My father's maiden aunt came to live with us in November of 1947. Aunt Agnes had congestive heart failure and could no longer care for herself. But aunt Ag just got sicker. Her pulmonary edema worsened in spite of the digitalis and diuretics her doctor had given her. She then contracted pneumonia. Unable to breathe properly, she was terrified.
Late on that cold November afternoon, my mother called the doctor. He made house calls. While we were waiting, my mother ordered my 4-year-old sister and me to load all of our empty redeemable glass bottles into my Radio Flyer wagon. Mary and I pulled and pushed that wagon half a mile to Fox's Delicatessen on Main Street. Mr Fox counted the bottles as my sister told him all about Aunt Ag and the doctor coming and how we needed to pay him. Mr Fox then handed me three $1 bills. Mary and I returned home, gave the money to my mother who laid the three $1 bills, like some trophy, on the kitchen table—ready for the doctor.
Dr James Norton arrived soon afterward. My mother greeted him at the door and, realizing that his time was valuable, quickly ushered him in to see Aunt Ag. It was immediately clear that the woman was in a bad way. She was making a sound that I would later know as a “death rattle.”
Dr Norton calmly removed his coat and sat down beside her. He opened his immense black bag, removed a stethoscope, and listened to her heart and lungs. He examined the medicine bottles by her bed and slowly shook his head. He then withdrew a stainless steel syringe from the bag, attached a needle to it and then stuck it into a labeled bottle that contained a clear liquid. I recall watching in fascination how he first injected air into that bottle, then, without effort, the syringe filled automatically. He saw my interest and gave me a wink. I looked away.
When I looked back, he had already placed the needle into a vein in one of Aunt Ag's arms and slowly injected the liquid. As he did so, Aunt Ag, who had been terrified as she gasped for air, started to relax. Dr Norton withdrew the needle, replaced it in his bag, and then took hold of her hand and held it gently.
Aunt Ag's eyes closed as she mumbled, “Thank you, doctor… thank you, doctor….” For the first time in days, she appeared calm. She laid her head back on the pillow and finally seemed at peace. Dr Norton just sat there, holding her hand for what seemed like a long time. My mother, standing in the doorway, blessed herself. The worried look that usually dressed her face had disappeared as she watched Ag drift into a deeper and deeper comfortable sleep.
Finally, Dr Norton stood. He felt Aunt Ag's wrist, then raised each eyelid. He slowly walked over and hugged my mother and then went to the telephone and called Monahan's Funeral Home. “Don't worry, Mrs Kelly,” he said. “I'll take care of the paperwork back at the office.” My tearful mother proudly handed him the three $1 bills. I do not think that she could have been more grateful.
Later that evening my mother insisted that she heard many people talking and laughing at a happy party outside of our kitchen. She went out to investigate but found nobody. She was convinced that she had heard the voices of angels and long-departed friends welcoming Aunt Ag into heaven. For the first time in many weeks, the house was quiet and peaceful. My mother seemed contented and hummed to herself as she prepared a late supper for us.
And on that day I decided to become a doctor.
Back then, people accepted the inevitability of death and realized that medicine had its limits. Patients and their families respected a physician's efforts and usually understood that payment was expected when a service was rendered. Many doctors adjusted fees in relation to a family's financial situation. Dr Norton would charge us $3 for a house call but could charge one of the wealthy families in town as much as $25. I understand that neurosurgeon Loyal Davis would charge a patient the equivalent of 1 month's salary for a brain tumor operation. Others had similar systems, but usually it was the following paradigm: doctor does a service; patient (or family) pays the doctor. Poor people paid little or nothing at all; rich people paid a lot more.
A lot has changed in 60 years. Doctors now have more in their therapeutic arsenals, patient expectations are higher, and the practice of medicine has become more complicated—and expensive. What would have happened with poor aunt Ag today?
