Accountable Care Organizations; Die, Die, Die!!

The Final rule making regarding ACO’s (Accountable Care Organizations) was released in March. Since then, no further detailed information has emerged. It appears to be an almost identical version of what was originally released in the ACA. I can’t understand why it took so long for people to review and begin digesting the ACO model. In some regards it has the appearance of the capitation models of old. In other respects it appears to be a new variation of that old theme, with some nuances thrown in for good measure. Either way you look at it, it needs to die.

The main goals of the ACO is their “three part aim; (1) better care for individuals; (2) better health for populations; and (3) lower growth in expenditures”. Overall the majority of the “aims” of the ACO are to maintain budget neutrality for Medicare or produce cost savings that can be placed back into Medicare coffers. One additional proposal, that will more than likely be implemented, and may be mandatory for participation, is the idea of a “two-sided cost saving, risk-sharing model”, that is most assuredly one-sided.

Quoting the ACO final rule : (Further excerpts at the end of post)
“++ Providers should be accountable for the cost of care, and be rewarded for reducing unnecessary expenditures and be responsible for excess expenditures.
++ In reducing excess expenditures, providers should continually improve the quality of care they deliver and must honor their commitment to do no harm to beneficiaries.
++ To the extent possible, and recognizing differences in payers’ value-based purchasing initiatives, providers should apply cost reducing and quality improving redesigned care processes to their entire patient population”.

I take all of that to mean that physicians should continue to provide high quality care while utilizing fewer resources. Or in simpler terms: rationing. While providers are supposed to work harder to provide more, they are also supposed to be paid less. AND, while being paid less, they are going to “share” that saving with Medicare. With less than 6 months to go until its implementation, no one, even Medicare, knows what those numbers are. And Medicare is asking providers to volunteer to participate in a huge, unknown black hole!

Specifically, there are many unknowns when calculating savings and payments to an ACO. First, how much would normally be spent in a fee for service environment for the group of patients assigned to an ACO? Second, If the ACO spends less than expected, what is the threshold amount before HHS would consider that to be an actual savings and not a statistical variation? Third, once that saving has been verified, what percentage goes to the ACO and how much back to Medicare? Fourth, why would Medicare place a cap on the amount of saving an ACO can be paid? Fifth, how can an ACO have full financial control and responsibility over its “members” when they are still free to see any physician they wish, whether in the ACO or not?

Sounds to me like a very bastardized form of capitation where there is increased work, documentation, reporting, limited reward for all the effort expended, unlimited risk and responsibility on the part of the ACO or providers and the ONLY risk to Medicare, at the very greatest, is to pay what they have always paid under the fee for service model.

In the simple capitation model, a group was assigned a certain number of patients or the insurance company calculated how many of their members were patients of a given practice. Then, the HMO calculated a rate per covered life and paid that to the practice. All of the care provided to the entire group was to be covered by that payment. If the provider spent less than they were paid, they made money. If they spent more, they lost money.

All the patients were required to use that provider, but there was an open enrollment period to change if they wished. In this scenario, if the provider managed resources well, and you had a moderately health patient base, it was profitable. The major risk occurred when a practice or group had one or two very ill patients that needed, say extensive chemotherapy, an organ or bone marrow transplant. In either event the reward and the risk was the practice’s to assume.

I actually worked as a student aid during college for the federal government. Each fall as the end of the fiscal year approached, the administrative head of each department would come around and announce how much money was left in the budget that had to be spent by September 30. Why? In the world of government, savings was never rewarded. If a department spent less than budgeted then their budget was cut the following year by the amount of saving. Experience had taught us all that just because you are able to spend less one year doesn’t mean you’ll have the same luck the following so it was best to maintain your current budget and spend, spend, spend. Sound familiar?

If this holds true in the ACO environment (and there’s no reason to think the government is any better at managing money now), and a group of providers does save money caring for patients, what do you think the chance are that their “budget” for the following year will be reduced by the amount of their savings? That is to say that their new budget will be their old budget minus the savings they produced. They have to perform as well the following year even if their patients become more ill, consume more resources, or reimbursements decrease. AND if they go over budget, it is their responsibility to pay it back to Medicare!! Who is assuming all the risk? There is no such thing as risk sharing under the current ACO guidelines.

