Why is the sky blue? And why is healthcare so expensive?

Over the last several months at Georgetown I’ve had a lot of opportunity to hear about the problems facing our healthcare system, and some suggestions about how to fix it.  There’s a lot to say, and I have neither the time nor the energy to say it all, but I wanted to present some things I’ve heard and have been thinking about.  So here goes:

One of the major problems facing healthcare in the United States is that it’s expensive (anyone who has ever had a monthly premium, a child or a major health problem should be nodding their head right now).  The US government spends almost 2.3 trillion dollars a year on healthcare.  Healthcare consumes 16.2% of our Gross Domestic Product, and that is expected to increase to 19.6% by 2016.  Compared to other developed nations, the United States spends significantly more per capita on healthcare – about two and a half times as much as Britain and twice as much as Canada – and even spending that much, the United States was ranked 37^th for overall quality of health care in a report by the World Health Organization comparing 191 countries.

So why is healthcare in the United States so expensive?  There are many reasons (which I hope to elaborate on later), but one important one is that we are overspecialized.  We make excellent specialists here, and our acute care is the best in the world, but we fall short on the long-term preventative care provided by primary care physicians.  Experts have advised shifting the focus to prevention rather than cure (there’s a saying about that), especially because prevention is a lot cheaper.  Specialists are a vital part of healthcare, and again, are what make the United States a leader in acute care, but it’s not unusual for a patient to have several specialists caring for him in addition to his primary care provider, providing services that his PCP is perfectly qualified and legally authorized to provide.  Consider, for example, an elderly diabetic patient with high blood pressure who sees a family practitioner, an endocrinologist and a cardiologist.  The cardiologist cares for the blood pressure, the endocrinologist for the diabetes, and the PCP for everything else.  If the PCP handled the routine maintenance of all of these problems not only would the coordination and cohesion of his care increase, but the costs would drop dramatically, since the cardiologist and endocrinologist are paid much more for their consults. Having people get their care from a primary care physician, with occasional consults with a specialist, would go a long way to decreasing health care costs. 

So why don’t primary care physicians handle these things?  First of all there aren’t enough of them.  Most PCPs are overworked and the only way to increase the amount they get paid is to increase the number of patients they see.  The average visit with a primary care physician is already only 15 minutes long.  Given the limited time, their scope is also necessarily limited, and management of chronic disease is handed over to specialists, as are routine diagnostic tests, like colonoscopies.  Some primary care physicians are trying to do more of this themselves, but to do so means seeing less patients, and therefore making less money, which can be a major issue for PCPs trying to run a practice who already make half as much as their specialist colleagues. 

It’s not hard to see, either, why so many areas currently have a shortage of primary care physicians, and 50% of family medicine residency slots are filled by foreign medical students: When standing at the threshold of the decision of which field of medicine to go into, medical students (such as myself) face the prospect of finishing their residency in their early 30s with hundreds of thousands of dollars of debt, no equity in a home, no retirement, and no money saved for their children.  So when contemplating the choice of whether to make $125,000 a year or $250,000 a year it’s easy to understand why too few American medical students are choosing family medicine, especially when you couple that with the perceived lack of prestige associated with primary care.    

This then is the first thing that needs to change in the American medical system.  As a society our emphasis needs to shift from specialty care to primary care.  A doctor I spoke to was part of a think tank hired by IBM to help them cut costs in their health care system.  IBM spends $2 billion a year on health care for its employees, and of that $2 billion only 2% goes to primary care.  The think tank estimated, that if they spent 50% more on primary care, in other words shifted it from 2% of their budget to 3%, their total health care costs would come down by 15-25%.  If primary care were made more financially attractive, more people would go into it, which would ease the patient burden on current primary care providers, allowing them to broaden the scope of their practice and provide many of the same basic services specialists now provide.  As we make that shift, healthcare costs will come down as the money is shifted away from the top-heavy system in place now, where the bulk of the funds go to the doctors treating the least number of people, to a more balanced system that focuses on prevention and long-term care.    

That’s the theory anyway.  I recognize this is only one element in a very complex problem.  I’ve done a lot of thinking about other elements in it too, but this has already ballooned into a much longer post than I anticipated so I’m going to stop now and save the rest for future posts.  Sorry for the long windedness and please share your opinions.  I’ve got some other really interesting data to share and I’m interested to know your thoughts on the subject.  My opinions are subject to change J.