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Dr. Donald Saelinger: American healthcare system is broken for patients and healthcare stakeholders

First of two parts

Healthcare cost and quality are important concerns for Americans. The healthcare value issue was the major concern for voters in the midterm elections and is beginning to receive significant attention from politicians.

Why is it broken; why does it cost so much; who should pay for it; why is the quality less than excellent; who can fix it; how can it be fixed; is it a political/government issue?

As a physician with nearly 50 years of experience not only in attending patients (Internal Medicine and Gastroenterology), and also in health care business and leadership, I will attempt to answer these important questions and discuss potential solutions.

The short answer is that outrageous prices, enormous profits, massive inefficiencies and waste, huge administrative costs, inability to align incentives and reluctance to change the business model from fee for service to a value-based system are the root causes for the healthcare cost/quality problem in America.

Dr. Donald Saelinger

As I reflect on these past 50 years, many substantial advances have been made in the treatment of many conditions including cardiovascular disease, malignant diseases, hepatitis C and HIV. American health-care innovation has transformed many grave illnesses into manageable conditions. However, this innovative and technological transformation has a very high cost, and is sometimes administered poorly and is not available to all citizens.

The current healthcare model in the United States is economically unsustainable.

Population growth, demographic shifts and chronic care costs all suggest that something needs to change.

The United States spends over 3.5 trillion dollars (approximately 20% of the gross domestic product) annually to provide healthcare for Americans, nearly as much as the entire German economy.

This is roughly $10,000 for every person in the United States and these costs continue to escalate at a rate substantially greater than the cost of living increase.

In spite of these inflated costs, the quality of our care is significantly inferior to that of other developed countries. The Commonwealth Fund, a national not-for-profit healthcare think tank, continuously rates the United States health care system as the worst among 11 developed countries, and it spends three times more per capita than do other developed countries to achieve inferior outcomes.

Photo from the Commonwealth Fund

The Commonwealth Fund focuses on care process, care access, administrative efficiency, equity, and healthcare outcomes. Multiple indicators are evaluated in each area. The Fund concluded that among 11 developed countries, the United States fares the worst, following Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, and England.

Complexity and costs

From a patient perspective, the complexity and costs seem irrational and do not have rhyme or reason. It is shocking especially at a time of significant and sometimes life-threatening illness.

I recently attended a patient whom I will call George. He is a 49-year-old plumber, married with two teenage children. He was referred for a screening colonoscopy by his primary care physician. He had health insurance through his employer. Colonoscopy revealed that he had a stage II colon cancer. I met with George and his family about his diagnosis and outlined a plan for treatment which included multiple laboratory tests, a variety of scans, surgical and oncological consultation, and follow-up examinations on an ongoing basis.

I answered all his questions, however, the issue of cost was not discussed. George had a complete staging evaluation, surgical resection, and adjuvant chemotherapy. At a follow-up visit three months after his surgery and chemotherapy, he was doing well but was devastated by the number and size of the bills that he had received. He had no idea what the items listed on the bill represented as they were not detailed. He had just returned to work as a plumber but was considering bankruptcy and was concerned about his home.

I reviewed some of his billing statements with the help of our office business person, and together we were not able to establish the meaning or etiology of many of the charges on his multiple bills. George noted that he had bills that totaled about $35,000, in spite of the fact that his insurance had already paid much of the total cost.

George was happy with his medical care. The good news for him was that his primary care physician, and I, along with the surgeon and oncologist were part of a sophisticated integrated delivery system with an excellent electronic medical record (EMR) which allowed for rapid referrals, surgery, and followup.

Photo from the Commonwealth Fund

Unlike George, many patients are unhappy because they are not able to find a competent primary care physician. This is a significant problem for many patients as appointment wait times are long and urgent access is difficult resulting in expensive emergency room visits. Frequently, primary care physicians attend to wellness care and minor illness but when patients have more serious problems, they function as a triage person to various specialists which can be very expensive.

Additionally, patients are unhappy with the fact that their primary care physician does not attend them when they are in the hospital as that is delegated to an unknown hospitalist with an inherent lapse of relationship, followup, and communication.

From a hospital perspective, American medicine has moved to a profit-making model, as hospitals have become ”systems of care.” Until a few years ago, independent physicians admitted patients to a hospital and attended them before during and after their hospital stay. Now, physicians are employed by the “system” which sets prices, procedural rules, appointment making, and record-keeping systems.

Financial gain rather than patient care is often the driving force, with the largest share of that money winding up in the pockets of stockholders and administrators, not healers.

Hospital systems employ specialist physicians whose procedures generate the highest fee for service revenue (Orthopedics, Oncology, and Cardiovascular surgery). Physicians use hospital-supplied electronic medical records which are frequently designed for coding, billing and collecting rather than patient care.

High quality electronic medical records in integrated systems of care, however, do provide a high level of continuity and do reduce the costs of duplication.

Hospitals and hospital systems, however, are significantly challenged as a result of recent changes in the healthcare environment.

Part II tomorrow: Causes and Solutions

Dr. Don Saelinger is a distinguished physician, an internist and gastroenterologist, who founded Patient First Physicians Group in NKY in 1976. He sold it to St. Elizabeth Health care in 2009. It became St Elizabeth Physicians and Dr. Saelinger became Sr. VP of St. Elizabeth Medical Center. He retired from St. Elizabeth in 2010 and has been involved in various consulting roles for Healthcare business and policy around the country. He has also been involved with various locum tenens (definition: one filling an office for a time or temporarily taking the place of another) positions in Gastroenterology. He recently retired as GI section chief and Medical Subspecialty division chief at Straub Medical Center and Hawaii Pacific Health in Honolulu, Hawaii, and has returned to locum tenens roles in Gastroenterology and healthcare business consulting. He is the oldest of ten children of William and Marcella Saelinger of Northern Kentucky. See his full bio here.

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