Simpler still, why would anyone volunteer to have their income reduced, workload increased and savings garnered in an environment where they have no control over the lives they are legally and financially responsible for? The current fee for service system seems like a much better way on all fronts, at least from my point of view given the current suggested ACO model. HHS and Medicare both acknowledge that in order for ACO’s to work, the majority of saving will occur on the hospital side of the equation. Without their participation, it doesn’t really matter whether the physician providers are on board or not. In my community, NONE of the hospitals are planning on voluntary participation in any ACO model. Sounds like they’ve figured it all out already. ACO’s are a long term losing proposition.

Obama wants shared sacrifice? Die ACO, die. Come up with something more reasonable and equitable.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.

++Section 1899(a)(1)(A) of the Act further provides that,”groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an [ACO]”. Section 1899(a)(1)(B) of the Act also provides that ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for “shared savings”.

Specifically, sections 1899(b)(2)(A) through (H) of the Act provide, respectively, that eligible groups of providers of services and suppliers must meet the following requirements to participate in the program as ACOs:

• The ACO shall be willing to become accountable for the quality, cost, and overall care of the Medicare fee-for-service (FFS) beneficiaries assigned to it.
• The ACO shall enter into an agreement with the Secretary to participate in the program for not less than a 3-year period.
• The ACO shall have a formal legal structure that would allow the organization to receive and distribute payments for shared savings to participating providers of services and suppliers.
• The ACO shall include primary care ACO professionals that are sufficient for the number of Medicare FFS beneficiaries assigned to the ACO. At a minimum, the ACO shall have at least 5,000 such beneficiaries assigned to it in order to be eligible to participate in the Shared Savings Program.
• The ACO shall provide the Secretary with such information regarding ACO professionals participating in the ACO as the Secretary determines necessary to support the assignment of Medicare fee-for-service beneficiaries to an ACO, the implementation of quality and other reporting requirements, and the determination of payments for shared savings.
• The ACO shall have in place a leadership and management structure that includes clinical and administrative systems.
• The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.
• The ACO shall demonstrate to the Secretary that it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans.

Section 1899(d) of the Act establishes the principles and requirements for payments and treatment of savings under the Shared Savings Program. Specifically, section 1899(d)(1)(A) of the Act provides that, subject to the requirements concerning monitoring avoidance of at-risk patients, payments shall continue to be made to providers of services and suppliers participating in an ACO under the original Medicare FFS program under Parts A and B in the same manner as they would otherwise be made, except that a participating ACO is eligible to receive payment for shared savings if the following occur:

• The ACO meets quality performance standards established by the Secretary;and
• The ACO meets the requirements for realizing savings.

Section 1899(d)(1)(B) of the Act establishes the savings requirements and the method for establishing and updating the benchmark against which any savings would be determined. Specifically, section 1899(d)(1)(B)(i) of the Act establishes that, in each year of the agreement period, an ACO shall be eligible to receive payment for shared savings only if the estimated average per capita Medicare expenditures under the ACO for Medicare FFS beneficiaries for Parts A and B services, adjusted for beneficiary characteristics, is at least the percent specified by the Secretary below the applicable benchmark. The Secretary shall determine the appropriate percent of shared savings to account for normal variation in Medicare expenditures, based upon the number of Medicare FFS beneficiaries assigned to an ACO. Section 1899(d)(1)(B)(ii) of the Act, in turn, requires the Secretary to estimate a benchmark for each agreement period for each ACO using the most recent available 3 years of per beneficiary expenditures for Parts A and B services for Medicare FFS beneficiaries assigned to the ACO. This benchmark must be adjusted for beneficiary characteristics and such other factors as the Secretary determines appropriate and updated by the projected absolute amount of growth in national per capita expenditures for Parts A and B services under the original Medicare FFS program, as estimated by the Secretary. Furthermore, the benchmark must be reset at the start of each new agreement period.

Section 1899(d)(2) of the Act provides for the actual payments for shared savings under the Shared Savings Program. Specifically, if an ACO meets the quality performance standards established by the Secretary, and meets the savings requirements, a percent (as determined appropriate by the Secretary) of the difference between the estimated average per capita Medicare expenditures in the year, adjusted for beneficiary characteristics, and the benchmark for the ACO may be paid to the ACO as shared savings and the remainder of the difference shall be retained by the Medicare program.

