The great health care sinkhole

By Robert S. Kiefner, M.D.
Concord Monitor (N.H.), April 3, 2013

The bizarre and tragic loss of a Florida man a few weeks ago, slipping to his death from his bedroom into a sinkhole, offers up a fitting metaphor for the great abyss between cost and value in health care and how it has the potential to swallow us up without warning.

The periphery of that huge health care sinkhole is occupied by guys in suits – insurance companies, Big Pharma, and overpaid hospital executives and their legions of lawyers and lobbyists. In Steven Brill’s recent Time magazine expose, “Bitter Pill,” he shows how the elite of a separate health care economy are all doing quite well, while middle-class folks with serious illness are going bankrupt as a consequence of being under insured or just plain priced out of the market.

Equipped with shovels on the edge of the great sinkhole, health care executives contend that they are filling up the hole. In reality they are digging it deeper to everyone’s peril.

In the world of for-profit medicine, doctors also need to be held accountable, particularly among sub-specialties, as the gap between the pay of primary-care physicians and specialists continues to grow.

The five minutes during which an orthopedic surgeon applies a cast to a broken wrist, a dermatologist freezes a couple of barnacles on someone’s face, or a radiologist interprets an MRI are still reimbursed vastly more than a family physician might charge for an hour of managing a patient with multisystem disease, sorting through the pharmacy the patient has brought into the office in a brown paper bag, and making referrals where necessary, all while being trying to enact evidence-based medicine and maintaining an awareness of cost/benefit ratios.

The much-reported deficiencies relating to the care of the mentally ill would certainly be better addressed if we applied a fraction of the reimbursement for a broken foot to the care of a broken mind.

While the Affordable Care Act attempts to improve the lot of primary-care physicians by marginally enhancing reimbursement and recognition of the effort going into a “Patient Centered Medical Home,” the attendant costs, regulations and overall bureaucracy effectively erode the gains. Indeed, the sheer number and complexity of rules and regulations generated by the Affordable Care Act and Accountable Care Organizations have made it well nigh impossible for solo physicians, lacking in resources, to venture into private practice.

And so we witness the ascent of great and powerful hospital executives, modern-day health overlords charged with developing local networks of care, financed by the now famous “Chargemaster” system described by Brill. Two-dollar Tylenols, $70 gauze pads – it’s enough to make you cry into your $50 “mucus recovery system,” aka Kleenex. But it all adds up to million-dollar CEO salaries, even in community hospitals. No doubt that these are bright, clever and caring people, but no hospital CEO deserves to make a multiple of the salary of the president of the United States.

The perversity is ratcheted up another notch when one contemplates the multimillion-dollar salaries of CEOs of health insurance companies. But instead of making money on gauze pads and Tylenol, they prey upon individuals and businesses. A family of four may expect to pay over $25,000 for a year of coverage, complete with an $8,000 deductible in some markets, given the lack of major cost controls in the ACA.

While Obamacare may have expanded the safety net by encouraging the expansion of Medicaid, coverage of kids up to the age of 26, enhanced coverage of preventive services, coverage in the presence of pre-existing conditions, and lack of lifetime limits, plenty of folks are still going to fall through the net and into bankruptcy or worse.

There will be those in the great medical-industrial complex who would dispute the notion that U.S. health care is in desperate shape, who would offer their own numerical analysis to support the status quo. These are the people who use statistics the way a drunk uses a lamppost, for support rather than illumination.

While acknowledging and promoting the gains of the ACA, we need to resume the journey toward a single payer, where everyone enjoys the security and dignity of being covered by insurance. We’re not talking “free” care, just quality care at a truly affordable price. Where there are excessive profits, there cannot be compassionate and accessible care for all. Let’s fill in this enormous sinkhole, so that everyone gets a good and safe night’s sleep.

Dr. Robert S. Kiefner is a family physician in Concord.