How to Spend Less and Get More from Medicine

Currently, the United States spends approximately 3 trillion dollars on healthcare, which is roughly 18% of our gross domestic product (GDP).  Not only is this more than every other country in the world, but it’s also more than the next 10 largest spenders combined.  Looking backwards, healthcare spending rose steadily from about 9% of our GDP in 1980 to about 16% in 2008.  Looking ahead, by 2020, healthcare spending is estimated to rise to 21% of our GDP; or 1 out of every 5 dollars spent.

On the other hand, the World Health Organization recently ranked the United States 37th out of 191 countries based on healthcare performance.  Even more troubling is to look backwards and ahead; data show the US healthcare system improving more slowly than that of other countries over time.

There’s no denying the numbers: we pay more, but get less– and those trends appear to be worsening.  Efficiency, as defined in context of healthcare, is achieving the best clinical outcomes at the lowest cost.  Bloomberg recently completed a study to determine the most efficient countries for health care, and it should come as no surprise that the United States ranked 46th out of 48 countries assessed.

Naturally, our path to greater efficiency must begin with accepting the concept of value in the healthcare equation, or the idea that our job as healthcare providers is to identify the right intervention for the right patient at the right price.   It may sound simple, but this is in fact in direct contrast to our natural inclination.  Here’s an example:

A few years ago, the United States Preventative Task Force made national headlines with its recommendation that women between the ages of 40 to 49 no longer need routine screening for breast cancer.  People were furious, and healthcare providers were conspicuously at the top of the list.  Not only are we trained to be empathetic, but in most cases, it comes naturally to us; it is, after all, what drew us to our profession.  We treat every patient as if he or she were our mother or our father (or son or daughter), ultimately giving that patient the best care possible.   Why, then, would I as a healthcare provider not want to screen my patients for breast cancer?  I certainly would want my Mom to be screened.

Here’s why: roughly 1 in 1700 women screened between the ages of 40 to 49 actually ends up testing positive for breast cancer.  The overwhelming cost of the negative mammograms simply outweighs the cost of preventing the positive case.

For years, the United States has been the ‘spoiled rich kid’ when it comes to medicine: we get whatever we want, without much regard to cost.  Now, we as healthcare providers are painfully aware that this approach hasn’t been successful and isn’t sustainable.   The Cadillac may very well take us where we need to go, but we must learn to take the Ford instead; it may very well get us there just fine, and at a lesser cost.

To spend less and get more, our medical decisions must be made based on objective evidence rather than subjective determinants like ritual, instinct, anecdotal information, and most powerfully, commercial influence.  Coined by Gordon Guyatt in 1991, the term evidence-based medicine refers to a decision-making process rooted in medical evidence.  The most commonly used definition today is taken from Dr. David Sackett: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.”

A recent study estimated that about half of the hundreds of thousands of drug-related deaths that occur each year are preventable, and more recently, it was shown that better information may have lead to better outcomes in the same environment.   A lack of “better information” may not point to a scarcity of good information- after all, we do live in the age of information- instead, however, it more likely points to our lack of reliance upon it.  The information is available; our culture as healthcare providers must evolve so that we habitually incorporate proven measures into clinical practice.

Returning to the concept of value, we as healthcare providers must continue to remember the concept of empathy, but realize that decisions must be made based on objective, evidence-based information.  We can no longer afford to act as the ‘spoiled rich kid’; we must continue to practice with our heart using emotions, but ultimately must make decisions with our brain using data.


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