The Secretary is required to establish limits on the total amount of shared savings paid to an ACO. Incorporation of downside risk into the Shared Savings Program, while retaining a FFS base, has been encouraged by commenters on the November 17, 2010 RFI (including MedPAC), other stakeholders and policy experts as an entry point for moving ACOs to risk-based arrangements. MedPAC suggested offering a two-sided risk model in addition to the one-sided model, and over time, making the two-sided model the dominant or only option available to program participants. Further, to encourage ACOs to participate in the two-sided model, MedPAC recommended that it could be distinguished from the one-sided model by features such as a larger share of savings and risk corridors to protect ACOs from high levels of losses.


A Fat Tax We Can All Live With

Arizona’s governor, Janice Brewer, announced last April the state’s intention to consider a “fat tax” for overweight individuals on Arizona’s Medicaid roles.  The tax would cost $50 per year and only be levied on childless adults.  According to the Centers For Disease Control (CDC), approximately 25% of the state’s Medicaid recipients are overweight.  The tax would apply to those individuals who were overweight and who did not comply with their physician’s recommendations for a healthier lifestyle. Also considered for similar taxation are smokers, and diabetics who fail to control their diabetes.  And just to be fair, Arizona is one of the states identified by the CDC as having a prevalence of obesity measuring 24-29% of their general population.

While many incentive programs, both negative and positive (punishment vs. reward) are currently in place in various forms, this may be one of the first levied by a state for a Federally funded program.  The idea itself is not new and had been suggested as far back as WWII.  Some programs have been successful in their objective to increase the health of the individuals involved, such as Safeway’s discounted health insurance premiums for employees who are non-smokers, maintain a healthy lifestyle, watch their weight and cholesterol levels.  The State of Alabama levies a health insurance surcharge on state employees who smoke or are obese and do not seek assistance to combat or control those issues.

The real question is whether the implementation of a fat tax can coerce some of the unhealthy to change their ways.  Does a tax of $50 per year represent enough of a negative incentive to change a lifelong habit of a sedentary lifestyle and poor eating habits? If the results of increased taxation on alcohol and tobacco are any indication, the answer could be an emphatic “yes”.  But the way taxes are levied on alcohol and tobacco are different.

Cigarette smoking has been on the radar of public health officials for years and taxation of tobacco products is used to help fund specific health care initiatives, most recently the expanded SCHIP program.  But did the increase in taxation of tobacco cause a decrease in consumption? Studies have looked at the various reductions in tobacco use in different groups with an increase in the amount of tax.  The last increase in cigarette taxation by the Federal government raised the rate from 62 cents to $1.01 per pack.  The tobacco industry predicted a decrease in US consumption of 6-8 %.

When comparing the tax rate per state on tobacco vs the rate of cigarette smoking for 2009, except for California and Utah, there does appear to be a negative correlation between the amount of tax paid compared with the amount of cigarettes smoked.  In 2008, all states combined collected $16.5 billion in tax revenue and $16.6 billion in 2010 at the federal level.  It appears that applying a negative incentive, or punishment, to the object of one’s desire does result in decreased consumption.  But does this hold true for other “sinful consumption”?

Another frequently cited item of sin, alcohol, is also the subject of much debate and discussion with respect to its negative effects on society and health.  It is also taxed, at the state and Federal level, and a significant source of revenue for both. For 2008, the 50 states collected $5.8 billion in alcohol related taxes while the Federal government collected $9.5 billion in 2010. Studies have been conducted looking at the effects of increased taxation on its consumption, in all of its forms.  Across the board, these studies show a negative correlation between taxation and the consumption of alcoholic beverages.  That is to say that as taxes increase, use decreases.  An interesting observation is that even as taxes are increasing and consumption decreases, the amount of taxes collected is greater year after year. This is a well-known phenomenon expressed eloquently here by Alexander Hamilton.

If it works for tobacco and alcohol, why tax only overweight Medicaid recipients as Arizona proposes and just tax everyone who chooses to consume, well known, unhealthy fast food? I infrequently enjoy a fast food burger and would have no problem saying “no” more often if the price were to increase even a small amount.  The cost of a “meal” at some fast food restaurants is more than it would cost me to buy something healthy at the grocery and fix it myself.  In that case, it truly is just the convenience of fast food that is appealing.  With obesity and its health related issues at epidemic proportions in the United States, perhaps a tax can do what no health care provider has been able to accomplish.