We would not have called a doctor, but if we had we would have been instructed to call 911. An ambulance would have arrived on the scene (cost, $1100) and EMTs would have loaded the old lady onto a gurney that they would jam into their vehicle and, sirens blaring, make the trip to the local hospital emergency room (cost, $1285). IVs would be started ($110), chest x-rays and probably a chest CT scan ($840) would be performed, and blood gases drawn. She would probably have been intubated ($650). A Swan-Ganz catheter would be inserted ($1200), a portable chest x-ray obtained ($186), assisted respiration begun, cultures taken, and intravenous broad-spectrum antibiotics started. She would have been cared for by an emergency medicine specialist and then seen by an intensivist, a cardiologist, a pulmonologist, a specialist in infectious diseases, and a parade of housestaff, social workers, and representatives from the billing office before being carted off to bed 5 in the intensive care unit ($2382 per day).
Over the next several days, a bevy of professionals would work on the lady in bed 5 in the ICU. Daily portable chest x-rays would be obtained as well as daily laboratory work including arterial blood gases. She would receive diuretics, analgesics, and inotropic agents as well as the antibiotics. And there would have been a 50% chance that she would actually walk out the front door of the hospital. If she did, the odds would have been very good that she would be back in a less than a year and may not have been so “lucky” the next time. And the cost of this therapeutic tour-de-force? Possibly over a quarter of a million dollars!
And what would have happened to Dr Norton today? He would have been sued for malpractice and would probably have lost his license.
“I intend to live forever, or die trying.” -Groucho Marx, 1958
Over the past 50 years a complex and profitable industry has evolved that is dedicated to the treatment of incurable diseases. Certainly there are some triumphs—people have survived to have years of meaningful and productive life after major medical effort. Regrettably, these are few in comparison to the many thousands of 80- and 90-year-olds that fill the intensive care units across our country—and despite heroic efforts, die then or a few months later. The costs of hospitalizations, surgery and perisurgical costs, radiation therapy, various chemotherapy protocols, physical therapy, sometimes a second-look surgery, more chemotherapy, and terminal care quickly add up. And what is the expected result?
They ultimately die after heroic efforts costing hundreds of thousands of dollars. Let us consider, as an example, the treatment of a patient with a glioblastoma. With aggressive therapy, we increase the expected survival from the natural history of the disease—17 weeks after diagnosis—to a mean survival of 52 weeks and possibly more. The cost of treating a patient with a glioblastoma from diagnosis to death is about $450 000 in the Northeastern United States. Is the extra 35 to 50 weeks of survival worth it?
Few Americans consider death an option. Money is no object when someone else is picking up the tab. If that $450 000 came directly out of a patient or family's pocket, how many would actually choose to pursue a course that involved one or occasionally more major surgeries, 6 weeks of radiation therapy, trips to a neurooncologist for chemotherapy, then aggressive protocols such as bone marrow rescue after high-dose chemotherapy and whatever? Instead of impoverishing their families, how many would elect to take a trip somewhere or spend a few months of quality time with the grandkids, etc?
Because insurance companies, Medicare, or Medicaid pay the bills, most patients consider health care a right, not a privilege—especially because they or their employers have been paying those high health insurance premiums every month and the taxes that fund Medicare and Medicaid. This sense of entitlement results in a spendthrift mentality when it comes to the purchase of health care services.
“Production is the only answer to inflation.” -Chester Bowles, 1984
Maybe so, Chester, but it does not work in medicine. Insurance companies, trying to reduce the medical loss ratio, keep changing the rules. To deal with insurance companies, physicians must add staff, particularly billing personnel. Salaries and benefits increase overhead. Physicians, in an attempt to compensate for increasing overhead and falling reimbursement rates (or those that do not keep pace with inflation), increase fees and keep adding on new procedural codes as newer technology becomes available. New procedures and technologies pay better than old procedures whose reimbursement codes were written many years before and have not kept pace with inflation. Patient demand for newer procedures and better services has increased, as has the supply of new drugs, technologies, and procedures. Medical device companies market expensive instrumentation to hospitals that, in competing with each other for patients, must have the latest technology. The result is a steady escalation of costs.
