How American Health Care Killed His Father
Businessman David Goldhill gave some thought to his father's possibly or even probably preventable death in a hospital from hospital-acquired infections. He wrote in The Atlantic in 2009 that "health insurance isn't health care" -- although that's how we now see it:
About a week after my father's death, The New Yorker ran an article by Atul Gawande profiling the efforts of Dr. Peter Pronovost to reduce the incidence of fatal hospital-borne infections. Pronovost's solution? A simple checklist of ICU protocols governing physician hand-washing and other basic sterilization procedures. Hospitals implementing Pronovost's checklist had enjoyed almost instantaneous success, reducing hospital-infection rates by two-thirds within the first three months of its adoption. But many physicians rejected the checklist as an unnecessary and belittling bureaucratic intrusion, and many hospital executives were reluctant to push it on them. The story chronicled Pronovost's travels around the country as he struggled to persuade hospitals to embrace his reform.It was a heroic story, but to me, it was also deeply unsettling. How was it possible that Pronovost needed to beg hospitals to adopt an essentially cost-free idea that saved so many lives? Here's an industry that loudly protests the high cost of liability insurance and the injustice of our tort system and yet needs extensive lobbying to embrace a simple technique to save up to 100,000 people.
...Indeed, I suspect that our collective search for villains--for someone to blame--has distracted us and our political leaders from addressing the fundamental causes of our nation's health-care crisis. All of the actors in health care--from doctors to insurers to pharmaceutical companies--work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that--most important--remove consumers from our irreplaceable role as the ultimate ensurer of value.
These are the impersonal forces, I've come to believe, that explain why things have gone so badly wrong in health care, producing the national dilemma of runaway costs and poorly covered millions. The problems I've explored in the past year hardly count as breakthrough discoveries--health-care experts undoubtedly view all of them as old news. But some experts, it seems, have come to see many of these problems as inevitable in any health-care system--as conditions to be patched up, papered over, or worked around, but not problems to be solved.
That's the premise behind today's incremental approach to health-care reform. Though details of the legislation are still being negotiated, its principles are a reprise of previous reforms--addressing access to health care by expanding government aid to those without adequate insurance, while attempting to control rising costs through centrally administered initiatives. Some of the ideas now on the table may well be sensible in the context of our current system. But fundamentally, the "comprehensive" reform being contemplated merely cements in place the current system--insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform.
I'm a Democrat, and have long been concerned about America's lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system--largely problems of incentives--our reforms won't do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand, the role of insurance; focus the government's role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy.
These ideas stand well outside the emerging political consensus about reform.
The cost of his father's care:
$636,687.75Ten days after my father's death, the hospital sent my mother a copy of the bill for his five-week stay: $636,687.75. He was charged $11,590 per night for his ICU room; $7,407 per night for a semiprivate room before he was moved to the ICU; $145,432 for drugs; $41,696 for respiratory services. Even the most casual effort to compare these prices to marginal costs or to the costs of off-the-shelf components demonstrates the absurdity of these numbers, but why should my mother care? Her share of the bill was only $992; the balance, undoubtedly at some huge discount, was paid by Medicare.
Wasn't this an extraordinary benefit, a windfall return on American citizenship? Or at least some small relief for a distraught widow?
Not really. You can feel grateful for the protection currently offered by Medicare (or by private insurance) only if you don't realize how much you truly spend to fund this system over your lifetime, and if you believe you're getting good care in return.
...Before we further remove ourselves as direct consumers of health care--with all of our beneficial influence on quality, service, and price--let me ask you to consider one more question. Imagine my father's hospital had to present the bill for his "care" not to a government bureaucracy, but to my grieving mother. Do you really believe that the hospital--forced to face the victim of its poor-quality service, forced to collect the bill from the real customer--wouldn't have figured out how to make its doctors wash their hands?