You could also call a “fast food tax” a “use tax”. Most use taxes are aimed at those individuals who consume or use specific items or products. In addition to tobacco and alcohol, common examples include gasoline and tires. The revenue from a fast food tax could be used to fund some portion of individual states Medicaid programs or even healthier living education.  Many of the programs’ recipients are likely fast food consumers and have one or more unhealthy lifestyle associated diseases that is paid for by Medicaid.  Indirectly, if they continue to make unhealthy fast food choices, they would be helping to pay for a part of their own care.  Sounds good to me.

Doc B

My Opinion is free.
Advice is worth exactly what you pay for it.


Violence In A Health Care Setting Is Still Unacceptable

Most instances of violence against health care providers occur in relation to psychiatric patients and facilities.  Just because a patient is a psychiatric patient, doesn’t excuse the person or their behavior. But, take a step back and consider violence in the non-psychiatric patient population.

I was actually considering writing about an anecdotal experience at a facility I’m familiar with where a physician was performing a bedside procedure on a patient (he had gotten consent prior). The patient, as the story was told to me by an eyewitness, was an appropriate hospice candidate but he/she and family decided to pursue more aggressive treatment. Part of that treatment involved the need for the bedside procedure mentioned earlier. Once the procedure started, the patient had made comments that he/she was experiencing pain and wanted the doctor to stop. The doctor, wanting to finish since only a few minutes more would be required, desired to continue. As was recounted to me, the patient then promptly slapped the physician, who was of course shocked by this behavior. The doctor stopped what he was doing and informed the patient that no more procedures would be done and the patient should consider hospice.  The doctor then walked out of the room and did not return. I was going to title this particular blog “Slap Your Doctor, Go to Hospice”.

The idea of the whole incident was funny to me, and anyone who has heard the story, mostly because the physician involved can be an ass and likely deserved it. Granted, he should have stopped when asked. The physician’s behavior alone could represent assault on a patient. There are more than a few nurses who have felt the wrath of “Dr. Slap” sometime in the past and probably wanted to slap him too. That patient is their hero.

But researching the story made me run across several articles where health care providers were the recipients of violence committed against them by the patients they care for, sometimes with a loss of life. I actually ran across a blog post by KevinMD, the self-proclaimed social networks voice of medicine.  But not for me.

In his blog post he describes several issue of violence involving patients and health care workers. Most involve psychiatric patients, but not all. In one such instance a patient bludgeoned a nurse with the leg from a broken chair. Another involved the shooting of a physician by a patient’s son, distraught over the fact that her mother’s treatment didn’t go as he expected. After shooting the physician, the son went to his mother’s room at the hospital, shot her and then himself.

Stories abound in the Emergency Departments where intoxicated, drug dependent, frustrated patients become violent unexpectedly, striking the very people who are trying to help them. Nurses are an especially easy target since they often have more contact with patients. One quote rang in my ears; “…..and others said it is important to combat the notion among police, prosecutors, courts — and, at times, nurses themselves, who are often reluctant to press charges — that violence is just part of the job.” Violence should never be accepted as “part of the job”.

Some have cited a decrease in funding for mental health and substance abuse programs due to the economic downturn. Others look to the frustration people experience when they go to the ED in search of “McDonald’s” service in an already overburdened ED. Whatever the cause, the numbers of cases of violence are on the rise. So much so in fact that JCAHO (The Joint Commission on Accreditation of Hospital Organizations) released their own statement on the issue. State Workers Compensation department are also expressing interest since many claims for injury fall into their domain, increasing their Departments costs. Laws are finally being passed providing some legal remedy to health care workers who are the victims of assault. In New Mexico for example, it raised health care assault to a felony from a misdemeanor and provided an avenue to collect data on health care worker assaults.

OSHA published “Preventing Workplace Violence for Health Care & Social Service Workers” in 2004. In that publication, OSHA recommends a “zero tolerance” for violence, regardless of its cause. They also cited statistics showing the average rate of violence in the private sector workplace to be 2 per 10,000 full time workers, while nurses on the other hand suffer the most instances of assault leading to injury a whopping 25 per 10,000. The Bureau of Labor Statistics has data showing a similar risk of violence.

