Saturday, May 16, 2009

Ideas for reducing costs of healhcare -joining the debate

I write from the perspective of a physician who has followed the curve of excess costs from the days (1950s) when there was very little money in medicine. On my first posting, I trace the sequence of events that led to the present state of high costs, large variations in use, and large errors and harm.


Medicare has clinical and cost data across the country. Why not use it to curb futile and unnecessary costs?

1.Track hospital mortality rates for costly procedures and drop hospitals who exceed the death rates by a certain margin. There are still hospitals for excessive mortality in many areas. Drop them from medicare for those procedures.

2.There are many hospitals doing procedures that are too small in number to be good at the procedures. There is a minimum number of operations that need to be done; below that number it is unsafe. Drop those small volume hospitals from medicare for those procedures.

3. The huge amount of money spent in the last 6 months of life can be curbed. Define what is futile care in the elderly (I am in that age group and do not want futile care) and refuse to reimburse futile efforts.

4. Move patients who are receiving futile care into hospice and palliative care.

These suggestions would save money but will need congressional backing. Medicare already has the data. USE IT! This will save money and improve the overal health of the population.


  1. Nice post. The technology has gotten ahead of the evidence in so many things, driving up costs without benefiting patient. Examples:

    Lumbar discectomies and fusions (especially when there is no myelopathy or worse--done for low back pain alone)---now we know are no better than conservative care at two years.

    Coronary stenting in non MI or acute coronary syndrome patients (done for angina)--It is no better than medical therapy in terms of any hard outcome. However, it is very costly, and now with coated stents leads to a windfall for Sanofi-Aventis because of the need for indefinite Plavix after a medicated stent.

  2. We need to accumulate a list like you have started. Both of your examples are part of a long list of procedures, drugs, and devices that are costly but not effective or at the same level of effeciveness as less costly treatment.

    Thank you for the start. I hope others will join in the listing. Perhaps someone will pick up the list and begin to make real changes. There is more than enough money in the system to take care of all Americans if it were correctly applied. Clifton Meador

  3. In your very well done blog you point to for profit systems. As one who helped design an implement the nations 6th largest system (, I submit the problem is more pervasive. The not for profits incuding most university based systems are little more than an expensive monument to the egos of management and board of directors.
    Once medicine was in the hands of real doctor/diagnosticians who took care of and knew intimately whole families (warts and all). Then came the specialists and proceduralists sponsored by the useless AMA. This was followed by renaming medicine as healthcare with the entry of the "insurance" industries with their Madoff modeled compensation packages for executives. This was quickly followed by the Pharma folks who saw the opportunity to charge Americans 80% more than the rest of the world for drugs. Why? Because they could.

    Now these same folks are begging to be at the table to help "reduce" costs. This is akin to putting the wolf in the hen house.

    My oldest Son has lived and run his own business in France for the past twelve years and is quite pleased with that country's national health insurance. Similarly, as you know, my wife a nurse and 500 bed hospital administrator walked away in 1993 voluntarily from a combined $500K/yr in income as we believed the system of which we a part had lost its focus on mission.

    Clifton, why does a hospitalist make twice what a general internist makes when the latter has done all the real work? Moreover, why do insurance executives make Madoff type salaries and stock awards off the back of sick people? I think the answer lies in the fact that our 535 congressional members have cadilac (soon to be Lexus) benefits and therefore don't get it.