We All Want Longer, Healthier Lives. But It's Going to Cost Us.

We All Want Longer, Healthier Lives. But It's Going to Cost Us.

By David Brown
Washington Post
Sunday, January 11, 2009; B01

Over the next few months, this country will engage in the first serious national discussion on health care in 15 years. Most of the talk will be about ways to make medical insurance available to all U.S. citizens. There will be a fair amount, too, about the need to make the hodgepodge "system" of American health care safer, better and more efficient. What we're unlikely to hear, though, is something like this:

Arresting the growth of health care spending in the United States is impossible. The policies and programs we're suggesting will either accelerate the upward trend or slow it temporarily, but they won't stop it. Health care costs will go up year by year until you die, and probably until your children die, too.

This difficult truth, which has emerged over the past half-century, is leading the United States and the rest of the industrialized world into a new era of humankind.

We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish. Whether we can somehow avoid the collision is perhaps the most important domestic issue of this century. From now on, health care costs will be up there with globalization, terrorism and climate change as a force shaping our world.

For most of recorded history, food production was the chief goal of human labor. In the United States, that time is long gone. We spend a little less than 10 percent of our income on food, down from 25 percent in 1930. We spend twice as much -- 21 percent -- on shelter. But health care -- that's where we really get our wallets out.

Last year, 16 percent of the nation's gross domestic product went for health care, about $7,600 per person. In terms of human effort, health care is the new food. By 2016, when it reaches 20 percent of GDP, it will be the new shelter. If it grows at its present rate through the first three-quarters of this century, it will consume 38 percent of GDP by 2075. It will then be the new food and shelter.

This isn't a mistake. If it were, we might have a chance of stopping it. It's success -- the way things are supposed to be, and the way we want them to be.

"At the end of the day, when it comes to controlling health care costs, the enemy is us," said Drew Altman, head of the Henry J. Kaiser Family Foundation. "Americans want the latest and best in health care technology, and we want it down the street, and we want it now."

Medicine lies at the intersection of two profound forces. One is the desire to survive, which motivates all living things. The other is the ability to make things, which distinguishes humans from other animals.

Crowding that intersection are thousands of opportunities for avoiding or curing an illness, feeling better, living longer and being happier than our grandparents ever could have imagined. These opportunities take the form of implantable defibrillators, replacement knees, periodic colonoscopies, weight-loss surgery, life-long antidepressants, anti-retroviral medicines, breast tumor gene scans, biologically targeted chemotherapy, heart-lung transplants and prenatal tests for dozens of dread diseases.

These are just a few of the fruits of our desire to survive and our capacity to create -- and there's lots, lots more right around the corner.

All these things, of course, haven't come for free. Health care spending has grown faster than the economy, by an average of 2 to 3 percent a year, at least since the end of World War II. In the first five years of this decade, it averaged 6.9 percent a year.

Medicare, the federal government's insurance program for the elderly and disabled, provides an especially dramatic snapshot of health care's growing claim on our wealth and labor. In 1970, Medicare was 0.7 percent of GDP -- 70 cents of every $100 the country produced. By 2005, it was 2.7 percent. Last year, it was 3.2 percent, according to the Medicare trustees' annual report. In 2082, the program is projected to be 10.8 percent of GDP. Over the past half-century, total federal income tax receipts have averaged 11 percent of GDP per year. So unless something changes, in about 75 years, Medicare alone will cost as much as the sum of all our federal income taxes.

This kind of growth doesn't come just from jacked-up prices, a bureaucratic and inefficient delivery system or increasing numbers of sick and old people. Something else has to be going on to explain such steady, predictable, relentless growth.

That something is innovation. Various health economists have estimated that somewhere between 40 and more than 65 percent of the growth in per capita health care spending since 1940 can be attributed to advances in medical care. Each year, there's more that can be done and more that's judged worth doing.

