Monday, March 19, 2012

Cost or Care

God has given you one face, and you make yourself another ~ William Shakespeare

"Our age has shifted all emphasis to the here and now, and thus brought about a daemonization of man and his world. The phenomenon of dictators and all the misery they have wrought springs from the fact that man has been robbed of transcendence by the shortsightedness of the super-intellectuals. Like them, he has fallen a victim to unconsciousness. But man’s task is the exact opposite: to become conscious of the contents that press upward from the unconscious. Neither should he persist in his unconsciousness, nor remain identical with the unconscious elements of his being, thus evading his destiny, which is to create more and more consciousness. As far as we can discern, the sole purpose of human existence is to kindle a light in the darkness of mere being. It may even be assumed that just as the unconscious affects us, so the increase in our consciousness affects the unconscious.”  ~ Carl Jung

The dilemma of this enigma called Healthcare continues to spiral. The direction of that spiral remains unknown. Someday I feel that we are climbing the beanstalk towards the friendly giant and at other times it feels like we are screwing ourselves into the magma of hell.

What is it that we hope to achieve? Coverage for all, is a definitely humanistic motive, but at what cost? That is the moral dilemma, worthy of a solution.

In the meantime, the drumbeat of cost containment and educating the growing society of physicians seems to be taking shape. Now before we get mired into all the minutiae, let me posit the unintended consequence of such a thought. The concept is simplistic, if we teach the students the cost-factors of healthcare then they will be more cognizant of the appropriateness of care delivered. The idea at face value seems very intelligible. So where is that elusive answer? The problem being that by forcing an issue of cost-containment onto the student psyche maybe will unintentionally bias them towards cost rather than care.

Lets talk about the cost of treating cancer. The embedded costs of the newer drugs continue to climb. The rationale for this has an available pieces of information; To bring a single drug to market, between 5000-8000 products are evaluated and then a single drug or none may come out of it. The cost to bring that drug to market for commercial use is estimated at $1,000,000,000.00 (or $1 Billion). This cost is to satisfy the FDA demands for safety, which go far beyond the need, it is a knee-jerk reaction to the old “Thalidomide-disaster." We certainly never want that to happen again, but there are reasonable risk-mitigating strategies in place without the over indulgence of the regulatory burden.

For every sneeze and itch if we are to devise a regulation, proffering “means justifying the end,” the regulators need to know that there are unintended consequences of the same, for instance little, or no more innovation, which would be pathetic, or companies running out of money, just to fulfill those imposed demands, before products can be brought to market – a sad scenario under any circumstance.

The pharmaceutical companies are obviously looking for a return on their investment from the capital placed at risk (the drug may not work as predicted) during the development phase and therein lies the cost. If the use of the drug is in a smaller population (a rare cancer/disease) then the cost of the drug per use will be quite expensive and the reverse is and should be true. However there are a few companies that take advantage of situations and affix a large premium for new discoveries shortchanging themselves by keeping it out of the reach for most.

And associating cost-containment with limiting care would not be advisable. I realize the writers, journalists and some doctors have signed on to this, but they are shortsighted. Caring is by and large a human thing. It defines us. We certainly can communicate with individuals and discuss the ramifications of certain futile care, but restricting care at a predefined age or disease stage for surgical or medical need is a fallacy. It may save money in the short run, but it will surely change the country, for the poorer, in the long run. This runs foul of our own incentives that we propose daily.

We recommend that to live healthy lives, people must exercise, lose weight, eat healthy etc. But now when they do and live longer, they will have run out of options for intervention at the wrong time down that road. Better think through this fellas! You, are one blink away from reaching that milestone yourselves ~whoever and where ever you are.

But then there is another flaw in this complex conundrum; the patient/consumer. You see for this complexity to be simplified, the consumer must also play a part in this real life drama and based on all parameters of this thought experiment, probably as much as 50% effort if not more.

I came across an interesting statement from an associate the other day. He said, that it was amazing to him that most of the workers at his jobsite were frequenting the doctors’ offices for minor complaints. Afflictions such as sore throat, a one-day dry cough, or a minor ache or pain or just simply a “fear-of” illness were a common source of “calling in sick.” Of course there are several issues here, but we will restrict ourselves only to the medically manifest ones.

To tackle the problem, both sides of the equations have to be solved. Consumer empowerment of good personal health will go a long way. Making access easy without repercussions for blatant abuse is the sacred cow that needs to be slaughtered. The physician side of the equation has some disincentives too. The over-diagnostic behavior and over-prescribing is also leading to abuse at the provider level (though I get incensed using the derogatory word "provider"). For instance, recommending a cardiac catherization on a 90-year old male who has a minor surgery for a limited squamous cell skin cancer is imprudent, and similarly subjecting a 75-old female with chronic back discomfort for a MRI runs foul to reality and good prudence. Both are odious in their respective claims.

Obviously for all concerned, to have a “skin” in the game will also prevent abuse and fraud of the system. Unfortunately the fraudsters use today’s technology while the “watchers” use the 20th century version of the same. Personal greed and fraud come from the same branch of human thought. Both are polluted with the same humor of reason. Both destroy humanity.

Asking the people to behave themselves is like asking an average child of four or five to not finger-lick the cake. It won’t happen! The people “getting away with it” have a preconceived bias based on the current societal mores and they can with this bias, keep pulling the levers of fraudulent behavior. After all for them, “what’s good for the goose is good for the gander.” They remember JFK's quote differently, "Ask not what your country can do for you, ask what you can do for your country." The sea change to civility, needs a paradigm shift, the sort that changes discourse. It cannot be done by fiat, governmental or private, it can however be done one on one, through engagement.

I find the shift, taking place in the Social Media between people who have never known each other, never met face to face or heard each other’s voice and yet through the power of words the dialogue is changing us all.

Lets all join in on this most worthy of causes and enchant our selves with human dignity and decency.

From caring comes Courage ~ Lao Tzu

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