Keeping Score

Traditionally, medical care spending was regarded as fulfilling basic need. Numerous programs were devised during the past fifty years to increase the amount and level of services and none exceeds the influence of Medicare. The nation's health spending during 2007 increased 6.1percent to $2.2 trillion, or $7,421 per person, exceeding by far that of any other nation. Although the rate of increase was somewhat slower than previous years, the increase was faster than the overall economy. Health care consumed 16.2 percent of Gross Domestic Product (GDP), an increase from 16 percent in 2006. Federal, state and local governments paid for 46.2 percent of health care spending in 2007, an increase from 45.3 percent in 2004 and 37.6 percent in 1970.

According to the McKinsey Global Institute, health care spending in 2003 was $1.7 trillion and $477 billion was more than would be expected in comparison with thirteen peer countries comprising the Organization for Economic Co-operation and Development (OCED), even adjusting for wealth. Hospital and physician care accounted for nearly 85 percent of 2003 spending above the expected. In 2006, health care spending was $2.1 trillion and $650 billion was more than would be expected in comparison with OCED countries, adjusting for wealth. Outpatient care including that of hospitals was the largest and fastest growing segment accounting for $436 billion of the $650 billion. Drugs were $98 billion and administration was $91 billion.

What Is The Goal, How Do We Get There?

Doing the wrong thing is not effectiveness; doing more of the wrong thing is not efficiency. The high level of resource commitment and repeated efforts at reform leave no doubt as to the high priority the U.S. places on health and medical care. Equally telling is the lower health status relative to other industrialized countries. The U.S. is not effective or efficient at achieving optimum health status for individuals and the population. The disregard, lack of understanding, inappropriate response and manipulation of health data is frightening. An excessive amount of medical care is detrimental to achieving optimum health status. Good intentions do not compensate for doing more of the wrong thing or taking the right thing to excess. The economic and political systems are guilty of both. Is the goal more medical care or better health?

A Matter of Priorities

All evidence indicates the U.S. economy fails to cover the full cost of business. Deferred maintenance and social costs are underfunded in favor of generic economic growth fueled by consumption and there is failure to account for hidden costs. What would be the price of cigarettes if medical care costs were included? Responses to problems are indirect and expensive without resolving the issues. Is the legal system an effective or efficient means to address the public health issue of smoking? Resolutions fail as solutions. How have state governments used the tobacco settlement money? Has medical care cured the cancers or the respiratory and cardiovascular diseases caused by smoking as compared to the prevention of these diseases by avoiding smoking? Does the interaction of consumer demand, economic enterprise and the political system create a game of musical chairs to play the odds and avoid critical thinking about health? Could it be that early death was the cheapest health solution and survival with chronic diseases is an expense society did not anticipate?

High Expectations

Public support of biomedical sciences, medical research and medical care comes with high expectations which frequently bear no relation to the nature and status of those endeavors. The public is interested in cures and they are conditioned to expect what they want to be true, which is misunderstood and overstated. From the laboratory to the clinical setting to everyday life data are gathered, analyzed, interpreted and organized to reach conclusions that shape medical care. The conclusions are derived in a context of biological variability, biological adaptability and behavioral uncertainty. Every step is subject to error, bias and ignorance. The unknown vastly exceeds the known and the boundary between the two moves slowly and erratically revealing contingent truths. It is at all times a work in progress and whether or not it is oversold, it is overbought.

A Fish Out of Water

Pricing and resource allocation are crucial functions of an economy. Value systems determine how this is accomplished and conversely the process contributes to defining a society and molding the character of its citizens. It is a process fraught with hazard. Small miscalculations and delayed consequences build over time to generate substantial impact. The pursuit of short-term objectives without consideration of broader and longer-term goals increases the danger of demand exceeding capability. Impatience to generate increasing quarterly profits to support greater allocation of discretionary resources fuels the consumer economy with emphasis upon choice and competition. Medical care developed within this framework and it became a consumer business. Many think medical care is broken but more likely it is a fish out of water.