Checkup

Vital Signs: Who's going to pay? Part II

Dr. George Bartley

Dear Reader:

In the last issue, I highlighted the challenging question of how the increasing costs of health care should be addressed and expressed the hope that debate on this critical issue might occur during this election year in the United States.

The first question I'd pose to the candidates: "Is cost-shifting of health-care expenses justifiable and, if not, what would you do about it?" Aspiring public servants might feel ambushed by such a direct inquiry, but it gets right to a surprisingly under-appreciated fact of health-care economics. Because reimbursement for the care of many patients falls short of the cost of such care, providers have to make up for it on other patients with hopes that the overall financial result permits them to keep their doors open. Costs get shifted, usually from patients with government-sponsored insurance to those with other forms of coverage.

One example of cost-shifting is the implantation of a mechanical pump to treat heart failure. These lifesaving devices are extremely expensive, so we're pleased that Mayo Clinic in Jacksonville has been designated by the government as one of the few sites that can receive reimbursement from Medicare for the operation. The payment basically covers the cost of the pump, but the expense for the operating room team, medications, and a fairly lengthy hospitalization falls to us. If we wish to continue providing this service, we have to make up for the unreimbursed costs elsewhere.

Another cost-shifting problem occurs when people have no health-care insurance, either by circumstance or by choice. Persons who are uninsured do not necessarily go untreated. Rather, they often seek care through urgent care centers or emergency rooms, where treatment is administered "piecemeal" without integrated follow-up by a coordinating physician. This is inefficient and expensive. Furthermore, because the uninsured frequently cannot pay their bills, the cost of their care is absorbed by everyone else.

Is such subsidy appropriate? That's the multi-billion-dollar question that needs to be brought to light rather than pretending that it doesn't exist.

There are three characteristics that most people identify as desirable in a health-care system: low cost, ready access, and high quality. I am not aware of any nation where all three goals are simultaneously achieved. Some countries avoid cost-shifting and spend less than the United States for health care while reporting satisfactory outcomes. However, patients sometimes wait months or years for tests or elective operations. Worse, treatment for some diseases is simply not permitted if the patient is over a certain age or once the year's budgeted funds for health care are depleted. It's my guess that most Americans would find such rationing of care unacceptable.

It's usually a bad idea to ignore the signs and symptoms of illness, hoping that they'll go away. Trusting that an unhealthy health-care system will get better on its own is similarly irresponsible. Citizens of the United States have a great opportunity this year to discuss what our health care should look like and how we — all of us — are going to pay for it. In the next issue, I'll outline some solutions that Mayo Clinic has proposed.

Sincerely,

George B. Bartley, M.D.
Chair, Board of Governors