And the effect has been profound. Consider heart disease, the leading cause of death in the United States. From 1980 to 2000, deaths from heart disease fell 40 percent. If the 1980 death rate from heart attacks had held in 2000, about 342,000 more Americans would have died in that year alone. A team of researchers recently calculated that 47 percent of those lives were saved by better medical care -- involving such developments as clot-dissolving drugs, coronary stents and medicines to prevent congestive heart failure. About 44 percent were saved because people had reduced their risk factors -- quit smoking, lowered their cholesterol and gotten their blood pressure under control, with many of those improvements also the effect of better drugs and medical care.

Two years ago, another group of researchers, led by Harvard economist David M. Cutler, looked at the money spent on health care from 1960 to 2000 and asked the crucial question: What did it get us? Their answer: Plenty -- but improvements are costing more all the time.

Their study found that over those 40 years, the life expectancy of people of all ages had increased. Not surprisingly, investments in the health of children were more cost-effective than investments in 60-year-olds. What's more interesting is that extending life cost more as the 20th century progressed, even taking inflation into account. In the 1970s, it took $46,870 to add a year to the life expectancy of 65-year-olds. By the 1990s, it cost $145,000.

As we become healthier, it takes more effort to extend our lives than it did in a time when we were less healthy (and dying prematurely). Fifty years ago, American medicine picked the low-hanging fruit of life-extension as clean water, vaccines, antibiotics, insulin and other cheap innovations became available to everyone. Now, we're going after the higher and more expensive stuff.

Take implantable cardioverter-defibrillators, or ICDs. These "ambulances in the chest" shock hearts out of the fatal rhythms that are a major hazard for people who survive large heart attacks. Vice President Cheney has one wired into his heart.

Three years ago, a team of researchers calculated that putting an ICD into a heart-attack survivor added one to three years to the person's life expectancy. The cost? Between $30,000 and $70,000 for every year of life gained. In the world of "cost-effectiveness analysis," that's judged to be worth it, the convention being that a treatment that buys an extra year of life for $50,000 or less is "affordable."

Medicare estimates that about 500,000 Americans now qualify for an ICD on medical grounds. Undreamed of when our parents and grandparents were having heart attacks, these devices are keeping or will keep thousands alive. Sowho's going to give one up in the interest of slowing the growth of health care spending? Not I. And I suspect not you, either.

Of course, there are ways to save money.

Administrative costs consume 24 percent of health care spending, according to one often-quoted estimate. Establishing a more unified health care system could probably cut that in half. There is also tremendous regional variation in medical care in the United States, so bringing everybody into line will reduce costs.

Then there's prevention, a favorite money-saving ace in the hole. The trouble is that prevention also costs money. A study that got front-page coverage nationwide in the week after the election not only demonstrates that but also shows how much we value small improvements in health. A group of researchers in Boston found that if you prescribe cholesterol-lowering drugs to people whose cholesterol levels are normal but who have evidence of mild body-wide inflammation, you can reduce their chances of developing cardiovascular disease by about half. "It's a breakthrough study," effused the head of cardiology at the Cleveland Clinic. "These are findings that are really going to impact the practice of cardiology in this country," said the head of the National Heart, Lung and Blood Institute at the National Institutes of Health.

What few stories pointed out was how little bang you actually get for this prevention buck. You have to treat 95 people for two years to prevent one "event" -- death, heart attack, stroke. At a cost of up to $1,200 a year for the drug, Crestor, that's a big investment to make year after year to help a few people. Given the response to the study, however, I suspect it's an investment we'll soon start making routinely.

Furthermore, there's little evidence that preventing disease reduces health care costs over the long run, although it obviously extends lives and prevents misery.

So what's likely to happen?

Over the short term, many experts say, there will be the sort of adjustments that humans make whenever necessities -- food, heat, shelter -- become scarce. We'll pay more for health care. We'll give up small things in favor of it. We'll cut corners. We'll complain. And then we'll find other corners to cut and reluctantly pay still more. Of course, the "we" may not include all of us; some Americans pay little or nothing for their health care. But as a society, we'll all pay more.