KevinMD, in his blog post recommended that “doctors and nurses could do a better job of empathizing with patients who are under stress when they are hospitalized or are angry because they’ve waited hours for medical care,….” After reading the blog, I got the very distinct feeling he isn’t in the hospital very often and probably out of harms way. JCAHO believes more effort should be geared towards securing areas from violence including the use of metal detectors and inspecting bags. They also recommend the reporting of assaults and violence to law enforcement. Sorry KevinMD.

This may be the one time JCAHO and I agree.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.


Customer Satisfaction Does Not Equal Quality Healthcare

The new healthcare reform law appears to be using the idea of improved quality to justify the enormous expense of changing the way care is delivered in the United States.  As a justification for the need for change is the reporting currently being touted as a great measure of quality.  This information is gathered in many different ways and reported on the internet by various websites.   Two of the most widely used sets of data are the Healthgrades Reports and Hospitalcompare sponsored by the Department of Health and Human Services.

Healthgrades bases its reports on information received from Medicare.  Medicare receives its data from participating hospitals throughout the country.  Each participating hospital is responsible for reporting certain “core measures” of quality identified by Medicare for a given diagnosis such as pneumonia or congestive heart failure.  The data collected is directly related to the presence or absence of the physician’s documentation in the chart of those core measures.  For example; smoking cessation is listed as a core measure for pneumonia.  If there is no documentation that the physician discussed smoking cessation during the patient’s hospitalization, that core measure was not met, even if the conversation took place but was not documented.  Core measures and Healthgrades significantly reflect documentation as much as any measure of quality.  Placing so much emphasis on the “documentation“ of quality sometimes take precedence over the performance of quality.

Hospitalcompare on the other hand, uses the “HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay. Use the results shown here to compare hospitals based on ten important hospital quality topic “.  Many of the questions are similar to what you may see from a major hotel chain; “Patients who reported that their room and bathroom were “Always” clean”, and “Patients who reported that the area around their room was “Always” quiet at night”.  Questions related to care were most often related to issues of comfort such as pain and communication with staff.  None of which is a direct measure of quality.   The other areas based on specific health conditions rely on the collection of “core measures” with its inherent error because of the need for 100% documentation to actual measure quality.  Healthgrades also offers an award for the hospitals with the best HCAHPS scores.

One area cited in both of these websites is mortality related to treatment for specific conditions, whether or not a patient was discharged alive and if still alive one month and six months after discharge.  Also taken into account is a “risk adjustment” of mortality for a given patient for each of the diagnoses studied.  This means that additional complicating conditions are added into the mix for the patient’s main diagnosis when calculating a person’s risk of death.  In other words, the sicker a patient looks the more likely they are expected to die, regardless of the cause.  If the death is expected, it doesn’t count against a hospital as harshly.

Suppose two patients come in with a diagnosis of myocardial infarction (heart attack).  One patient has no other medical conditions documented at the time of admission.  He or she just came in with chest pain and had a heart attack.  The other patient came in with chest pain, but the history obtained in the Emergency department included diagnoses of high blood pressure, high cholesterol, diabetes mellitus, previous heart attack, and a family history of premature death from heart disease.  Which patient do you think would have a higher chance of dying?  From the patient perspective of a patient and family, it appears that the comfort related issues are most important.

Most times patients present to the hospital in an urgent or emergent situation without the chance to review the health grades reports or the hospital compare website.  They themselves likely don’t know their own diagnosis to make a comparison, even if they had the time before their trip to the hospital. Unless the admission is an elective one, choice doesn’t come into play. So, once admitted, comfort becomes a key issue.

In my own experience, patients most often complain about pain, lack of sleep, constipation, thirst and knowing when they will be discharged.  Their families seem to have similar concerns, even if the patients can’t state it themselves.  If urgent or emergent admissions are the main entry into the hospital system, are Healthgrades and Hospitalcompare merely academic?  With that in mind, it’s no wonder that customer satisfaction has become a mantra for administrators everywhere.

But these customer satisfaction efforts have made patients more demanding and families more obnoxious.  Since their concerns aren’t of a clinical nature, or related to actual care, the time spent responding to families requests take nurses, aides and physicians away from actually caring for their loved ones.  “Quality of care” for them means an empty trash can, a quiet pulse oximeter and let’s see how many times I can make you come with my finger on the call light button.  These measures of “quality” don’t measure anything except customer service demands.