Deflecting criticism, insurance companies blame the medical profession for their high costs. Meanwhile, insurance companies have created cumbersome expensive bureaucracies. And they divert funds that could have been used for the provision of health care to support stockholders' dividends and outrageous executive salaries, stock options, perks, and benefits.
The overall cost of health care in this country has grown from $75 billion in 1970 to $1 trillion in 1993 to more than $2 trillion in 2008—now 16% of our GDP and, if unchecked, may continue to increase to 25% of the GDP by 2030. Almost half of this health care spending is used to treat just 5% of the population. It is said that about 85% of one's lifetime total health care costs are consumed in the last year of a person's life; 45% of the total in the last month. Interestingly, expenditures are similar irrespective of whether or not patients have specified an advance directive or are cared for in hospitals or hospice. Insurance companies use the general public's fear of expensive terminal disease to justify their high premiums. Because the cost of expensive terminal disease is now born by a third party—insurance, Medicare, or Medicaid—the American public is somewhat sheltered from the true cost of health care, but as insurance premiums continue to rise, they are rapidly becoming aware.
“To err is human. To blame someone else is politics.” -Hubert Humphrey, 1967
At one time doctors had to admit to a dying patient and family that there was nothing more that could be done. Now, there is almost always something that can be done: a new drug, an innovative procedure, and so on. And if a doctor now tells a patient that there is nothing that can be done, patients and families search the Internet and find something. The American medical profession is being swept along on an inevitable course of escalating spending for health care over which we have had progressively less and less control but will get the blame.
The medical profession has not been effective in evaluating the cost-effectiveness and cost-benefit ratio of the new and expensive procedures we provide. It is not what we as physicians, innovators, and scientists have been trained to do—and we have a vested interest in the treatments we provide. Evaluating the cost-effectiveness of our therapeutic decisions is complex and difficult for us; how much is an extra year of life worth in dollars and cents? Is an additional year of life worth more for a multimillionaire than a sanitation worker? Many of us are not objective.
Ultimately, the government may do this for us for 1 simple reason: voters—not necessarily taxpayers—will be unable to afford the type of health care that they know to exist as they surf the Internet, and read the adverts in newspapers and magazines and news stories in the media. And they are being led to believe that we are paying more but getting less for it. Politicians and economists are quick to point out that annual US per capita health care spending is about $6500, twice that of Japan and exceeding all other nations in the world, whereas our average life expectancy is 77.6 years in comparison to that of Japan (81.4 years), Australia (80.4 years), Canada (79.5 years), and many other developed countries where the public pays less but lives longer.
In an attempt to define quality standards, our national organizations have and will continue to produce therapeutic guidelines for the management of specific disease entities. These will define and may ultimately dictate the standard of practice. The government and third-party payers could simply put a price tag on the various components comprising these standards and use compliance as a metric for reimbursement. Physician input will have less importance in the creation and monitoring of these. According to the third-party payers, we are no longer “doctors,” but “providers,” as are nurses, chiropractors, physical therapists, and so on. As time passes, cost and benefit considerations may shift more to the concerns of cost as we, as a profession, are reduced to technicians that follow nationally- mandated protocols on the treatment of a laundry list of diseases and conditions.
The sad paradox here is that exciting new technologies are now available and appearing on the horizon: endoscopic minimally invasive procedures, robotic surgical assistance, nanotechnology, stem cell therapies, neuroaugmentative and restorative therapies, and new chemotherapies that seem to actually be making a survival difference in diseases that were once considered hopeless. If we had taken a cost-conscious nihilistic approach to disease over the past 20 years or so, these advances would probably have never happened. The questions are: can we now afford these, and will our profession have free rein to explore them in the future?
Wouldn't it be wonderful to return to the good old days but with today's methods, tools, and toys? Back to a time when doctors had respect from hospitals and the community, and patients and their families and did not have to deal with insurance companies, hospital bureaucracies, and an alphabet soup of various oversight agencies? But we cannot go back. We have lost control of our profession and we let it happen to us when we began playing ball with the insurance companies in the 1940s and 1950s, jumped on the Medicare and Medicaid bandwagon in the 1960s, and almost trampled each other trying to get on managed care panels in the 1990s. When we allowed third-party payers to dictate if, when and how much they would pay us for our time and effort, we gave up control of our incomes, our freedom, and our future.