In the longer term, however, not just the United States but the entire industrialized world is facing a conundrum resembling a famous one of 200 years ago. In 1798, an English parson named Thomas Malthus published "An Essay on the Principle of Population as It Affects the Future Improvement of Society." He laid out a chilling scenario in which population growth outstrips food production and produces a cycle of famine, catastrophic population decline, recovery, famine and catastrophic decline, over and over.

This was the so-called Malthusian Spectre. It was a hugely influential -- and horribly frightening -- idea. It kept members of Parliament awake at night. But it never came to pass because of two as-yet-undiscovered truths that Malthus never imagined.

The first was that scientific agriculture would eventually double, triple and quintuple crop yields. The second was that when industrialization pulled huge numbers of people out of poverty, infant mortality fell, women became more educated, and the value of their labor rose. The net result was a huge decline in birth rates. This is known as the "demographic transition," and virtually every region of the planet has gone through it.

We will need something like the revolution of scientific agriculture and the demographic transition to rescue us from the Malthusian Spectre of health care spending.

What it might be -- ah, that's what nobody knows.

browndm@washpost.com

David Brown is a medical doctor and a health and science reporter for The Washington Post.

http://www.washingtonpost.com/wp-dyn/content/article/2009/01/09/AR2009010902296.html

David Brown, a physician and Washington Post health and science reporter, was online Monday, January 12 to discuss his Outlook article on why it's so difficult to bring down health care spending in the United States.

Outlook: We All Want Longer, Healthier Lives. But It's Going to Cost Us.
The 'Malthusian Spectre' and American Health Care

David Brown
Washington Post Health and Science Reporter
Monday, January 12, 2009; 1:00 PM

A transcript follows.

____________________

David Brown: Dear Chatters

This is the Live Online about the piece in yesterday's Outlook section on the reason for the relentless rise in health care costs over the last half century. So let's get started.

_______________________

Bloomington, Indiana: I think we can have an impact on costs if we get away from the medical model of treating illnesses that are preventable to begin with. Our current "system" is set up to profit from the treatment (not the prevention) of disease. It is the most expensive kind of "health" care. We need to adopt a different model for looking at health promotion and disease prevention. We have to get the profit out of the system. We have to look at this in a more of a community health perspective, get "upstream" on some of these conditions.

David Brown: There is a lot of interest in disease prevention as a means of saving money that would otherwise go for health care. Prevention is certainly important and I do not want to suggest for a minute that it isn't. But prevention, when implemented as a population-wide strategy, costs money, too. Getting people to eat less, eat differently, exercise more, sleep better, etc. takes substantial investment in public education, changing laws about food labeling and content, putting in place incentives for individuals to lead healthier lifestyles and employers to make healthful behaviors easier to do (such as by subsidizing health club memberships or putting gyms in work places, etc.). Even when all those things are done, the "yield" in terms of behavior change and improved health can be relatively modest and take a long time. The biggest such change in the last half century is the reduction in smoking. It has taken 45 years since the Surgeon General's report of 1964 to cut smoking in half or more. So prevention is possible, but it is not cheap or fast.

_______________________

Ashton, Md.: I read your article with interest. I work on health policy and I'm not as pessimistic as you seem to be. You quote Drew Altman as saying, "Americans want the latest and best in health care technology, and we want it down the street, and we want it now."

He's right, but only because Americans believe that the latest, most expensive technology is always the best. It's not. Shannon Brownlee's book "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer" is accurate. A lot of high tech, high cost treatments don't provide better value or better health. In fact, a lot of treatments leave the patient worse off than no treatments at all.

With that in mind, isn't it possible to ratchet down costs by doing actual research on what works and what doesn't AND (it's important) getting the information out to Americans that sometimes doing little or nothing is better for them than spending a lot of money on something that will reduce their quality of life?