Via Walter Russell Mead, who writes:
Our employer-based insurance system makes this problem worse. When your employeer pays your premiums, you become even more ignorant about just how much health care is costing you. Goldhill calculates that health care will cost an average 23 year old at least $1.8 million over the course of his or her lifetime. But we often don't realize how high this number is, because employers pay it. Much of that $1.8 million could go back into our paychecks if health care were cheaper, but because the cost of care is hidden, most of us don't know what we're losing out on.Goldhill argues that to fix our system, we need to start paying for it just like we pay for other areas of life that have both routine small costs and rare massive expenses. His proposal is to restrict the scope of insurance coverage to truly catastrophic costs--rare, unpredictable, serious illnesses--and to pay for all other care out of pocket. This would still give people the chance to pay for very expensive treatments through insurance, while giving them more information about the true costs of routine care. Putting consumers in the driver's seat in this way would revolutionize health care just as it has revolutionized many other industries.
Caught a little of him talking about this on C-Span last weekend. Here's a link if you're interested:
http://www.booktv.org/Program/14215/Catastrophic+Care+How+American+Health+Care+Killed+My+Father+and+How+We+Can+Fix+It.aspx
Also, Amy was that you on an episode of "Verminators" that I saw yesterday? You should have unleashed your dog on those mice.
JFP at February 21, 2013 11:57 AM
Amy Alkon
https://www.advicegoddess.com/archives/2013/02/how-american-he.html#comment-3617219">comment from JFPHah -- yes, guilty. Extermination is expensive, and although Gregg offered to pay for it, I traded squealing, "Eeek, a mouse!" in exchange for getting it free. (I do have my price!)
I was amazed that I could have almost no food in my house and have mice (and worse), but the exterminators told me that they look for warm places to go and chew through houses even if you aren't a dirty pig with food everywhere. Or anywhere.
Apparently, the rat infestation in LA was caused by two biddies in Pacific Palisades who fed them.
http://www.laweekly.com/2008-07-31/news/rathouse-of-the-palisades/
Amy Alkon
at February 21, 2013 12:55 PM
The last two paragraphs from Walter Russell Meade is so true, and applies to taxes as well. People look at their take-home pay and have no idea how much they actually pay in taxes.
Lisa at February 21, 2013 2:01 PM
I had major back surgery 3 years ago. The surgery went great and I was feeling better than I had in a couple of years. I spent 5 days in the hospital post-op without any complications. Imagine my surprise when I woke up 3 days after being released and I knew I was sick. Like seriously sick, something was very wrong. I ended up in quarantine in ICU because of a strep infection at the surgical site. I spent 8 more days in the hospital, had two more surgeries to debride the incision, at least 3 blood transfusions and it ended with 6 weeks of IV antibiotic treatments. Original cost of my surgery and hospital stay was about $70k - the costs after everything else was another $200k. I have to go back in for more back surgery. I've already warned my doctor that there will be different protocols - i.e., nobody comes near me without washing their hands in soap and hot water before coming in my room. This nonsense of using hand sanitizer before touching a patient is BS, and I believe what caused my infection. I really don't feel like having another near death experience!
sara at February 21, 2013 2:45 PM
Oh man the story about the rat house totally skeeved me out! Gross!
sara at February 21, 2013 3:37 PM
Nurses who specialize in preventing hospital-acquired infections make lots of money. Lots, lots of money.
A PTA friend of mine died from infection after back surgery last year. Had surgery, few days later was in coma, dead in less than a week. So Sara you are lucky, believe it or not.
Few people know to ask about post-surgical infection rates fro their surgeons and hospitals, but it can vary WIDELY and is very important.
momof4 at February 21, 2013 6:40 PM
Airline pilots use checklists. It's pretty much common sense for situations where errors can be fatal. Too bad for us, surgical errors are not fatal for the doctors, or they'd change their behaviors.
MarkD at February 21, 2013 7:29 PM
For about the past four or five years I have paid all my health care expenses out of pocket. That includes glasses, dental work, and medication. I have insurance, but believe in personal responsibility.
The problem with the system is that most companies won't offer a High-deductible health plan (HDHP) with less than a $10K deductible, so I have a Medical Spending Account (MSA) that rolls over year to year, but if I were to have some condition that occurs in year three with $3,600 in the MSA and a $10K, I'm on the hook for the $7400. But if it is an extensive medical issue, and I'm out of work, b how am I going to pay the difference.
