the cost of living is high, there’s also a rising shortage of primary care providers. Especially those PCP’s who work in lower income communities are finding it difficult to barely get by. Traditionally PCP’s have significantly lower salaries compared to most other specialties. Although an average PCP spends the same amount for their medical training and education as most other physicians do, their salaries compared to specialists like cardiologists, or neurologists is much lower. Given that these lower compensation rates are not keeping up with the rise in inflation, and as many insurance companies are collectively squeezing them even harder on their reimbursement rates (at last count Medicaid pays $15.00 per patient visit), many medical school graduates are shifting to other more lucrative specialties.

The Ghost or Healthcare Present would also point to the higher cost of rendering care in a managed care environment. According to general statistics in the past 30 years, healthcare expenditures for administration in the United States has risen approximately 50% and makes up about 31% of the nation’s $2 trillion healthcare bill. With insurance companies, both private and government requiring tougher and more stringent guidelines and duplication upon duplication of paper work for every time a patient is referred out to another specialist, and since this happens more and more as the PCP’s are unwilling to bear the brunt of the weight, what could have been a positive for most patients in this country has backfired. Now thanks to affordable care provided by our insurance coverage, we have more care but more hassles along with it.

All the while, the American population is poorer in health than they were some 50-60 years ago.  Presently, over 50% of the population is considered overweight, with 30% being morbidly obese. There’s also the rising number of patients with late onset diabetes, heart disease, and certain types of cancers, and just as many people suffering from sleep related breathing disorders like sleep apnea.

By all accounts, our focus on a nationalized healthcare to save money, or our need to privatize healthcare to turn it into a high profit industry, doesn’t seem to provide us with a promising outlook for the future. Given the lessons learned from our past, and present what we need in healthcare is a rude awakening from our financial poverty. Medical care shouldn’t be about making or saving money. It should be about what we can do to save lives, whatever the cost may be to our self serving needs.

Healthcare Yet To Come
When I was growing up and dreaming of becoming a doctor one day, I had in mind images of Marcus Welby and those doctors from St. Elsewhere, dancing around in my head. In short, I was an idealist wanting to save lives and making a difference. What I learned since then however is that this goes beyond individual want and need.

Currently there’s much talk about the future commoditization of healthcare. Namely that if we could only have better and more sophisticated solutions to keep the population healthy and prosperous, the problem with healthcare should take care of itself. Proponents of this model suggest that patients who are “consumers” would behave more prudently and cost effectively in choosing their medical services; That given the enormous array of healthcare options to choose from, both patient and nation would profit both in health as well as in collective wealth.

On the other hand, proponents for a nationalized healthcare, and not a “consumer driven model” described above, decry what they perceive as the growing excess from the widening stratification of healthcare.  They suggest that once everyone in this country has coverage and therefore unfettered access to a standardized model of medical care equal to everyone else, we’d all be healthy, wealthy and wise.

Considering that our nation’s health hasn’t improved much even with the increase in the amount of medical care currently available, the consumerist version of healthcare just seems to echo the growing trend that I see in mega sized super chains all across the country. Unlike Costco, the bargain warehouse store where the more you get the more cost effective it is, having more healthcare doesn’t necessarily equate with better health. In fact having more healthcare, may just amplify the waste we currently have.

On the other hand, unification of healthcare by an even more inflexible entity than the ones we currently have, namely the hybrids between private and government insurance, may not yield the kind of innovative solutions we desperately need. With a growing number of the healthcare population requiring more extensive medical care for a much longer duration than ever before, the estimated cost and upkeep of a standardized healthcare model may unduly punish the healthy and young for the sake of promoting and or prolonging chronic illnesses. According to the Medicare Payment Advisory Commission which analyzes Medicare issues for Congress, approximately 220 hospices got retrospective repayment demands of $166 million to $200 million. This was money that was owed, according to Medicare’s calculations, for providing excess care to those patients who didn’t die according to their “actuarial schedules”. Having nothing to compare to, a single minded entity, with one goal in mind, to provide equal coverage for all,while saving money doing it, may fall short of delivering on its ultimate promise of “God bless us, every one!”

Just as Scrooge turned away in fear from seeing his own demise, the thought of saving or making money through medicine drives fear into my heart. But in the end, Scrooge does decide to forsake his life savings, for the chance to save a life. Like him, I have hope every time I’m able to help someone breathe better, sleep better and live better despite all the financial complications this entails. Dream or no dream, there’s no better life than that.

West Side ENT