David Brown: There is certainly in American medicine a predilection for treatment over non-treatment and often for the latest and higher-tech treatment over lower tech, cheaper. "Dont's just stand there, do something!" is what I have always thought is the slogan of American medicine. These are cultural values. That said, it is certainly possible to change those values over time through education, consciousness-raising, etc., as Shannon Brownlee's book does so well. It is also true that there are lots of treatments whose benefits are marginal or at worth thinking twice about before doing, and this should be make clearer to patients. There are also many interventions whose relative benefit to other treatments, and to doing nothing, is not known or well-established. Doing such studies--cost-effectiveness studies and comparative-effectiveness studies--is very important. I suspect they will get a lot of attention over the next year as the Obama administration tries to address numerous health-care issues. But those studies are quite expensive to do and they take time.

_______________________

Washington, D.C.: You quote many medical costs in your article, ie $7,600 per person.

I am looking at a statement for a routine visit to my doctor. He billed $2,101. My BC/BS allowed $377.14 (17.9%) The remainder is written off.

What is the real cost here? How does this relate to costs I read in news articles? Are the numbers I read all inflated 5.5 times? I'm confused...

Thanks!

David Brown: The per capita cost for health care in the United States quoted in the article are actual amounts paid out, not billed costs. As you point out, there is a big difference.

_______________________

San Jose, Calif.: I believe part of the problem with rising health care costs is that most people don't know in advance what the medical procedures they undergo will cost. Wouldn't it help to publish prices for treatments, and calculate (or estimate) insurance coverage and out-of-pocket costs before procedures are performed? With HSA's, in theory patients have more control over their health care expenditures, and knowing costs in advance would help us make smarter, and hopefully less expensive, health-care decisions. Your thoughts?

David Brown: Well this is one of the ideas for how to make the consumption of medical care more like the consumption of other products in the economy. The problem is that in most cases the consumer is not paying the full cost of the intervention (but more likely a fixed deductible), although that is changing to some extent. I think patients also feel they are facing enough choices without having to add economic variables to the decision-making process, even if it is just for educational value. Of course, if people have a fixed life-time amount that will be paid for their health care, then that might change. Plus it is very difficult to put off an optimal treatment now because of the belief that the money will be more useful later.

_______________________

Nutmeg State: Ray Kurzweil, noted technological economist, is predicting we will live very very long in the coming future due to improvements in healthcare, the possibility of living hundreds of years may be feasable.

I'm worried that the "quality of life" curve will not rise as quickly as the "length of life" we will spend our later years hooked up to machines with no decent quality of life.

David Brown: This of course is an extremely important subject, and one that I obviously didn't touch on (although the story about end-of-life care by the Minnesota physician that was twinned with mine in the newspaper did). The amount of money it takes to add a year of life to an old person tends on average to be more than is required to add a year of life to a younger person. On top of that at some point the quality of that time often becomes substantially less, and in some cases actually not worth the investment. In many cases, the two curves you speak of are definitely not parallel.

_______________________

Silver Spring, Md.: D. Brown -- I thought the most interesting part of your article was your example about cholesterol-lowering drugs.

When you point out that the drugs cost approx. $228,000 (1,200 x 95 x 2) to save one life, that puts the risks and benefits of the drug into a stark perspective.

What is the political path to assigning dollars to benefits and then sticking to the standards?

David Brown: At the moment there is no political path in this country for that. In England there is a committee whose acronym is NICE (I believe it is National Institute for Cost-Effectiveness) that review therapies and ultimately decides that some of them are not worth doing because the clinical benefit doesn't justify the expense. I believe at least one biological therapy for cancer that is in use here is not used in England (or with substantial limitations) because the clinical benefit is often measured in months of extra life, and the expense may be $20,000-$40,000.

_______________________

Colorado: Hi Mr. Brown,

Why does innovation in health care cost so much? I wonder if there isn't a bit of slop in the system. For instance, a doctor gets paid higher than others with similar education, doctors have way higher insurance than most, med schools do a lot of research with soft money positions rather than hard money folks like in many other sciences, drug companies seem to devote most of their resources to marketing, companies that make medical equipment seem to be making pretty good profits. Am I wrong?

