In ancient literature, the Romans went to the ageless Cumaean Sybil for prophetic advice and apparently she had a good track record. My friends consider me the antithesis of the Cumaean Sybil. My stock predictions doom a company. Oscar-wise, Ebert beats me to a pulp every year, and sporting events and elections fare even worse.
Therefore don’t be surprised or offended if this sweeping generalization about the future of health care turns out to be completely wrong. I am seriously not a futurist. But information accumulating from different sectors of the healthcare industry suggests that the entire system is headed in the direction of the internet bubble of the 90s and the housing collapse that’s still with us.
Too much medical care Let’s start with an article in this week’s Archives of Internal Medicine that reported the surprising results of a mail survey to more than 600 primary care physicians, asking if they believed patients were receiving too little or too much medical care. The overwhelming majority replied “too much,” and they pointed toward four factors:
- First, malpractice fears (“you’ll never get sued for ordering an extra test but you sure can get slammed if you forget to order one”).
- Second, a reimbursement system that compels doctors to spend less and less face-time with patients, replacing “listening” with “ordering tests.”
- Third, a manual record-keeping system virtually unchanged over the past 100 years, resulting in endless duplication of notes, tests, and procedures.
- Fourth, specialists. Primary-care docs had harsh words for specialists who order far more tests and procedures than necessary, too often because they receive astonishing financial incentives to do so. I see this excess specialist testing when new patients arrive toting shopping bags and wheelie devices filled with medical records. As I plow through mountains of endlessly repetitive, negative test results I try to follow the thought processes of these specialists. Sometimes the only conclusions I can draw are intellectual laziness, greed, or college fees coming due for their children.
Since there’s virtually no system in place to put the brakes on unnecessary tests, drugs, and procedures, we can expect the concept of too much to continue unchecked. And as the next piece of news indicates, the real problem is that fewer people will be receiving any healthcare at all.
Dramatic shift in number of uninsured Americans The second big-news announcement was that the number of uninsured Americans took a dramatic leap this past year, from 46.3 million to 50.7 million, or roughly 16.7% of the population.
The combination of fewer people receiving any care at all with others getting more than needed makes the third report, released last week, almost inevitable.
Health insurance premiums skyrocket After several years of health insurance premiums rising 5% annually, in 2011 rates went up 9%, an average of $15,073 per family. Faced with declining health insurance enrollments (unemployment, remember?) and higher costs, insurance companies had to find the money somewhere, so they jacked up their rates. And by the way, being employed is no guarantee of health insurance: just 60% of the employed workforce receives health benefits.
So while premiums rise and over-utilization of services to a select few predominates the scene, prices for anything and everything in health care are exploding, spiraling out of control. Up, up, up, the language of “bubble,” bringing to mind the tulip-mania of 17th century Holland.
Here are few egregious examples. Overnight sleep studies, certainly one of the most over-ordered and generally useless of tests, now average about $3000. One patient recently told me she actually underwent six separate sleep studies in a six-month period “to get her mouthpiece right.” One owner of a four-bed sleep lab, essentially an office with four smallish bedrooms, anonymously confessed online to earning $300,000 a month (makes you want to reconfigure your garage, doesn’t it?).
Jazz Pharmaceuticals (what a name!) recently boosted the price of its prescription sleep aid Xyrem–this is a sleep aid, remember, not a cancer cure—from $2,100 per month to $4,143 a month, or about $130 a night.
Gilenya, a new oral drug to slow multiple sclerosis, costs $4,000 a month in the US, half that in the UK.
And what of the specialists themselves? Twenty minutes with a university-based endocrinologist recently set back one of our patients $400, which her insurance didn’t cover. My patient said, “And she didn’t even listen to me…she just ordered $3,000 in blood tests and walked away.”
Like the internet stocks of the 1990s and the housing market of the early 2000s, health care is in the foothills of its pre-pop bubble phase. And who’s holding the pin to pop the bubble?
My prediction, and do remember I’m not good at predicting anything, is…
People will smarten up and realize they need doctors, tests, hospitals, and drugs a lot less than they thought. Take a look at this Newsweek article from August, 2011, entitled, “One Word Can Save Your Life: No!” My sense is that people will begin to take better care of themselves, see less of physicians, and those who can afford it will buy relatively inexpensive hospitalization insurance (a low-profit item for health insurers) instead of coverage that covers endless doctor visits and tests.
Next, the much-reviled-by-the-insurance-industry “public option” (aka, universal healthcare or Medicare for all) will ultimately pass and we’ll all end up buying reasonably priced coverage from the federal government. And when the Fed becomes an insurance company having to foot the bill for everything it will ruthlessly set all medical, hospital, and drug fees to a fraction of what they are now. The $3000 sleep study will drop to a sensible $300, etc. (For more on this, see my recent health tip on the French healthcare system.)
In fact, universal healthcare insurance will be so affordable for both employers and individuals that the public will flee the for-profit insurance companies in droves. Companies like Cigna and Aetna will be forced back to their original life, property, and casualty roles while Humana and United will disappear without a moist eye from anyone in America. The not-for-profit Blue Cross giants will be appointed by the government to manage the public option or, better yet, will become a division of the government, like the postal system. The egregiously overpaid Blue Cross executives will either commit mass hari-kari or become GS-15 civil servants and compensated appropriately.
Like my prediction or not, when finally 50% of us are uninsured I don’t see another way forward.
David Edelberg, MD