We have acquiesced to the insurance industry, federal and state governments, and unrealistic expectations of patients and families brought on by billboard and Web-based hucksterism and news media hungry for “content.” Meanwhile, as overheads rise and reimbursements plummet, there are many, even now, who are willing to accept the security of a salaried position. If we allow these factors to control our future and current trends continue, we may all end up working for the government or become employees of a large hospital system. What our generation thinks and remembers will no longer matter as new graduates, who know no better, take our places and repopulate our field. Do we really want this to happen?
“Communism's like prohibition, it's a good idea but it won't work.” -Will Rogers, 1927
Certainly, this scenario is depressing and seems hopeless. But is this really the future? It can only be if we let it happen to us. We can stop this because we have something that nobody else has and cannot easily replace. And we have a “product” that our society needs. If we were any other business we would refuse to sell our product until the price was right; a price that considered the cost of doing business and sufficient profit that allowed us to live and keep the incentive to stay in business. We should never sell our products for less than we feel is fair and appropriate. We—each of us—should set his or her own fees, not some government bureaucrat and not some high school graduate at an HMO. Selling our service at prices below the cost of doing business is just plain crazy! But that's what is happening—many of our third-party payers, including Medicare and definitely Medicaid, expect us to do just that. And for a good reason: because we let them do it!
Some say that we must continue to work, irrespective of what we make, because it is our duty, our oath. Medical care is important for life itself. Okay, but then so is food! Let me tell you a story.
One day my wife sent me to buy some groceries at the local store. And it was an epiphany!
Ahead of me in the checkout line was a young couple with a cart full of groceries. Because I was impatient to get out of there, I found this irritating until I saw how they paid for the bags of groceries they were planning on carrying home. They did not pay with cash, credit, or debit cards. They paid with food stamps from the Supplemental Nutrition Assistance Program, or SNAP! The grocer told me that he is able to redeem these at full price.
The government was not asking the grocer to sell his goods at a cut rate. Yet they ask doctors to sell their services for Medicaid recipients at 10 cents on the dollar! For us, this does not even cover the cost of doing business for the time consumed taking care of one of these patients. This is just plain nuts!
In fact, this reminds me of a country in the Asian subcontinent. A jubilant new revolutionary government decreed that food should be free. Without the economic incentive to plant and harvest, farmers stopped producing and there followed famine and starvation. Since then, I am told, things there have gotten worse.
Our system of health care financing, including Medicare, Medicaid, indemnity insurance, and Managed Care, is like one of those chain letters. Remember those? There was a list of 5 names. It was up to you to send the letter on to 5 of your friends and send $5.00 to the name at the top of the list. You then patiently waited for the cash to roll in as your name moved to the top of the list as the chain of recipients continued to grow. The people at the top of the list may have received a pile of money, but I never saw any money out of one of those because by the time my name had moved to the top of the list, the chain of trust had been broken.
In medical third-party insurance schemes (including those sponsored by state and federal governments), we medical professionals support that chain of trust. Without our participation, they have absolutely nothing to sell. But as long as we support this system, that house of cards will continue to stand and liberal politicians will get elected and reelected while insurance company executives pull in their 7-figure-plus salaries, support reelection campaigns of politicians sympathetic to their cause, and sponsor sporting events and other pursuits that have little or nothing to do with the provision of health care. It is astounding to me that they have the unmitigated gall to underpay us, bog us down in piles of unnecessary paperwork, and come up with every excuse possible to delay or even deny payment for our services. They do it for one reason: they believe that we are stupid enough to take it!
“If we don't hang together, we will hang separately” -Ben Franklin, 1776
Federal and state governments and insurance companies are using our professionalism and compassion against us. And we have proven to them that we cannot work together and stand up for our own rights. This leaves us powerless. Of course, there are those who are afraid to oppose this injustice. And there are others who will think of ways of exploiting the status quo for their own short-term and short-sighted gains. These weaken us all. We must hang together and speak with one voice that is loud and clear. If we truly care about the future of our profession, we must all oppose what is happening to our profession.
