This week I am one of about 500 emergency physicians in Washington, DC for a meeting focused on political advocacy. The major topic of discussion is health care reform and its implementation. Everyone is interested in controlling costs. Policy makers claim a duality of interests: controlling costs and improving quality. They insist these two goals are not mutually exclusive and that there is reason to think certain measures to improve quality can simultaneously reduce costs.
One of the recurrent themes in discussions of health care is that the cost of health care has, for quite some time, been rising faster than the overall rate of inflation. This is certainly true. But it is a false comparison. When the Bureau of Labor Statistics reports the Consumer Price Index, it is based on a "basket" of goods and services. Most of the things in that basket don't change much over time. The loaf of bread in that basket is very much like the loaf of bread that was in that basket 30 or 40 years ago. (Of course it is much fresher than the old one.)
Is today's health care the same as what was available 30 or 40 years ago? Yes, that is a rhetorical question. Advances in medicine have been such that the health care dollar is buying something very different now from what it bought a generation ago. That makes comparisons difficult - especially the kinds of comparisons necessary to examine what something costs relative to what it cost in the past.
This is a crucial element in the consideration of what health care should cost, or of what we are willing to pay for it. We are spending a higher percentage of our gross domestic product on health care now than ever before. But we must ask not whether the rate of increase relative to the overall rate of inflation is too high, or whether the percentage of the GDP is too high, but whether what we're getting for the health care dollar is worth it. That is a very different question. Perhaps your answer to that question is no, leading you to the same conclusion - that we are spending too much on health care - but before we reach any conclusions, it is important to make sure we are asking the right questions.
Economists note that we spend a higher percentage of our GDP on health care than any other country in the developed world, which may be a better way to make comparisons, and yet it is unclear whether we are achieving better health outcomes than those other countries. If you like that line of reasoning - and I do - it is still important to understand that the logical conclusion is probably not that we are spending too much but that we are not spending wisely.
During the debate over health care reform legislation there was much talk about comparative effectiveness research. This research - intended to yield conclusions about what is useful and what isn't - is not something new, although we certainly need much more of it. What must be new, however, is an enlarged public understanding of what we know and how we should make use of it.
The Public Health Service produced a set of guidelines years ago about the management of back pain. Among the PHS recommendations, based on a solid foundation of evidence, was one that suggested no imaging studies (x-rays or others) be obtained unless the symptoms have been going on for at least a month and not improving with "conservative therapy." (What we're talking about here is not back pain after a high-speed motor vehicle crash in which there is reason to be concerned about a spinal fracture or a spinal cord injury, but rather run-of-the-mill back pain such as most adults experience at one time or another as one of those annoying facts of life in a human body.)
But what is the reality of medical care in our system? Many patients with back pain consult a physician and wind up with an order, very early on (long before a month's trial of conservative therapy), for an MRI of the spine. There are many reasons for this, but the most important, I think, is that patients are not interested in taking a conservative approach that is recommended based on good scientific evidence. They want to know exactly what is wrong, and right away. Physicians, eager to meet patients' expectations in a health care system in which the doctor-patient relationship is frequently characterized by consumerism and a view of the patient as a "customer," do what they think the patient wants.
We must reconsider our view of what it means to consult a physician. When we approach the doctor-patient encounter with expectations of specific things the doctor should do, most often that's what we'll get. Very often, we'll get more rational test ordering, a more scientific approach to prescribing treatment, and a better outcome if we tell the physician the problem and work with him or her to find the solution without preconceived expectations of how to get there. The doctor has gone through eleven to sixteen years of education and training after high school to acquire the expertise to figure out what is wrong with you and what to do about it. So go to see the doctor with an open mind, prepared to take advantage of all that learning.
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