Quality Improvement Will Make Health Care More Expensive

Physicians are probably the most highly trained, sophisticated workers in the world. After four years of college, physician training begins with four years of medical school and continues with four to eight years of postdoctoral work and supervised clinical experience. These newly trained physicians are then sent into the world at about age 34 to enter the work force as doctors who assist people with diseases and other health matters. As long as the patient pays the bills, they receive efficient care. Even when Blue Cross came along with expensive hospital coverage, the patient still paid the professional fees and kept expenses tight to the vest. If this arrangement had remained in effect without government intrusion, health care today would be about half of the present cost. It would be affordable to everyone.

The county hospitals did an excellent job of giving quality of care to the poor, usually with physicians donating their professional services. Most doctors I knew would plan to donate 8 to 10 hours a week to this charity. It was a good feeling for physicians and surgeons, and the patients we saw were deeply appreciative. Many told their families of the well-know doctors who took care of them in the county hospitals. All county hospitals had interns and residents to take care of these patients on an hour-to-hour basis with back up by the private doctor with whom they made the morning attending rounds.

There was no such item as uninsured. Everyone was covered by his or her hospital insurance, by his personal check, or by the county welfare departments. Hospital insurance could be equated with high deductible insurance since the physicians' fees could be considered the deduction, although always affordable. For those that couldn't afford these fees, all the physicians I knew would provide them with free care. Physicians expected to give ten percent of their time to charity, either in their own offices or at the county hospital.

Then the cry came from unions, governments and socialists that it was demeaning to go to county hospitals as charity cases; these patients should be placed in the mainstream of health care. This resulted in the Kerr-Mills bill, the first significant intrusion into general health care. However, this didn't pacify the cry for Medicare which came along in 1965 and resulted in socialized medicine for everyone over 65 years of age. Then all the disabled were added. Then all the patients on kidney dialysis were added. Medicaid was also implemented to replace the Kerr-Mills aid for the poor.

These huge programs caused the largest inflation in health care costs the world has ever seen. Hospital construction boomed to take care of all the people that now wanted first-class inpatient services that in the past were happy with outpatient or county hospital services. The county patients never understood the economics of health care any better than their own. They padded down in the hospitals and were usually able to get a few extra days of free care. The daughter of one patient refused to take her mother home on December 23 stating that it was cruel to burden them with her care just before the holidays. It would be better if she could stay for an extra week until all the festivities were over and the guests had returned home. Why should anyone be concerned about an extra week of "mother" sitting at $2,000 a day? Isn't that what free care is all about?

Physicians have been criticized for the last three decades as being the cause of most of the excessive health care expenses. The whole managed care system was implemented by the government to control health care costs and much of it was directed against physicians. I remember managed care meetings where the managers were almost in tears saying, "Why can't you docs just put away your pen? That would save us a lot of money." I received a personal call from the CFO saying that he noticed I saw most of my heart and lung patients four times a year. Wouldn't three times a year be adequate? That will save us 25 percent of our cost of office calls. So the big push was less tests, less office visits, less consultations, less procedures, and less of anything that costs.

Now we have total reversal. With the emphases in the last several years to improved the highest level of health care in this country and make it an even higher quality, there has been a big push to make sure more tests, consultations and procedures are ordered. Lipids are requested to be checked more frequently, even if normal. Mammograms in later life are still requested yearly, even though many authorities recommend every second or even third year. Same for pap smears. At the medical grand rounds at the University of California at Davis, a visiting GI professor stated that far too many colonoscopies are done. He even suggested that unless there are risk factors, one procedure in the 60s was adequate and if a polyp was found, a second procedure in the late 60s or early 70s. The HMOs, presumably for PR purposes, are now recommending colon screenings starting at age 50. The gastroenterologists are being overwhelmed with the number of colonoscopies that are being requested, and their schedules are quite full. Colonoscopies are not an inexpensive procedure.

Bureaucrats feel that doctors are not adequately performing all these supposed procedures and, therefore, have concluded that physician care is inferior. This attitude will not really improve the quality of care but will make health care considerably more expensive. The impression of many of the physicians suggests that health care expenses will increase 25 to 30 percent with questionable improvement. With health care consuming close to 20 percent of GDP, these are significant cost increases.

Social Security would have remained viable if the age of retirement would have been the index for life expectancy. Then over the past 80 years, the retirement age would have increased to 75 and Social Security would have remained viable. There was no way that with retirement years now twenty years longer than in the 1930s, the worker could pay an extra twenty years for everybody to live off of everybody else. There is no Social Security depository - benefits are paid out of the Social Security taxes.

The same situation should hold for Medicare. To preserve Medicare, it should have been indexed with Social Security. At the current Social Security threshold, benefits would start at age 67. It should also be gradually indexed to age 75 according to current actuary life expectancy. Medicare would then have remained viable.

But Medicare will crash sooner if the current proposed Secretary of Health and Human Services gets his way and lowers the age for Medicare to 55. This will precipitate disaster since the current unfunded liability of Social Security, Medicare, Medicaid and SCHIPPS programs is estimated at ninety-nine trillion dollars. The president-elect's infusion of one trillion dollars in new taxes will have no effect on these liabilities. But they will keep the crowds pacified until the next elections. Rather like the Romans who kept the masses pacified by throwing the Christians to the lions.

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