Over Christmas break, I was afforded the opportunity to spend a few weeks interning in a hospital working on some business projects. I spent some time analyzing and writing a report of the anesthesiologists' revenues and payments, their patient volume, and other measures of productivity and profitability. While the analysis was fairly straightforward, and the report was similarly cut and dry, the implications that followed were murky, opaque, and difficult.
These days, the media seems to divide health care policy into just two camps. On one side is the Liberal associated national health care plan, a la Canada or England's system. This system would entail universal coverage, little or no cost per visit, but also possible problems for choice of treatment or doctor. It could also be quite expensive.
On the other is the Conservative associated idea of free market health care, with very little government intervention, and a considerable weakening of the Medicare/Medicaid system. This option points to the necessity of doctor choice, treatment quality, vis-Ã -vis survival of the best doctors, but also leaves a great many people, possibly as many as 40 million, out of the health care loop.
The one debate that nobody is having right now, however, is the need for a better, more cost effective health care system. Research by the economist David Cutler indicates that only around 17 percent of Americans are currently satisfied with the health care system. The doctors and administrators gave personal weight to this number within just a few days of my arrival. There are issues with just about every facet of the business of providing health care, which in turn, makes it difficult for doctors to provide easily and effectively the care that people need.
The first morning of the internship I sat in on a meeting my boss, a department administrator, was having with one of his anesthesiologists. Instead of treating patients or working on a difficult case, she had spent the morning scanning through a 100-plus page audit of their compliance with insurance payers. Then, she had no fewer than four other meetings during which she had to explain particular compliance errors and explain why the department still deserved to be paid. Immediately, I understood why the administrative overhead costs of one patient in America exceed $1000 yearly.
The more I worked the better I could see the problems in health care. The greatest problems, and the reason for such exorbitant costs, for the doctors and patients are all focused around poorly aligned incentives, economically, not medically speaking. Patients, doctors, and insurers are all in agreement that a healthy patient is the best outcome. But when it comes to the question of who will pay for it, and for what will they pay, the three groups turn into a Scylla like creature, with every head pulling health care in a different direction.
Patients are most concerned, naturally, with their health and quality of life. For this reason, they will commonly choose the option that will provide the best chance of survival, regardless of the actuarial odds or tables. Sometimes these battles provide great stories of courage and strength, and sometimes they involve spending exorbitant amounts of money to extend a life by days if not hours. Often times, the costs of a particular course of action are not even clearly articulated or acknowledged. While patients and families shouldn't be faulted in the least for this mentality, the system cannot be improved if this issue is not addressed.
Doctors represent another difficult business issue. Atul Gawande, a Harvard educated surgeon at Brigham hospital spends an entire chapter of his newest book, Better, pondering the inherent dilemmas in physician pay. Most doctors are chiefly concerned with the care of their patients, and with the amount of care they can provide, even to those with little means to pay. And while good intentions go far, there will always be the necessity, as Rod Tidwell would say, to "show me the money."
After all, most doctors have endured four to six years of strenuous schooling, beyond the undergraduate years, with six plus years of residency, and are still exposed to 60-plus hour workweeks in a high stress environment. Who would want to go through all of that and not be paid decently, despite best intentions?
The third head of this monster is the health insurance industry, including government insurance programs. They are burdened with the majority of costs of health care, and have to find ways to pass these costs on to their users. Unfortunately, they are also the only major player that is seriously compelled to turn a profit even while trying to provide insurance. An in-depth analysis of insurance in this country would take pages and pages, but suffice it to say that it is perhaps the most complicated, costly, and interesting problem of the bunch.
That's also why I will have to leave my discussion on that note. The issue is complicated, and even with a few weeks of observation under my belt; I still probably don't understand half of the problems with the system. One morning, while I was asking my boss about some of the issues I have noted, he said to me, "You know what Jason, you could stick 10 of the smartest people in the country in a room, and they would solve social security in a few days, but couldn't solve health care in a lifetime."
Jason Coleman is a junior majoring in management. He can be contacted at
coleman.70@nd.edu
The views expressed in this column are those of the author and not
necessarily those of The Observer.