David Brown: Whether there is "slop" in the system depends, I suppose, on whether one thinks capitalism and entrepreneurialism is a self-purifying system that tends always toward optimizing efficiency. Certainly the huge profits of drug companies over the last century have been a major engine for innovation. The great investment by the taxpayer in medical education, and in medical research funded through entities such as the National Institutes of Health, has fuel that engine probably even more. Could this machine be run more efficiently? I don't know, but I suspect there are a lot of people who say that if you start trying to manage more directly there could be problems. I don't know enough economics to comment on this with any competence.

_______________________

Medical Education: Doctors need to be educated to concern themselves with the fact that treatment costs money, and to consider those costs in their practice. One young doctor looked at me like I was from another planet when I declined a routine test, on the grounds that in my case it was unnecessary and it would cost my self-insuring employer money.

David Brown: I believe young doctors are being taught to think of costs, or at least be aware that there are trade-offs that will ultimately be made on the national or population-wide level, as a result of clinical decisions. But it is very tricky and problematical to bring a lot of economic thinking to the interaction with individual patients, unless (for example) the person has to pay for their own prescriptions and the choice is between an expensive drug and a cheap alternative. Indeed, there are situations where a doctor knows that the patient is going to get a huge bill for a procedure he or she can't pay for and the procedure is ordered anyway because the doctor knows it may greatly benefit the patient (could even save a life) and society will eventually absorb the cost of it one way or another.

_______________________

Buffalo, New York: It seems to me that the contingencies of reinforcement are all wrong. Right now we have an illness care industry and not a health care industry. Doctors only get paid when people are sick. Where is the incentive to help people become healthier (for example, via lifestyle improvements) and thus need less health care?

David Brown: There has been a fair amount of effort to turn attention to disease prevention, both at the public health department level and at the level of the clinical encounter (such as at many HMOs). This is of course all to the good. But the question still is, when a person shows up with the disease, what do you do? And then the ultimate effect of prevention on a person's lifetime health-care expenses is uncertain. Studies have shown that the state of a person's health when he or she enters the Medicare system at 65 (or thereabouts) does not predict the amount of medical costs that person will incur over the rest of their lifetimes. People who enter Medicare in very good health often live a very long time, and incur medical expenses that are cumulatively equal to that of people who enter Medicare with lots of illness.

_______________________

Chesterfield, Va.: Everyone please note this chat is being led by a Medical Doctor, so he won't post comments critical of his profession. This is a very one-sided PR session for the Medical Lobby.

David Brown: I do happen to be a physician, and physicians do certainly bear some responsibility for the amount of money we (our society and economy) spend on medical care. But the main drivers, as I tried to say in the article, are our desires and the amazing capability to address those desires that we now have.

_______________________

Washington, D.C.: Your article seems to discount the possibility of rationing of care (I know rationing is a pejorative, but I view it is as an eventual reality). If the U.S. moves to government-guaranteed universal coverage, do you expect consumption patterns to remain the same? Also, the U.S. currently underwrites a significant share (perhaps of majority) of medical (especially drug) R and D, if payments to drug companies and providers are curtailed won't this slow technological advancement and thus lower the upward trajectory in costs?

David Brown: It is interesting that the word "rationing" has not come up earlier in this discussion. It is perhaps a good idea, then, that we end with the word. I think most people who have studied the problem of rising health care costs realize that there must eventually be some sort of rationing, perhaps not under that name. But some way of saying "We will do this, but we won't do that even though it's possible to do that." How we get to the point where we can do that with something of national consensus and a belief that we haven't violated the core American value of fairness---that is the question.

Thank you all for listening in and for the great questions. I am sorry I have had to leave so many unanswered. I enjoyed it.

_______________________

Editor's Note: washingtonpost.com moderators retain editorial control over Discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.
...

http://www.washingtonpost.com/wp-dyn/content/story/2009/01/12/ST2009011200003.html