Then there is the Flexible Spending Accounts. They don't rollover year-to-year. You can have them with a regular insurance plan. The regular insurance plan takes all personal responsibilities from the insured. Or in other words there is no concern with costs from the tests because the FSA is paying the deductible.
Until we have a system that requires the patient (or their proxy) to sign off on the expense, essentially showing the numbers to the user, there won't be any realization.
Jim P. at February 21, 2013 7:32 PM
The high deductible insurance is a double-edged sword. It can save you a lot of money on both ends. First because it is so much cheaper and secondly because doctors hesitate to order tests. With insurance, they are guaranteed some money, with a high deductible they may not see anything and thus are highly discouraged from ordering tests and treatment. This can save you from the cost and pain of unnecessary testing, but they can delay a diagnosis too.
Jen at February 21, 2013 8:40 PM
Gee. The citation names all sorts of things THIS would prevent.
Too bad so many only think about what they will get from a system that isn't what they are told.
Radwaste at February 22, 2013 3:09 AM
This is a weird blog post.
Crid [CridComment at gmail] at February 22, 2013 5:14 AM
OK, maybe not. More later.
Crid [CridComment at gmail] at February 22, 2013 5:45 AM
"Airline pilots use checklists. It's pretty much common sense for situations where errors can be fatal. Too bad for us, surgical errors are not fatal for the doctors, or they'd change their behaviors."
I will claim (keeing in mind that I'm coming from a biased point of view) that the civil aviation industry, which is often harshly criticized for its supposed lack of safety, actually has a far better safety culture than the medical industry. It goes way beyond checklists. A big part of the problem is that safety standards in medicine are enforced mainly by criminalizing unsafe behavior. (Okay, they're torts rather than crimes, but the effect is pretty similar.) This is a very uneven and inconsistent mechanism. What's safe or unsafe is determined only after the fact by a jury; the conscientious practitioner gains little insignt from medical malpractice law, and enforcement varies wildly from case to case.
Rather than creating an incentive to devise and use safe practices, it creates an incentive to avoid liability, which frequently runs counter to safety, and wastes resources which could have gone instead into improving safety practices. In the aviation industry, the results of lawsuits against airlines or aircraft manufacturers have very little influence over how the industry operates. (Part of this is because most companies in the industry are self-insured, and they don't mind going to court when they think they're in the right.) The difference is that everyone (okay, nearly everyone) understands that safety is in everyone's job description, and that the entire industry could vanish if a good safety culture isn't maintained. Medical people by and large don't have that worry; as long as there are sick people, there will be a medical industry.
Some time back I was telling my wife, who works in the medical industry, about the Aviation Safety Reporting System. This is a system where pilots, air traffic controllers, and other people in the industry can anonymously report on safety incidents and problems that they have observed, including any that they might have caused themselves. ASRS reports are anonymized, and then the system analyzes the reports for trends and reoccurring problems. It issues periodic summaries, and there is a database of individual reports that can be looked up. The law prohibits information that would identify an ASRS report submitter from being released to anyone; ASRS information may not be subpoenaed and may not be used as evidence in court, and the FAA is not allowed to launch an enforcment action based on an ASRS report. The ASRS system is administered by NASA, which has no enforcement authority and no incentive to release information about people who submit reports.
I suggested to my wife that the medical industry needs a system like this. She was at first appalled, but then intrigued. How much info could we learn about unsafe practices in the medical industry if we could actually gather some data from the people down in the trenches? Sadly, the malpractice-law industry would never permit it to happen.
Cousin Dave at February 22, 2013 7:41 AM
Cousin, don't you think general aviation was affected by the change in litigation over the years?
Radwaste at February 22, 2013 7:26 PM
Intriguing idea cousin Dave. I get so angry about the way we do things medically.
After the fact, I was told that doctors and nurses limited visits to my room when I was in labor (actually, officially i was Not in labor) because they feared that we would sue. If they didn't come in the room or administer pain relief, they were less likely to be found liable. I was admitted to the hospital but was not diagnosed as being in labor until about 10 minutes before my son was born. I guess pain relief does increase the opportunities for complications. Interesting.
So many decisions are made by the mighty dollar that it is difficult to even tell what is truly best for patients.
Jen at February 22, 2013 9:37 PM
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