However, even if we all did stand together—not just neurosurgeons, but every physician in the United States—that would only amount to about 0.2% of the US population. By ourselves, we have very little power with which to counteract the momentum of a trend that started in the 1940s and has now become a “steam roller.” This trend is basically this: the US population now believes that someone else should pay for their health care! They do not expect someone else to pay for their cars, dishwashers, and television sets. They even pay for their plastic surgery for crow's feet, micromastia, and liposuction, as well as their Viagra ($799 million in US sales last year) or Cialis ($680 million). However, surgery for a brain tumor, a ruptured disk, or whatever is a cost that the American public believes someone else should bear.
Nonetheless, it is clear that we need the power of the public on our side if we are to change this paradigm. Certainly, we can talk to patients and families as they visit our offices and tell them what a shabby deal we are getting from the insurance companies, HMOs, Medicare, and Medicaid. I have done this and people are generally sympathetic—but not sympathetic enough to make the effort that will actually change anything. In addition, most of the US population at any one point in time is healthy, and our problems pale in the vicissitudes of their everyday lives. In fact, they could not care less about our problems.
This is not their fault. It is our fault. We enabled this attitude when we started playing ball with insurance companies and federal and state governments. We let go of a paradigm that worked for centuries: doctor treats patient, patient pays doctor. Now insurance and government programs pay the doctor and the public has gotten the idea that health care is an entitlement. Now their focus is on the taxes that cover Medicare, Medicaid, and their insurance premiums; taxes and premiums are too high! And whose fault is that? In the public's mind, it is the fault of the medical profession! They focus on our high-technology equipment (unless they are sick; then they love high technology—the higher, the better). They look around our “fancy” offices, note the new Porsche we are driving, and see where we live; they see the waterfalls and grand pianos in hospital entry foyers and conclude that this is why medical care costs so much.
But the public does not see the billions of dollars diverted from the health care pool by insurance companies that support their bloated bureaucracies, real estate, dividends to stockholders, extravagant salaries, and benefits. Nor do they appreciate the cost of the inefficiency, fraud, and expensive bureaucracies that could otherwise be used to provide health care for Medicare and Medicaid recipients. And then there are hospital costs that have risen 4 times faster than inflation.
Here is how we get the American public on our side. But I am not saying that the following course of action will make them “like” us. Nonetheless, it will force them to turn their anger against our common enemy: the third-party insurers.
The plan: we should refuse to accept payment from third-party carriers that reimburse us less than the cost of doing business and less than what we feel our time is worth. The American government and American insurance industry have proven themselves to be bullies that cannot be appeased. There is little point in negotiating with them. If doctors do not agree with what Medicare, Medicaid, and third-party payers pay them, then they should opt out of Medicare, refuse to accept Medicaid, and drop participation with the insurance companies and HMOs that offer reimbursements of less than our amortized overhead plus what each of us think we should make per hour. It is our legal right to do so.
We are free men and women aren't we (unless we live in a US state where licensure is linked to participation with Medicare and Medicaid)? I do not propose going on strike; doctor strikes never work. We will still care for our patients. But the patient, not their insurance company, will pay us. They then can get reimbursed from their insurance companies. After all, they contracted with them—let the patients and the general public find out what rotten coverage they have. Of course, we can do some patients a “favor” by lowering our fees depending on their individual financial situation or by making a “gift” of our services if we so choose. But in this case we are doing the patient the favor, not some “suit” in an insurance company or some politician.
We must force our national organizations to rise above their own internal politics and stand behind us in support of this course of action. They have offered only token resistance or downright appeasement to the third-party payers long enough with their public awareness messages and lobbying efforts. It's about time that they represented and stood behind us and took some heat. They need to take on the federal government and the insurance industry and fight for our rights as professionals that the American public cannot do without.
And maybe, just maybe, we can save neurosurgery in particular and even medicine in general.
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