I don’t believe that there is one provider who doesn’t wish for access to healthcare for everyone.  We all want quality, cost effective, efficient care for all of our patients.  What we don’t want is to spend our precious time providing non-clinical service to people who can’t, don’t and will never understand the intricacies of patient care.  Physicians have gone from a position of respect in the eyes of their patients to one of public service.

How do you think your congressman would fare in a customer satisfaction survey?


Doc B

My opinion is free.


A Return to Simpler, Cheaper Health Care?

or I’m Not Your Daddy I’m Your Grandpa

Much is being written about the ever increasing cost of health care in the US, especially compared to the rest of the developed world.  As a nation, we spend nearly 16% of our GDP on health care.  All estimates predict that this amount will continue increasing unless costs can be controlled now.  Hence the passage of the Affordable Care Act (Happy Belated Birthday!).  Not only was it designed to extend coverage to more people, but make no mistake, it wants to do it at a cheaper cost.

Cutting the fat and leaving the lean in health care is much like going on a diet.  The math is simple; take in less and/ or burn more calories.  Health care math is similar; spend less and/or take in more money.  The ACA is attempting to do both.  In this analogy, the dieter, or the taxpayer/economy, is going to be a mere anorexic shadow of its former self.  The government plans to extend this coverage to 35 million plus, currently uninsured individuals, while slowing the rate of health care expenditures.  This means that as providers WE will be receiving less (again) for the same amount of work, while we get taxed at a higher rate to pay for what we are not receiving ourselves.

So many people complain about their health care that it makes me wonder whether or not they would like to return to “the good ol days” when a physician made house calls, patients paid with chickens, pies, etc..  Oh, and don’t forget that a lot of people died from their diseases.

Back ”in the day” when there was no such thing as “modern” health care, people accepted the fact that death was a part of life and that certain diseases or conditions were uniformly fatal.  Prior to 1923 when Banting and Best discovered, and Eli Lilly mass produced insulin, all type I diabetics died from diabetes within a few months to years.  The treatment at that time was a low carbohydrate diet that allowed the person to live but with the knowledge that death was soon coming.

Alexander Fleming discovered penicillin in 1929 but it wasn’t isolated until 1940 as a potential antibacterial agent.  It was produced  in quantity just in time to save countless lives during WWII.  Penicillin was used to treat routine bacterial infection, diphtheria, syphilis and tuberculosis.  Certainly a miracle drug if there ever was one.

Patients with kidney disease also anticipated a slow death, but not always so painful.  Hemodialysis was first used in a laboratory setting in 1913 on dogs but not perfected for human use until 1945.  Advancements since that time have made dialysis more efficient and available to many more people.  In the US alone there are approximately 400,000 people on hemodialysis.  The most, if not all, are receiving Medicare benefits to pay for this service at a cost of $55,000 per year per person. That’s 2.2 BILLION!

Something as simple as the annual flu has wreaked havoc on humans as long as we have inhabited the earth.  The ability of the influenza virus to undergo change and merge with other strains of virus made sure to cause much morbidity and mortality over the millennia.  First described by Hippocrates in 404 B.C., and recently causing worldwide scare as the swine flu in 2010, influenza continues to cause tens of thousands of deaths annually and many more during pandemics.  One can only imagine the number of deaths we would see yearly without the availability of the annual trivalent flu vaccine.

Mechanical ventilation and the modern intensive care unit became a standard of care after the “iron lung” was replaced by the more efficient positive pressure ventilator came into widespread use.  Over the years, the use of vasopressors, powerful broad spectrum antibiotics, in depth understanding of the physiology of stress and its effect on the human body have meant that even the most ill patient has a chance of beating death.

The cost of care is directly related to the advancements we have made in medicine over the past century.  The real change in the ever increasing costs of care is related to our refusal to accept that death is a natural part of life.   Along with that denial is the need to hang on at any cost.  Most of our health care dollars are spent in the last two years of life, many times in futile efforts to restore someone to a previous level of functioning.

As a nation we view health care and insurance as a right, an entitlement.  As such, it falls under the auspice of the federal government to manage.  In other countries the health care rationing you hear so much about has more to do with trying to make sure that the scarce resource of health care is being utilized where it will have the greatest benefit, have the largest impact and most efficient.

We aren’t ready to accept “rationing” just yet and that means costs will continue to rise or many, many people will be unhappy with their health care entitlement.

Doc B

My opinion is free.
Advice is worth exactly what you pay for it.