How did healthcare get to this point?

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I have been fretting about the Congressional dysfunction and, selfishly, on its impact on physician practices. Every year, too much time is spent on the short-term crisis (e.g., Medicare’s 3.4% cut to physician reimbursement) and too little time on a long-term fix. How did we get to this myopic and demoralizing state of affairs? Here’s my take.

Medicare was established back in 1965. Akin to Social Security, Medicare was designed as a ‘pay it forward’ program. Workers and employers contributed to a pool of money to provide care to those on Medicare and Social Security, with an understanding that future generations would do the same for them. It made a lot of sense. Unfortunately, both the Medicare Trust Fund and Social Security are slated to run out of funds in the next decade, leaving future generations to hold the bag. What went wrong?

• Life expectancy – Medicare was set up to provide healthcare for seniors for a dozen or so years. But seniors are living 4+ years longer than in 1965. The model hasn’t accounted for this 25%+ increase in longevity. There’s a net increase of 10,000 Medicare enrollees every day between now and 2030.
• The worker/senior ratio – When Medicare was created, there were about four US workers for every senior drawing on Medicare and Social Security. The ratio has fallen to 2.8 workers for every senior. It’s a function of smaller families (3 kids per family down to 1.6) and the aforementioned longevity.
• Technology – My dad died in 2020 after drawing on Medicare for 25 years. In his final decade, he had multiple joint replacements, a TAVR along with other cardiac procedures; numerous MRIs, CTs, and probably a PET or two. All were things that either did not exist in 1965 or would never have been done on someone his age.
• Pharma – Again using Dad as an example, he was on a slew of medications in his final years for hypertension, joint pain, arrhythmias, anxiety, and the like. None of the expensive medications he took every day existed back in 1965. Pharma advances have kept folks alive longer, and the longer one lives, the more parts there are that fall apart and need mending.
• Bureaucracy – Healthcare has become a bureaucracy. About 30% of the excess healthcare spend in the US can be attributed to administrative layers, per the Commonwealth Fund. Every layer we add between patients and clinicians adds expense.
• Tort reform – Tort Reform no longer gets the attention it deserves, quite unfortunately. Defensive medicine has become a given, an expensive given still in need of true reform.It remains a significant cost driver, in my estimation. A patient going to the ED with a headache may get an EKG to rule out something cardiac, an MRI or CT to rule out a stroke, and a carotid doppler ultrasound to rule out a blockage. Ka Ching, Ka Ching. Good care, yes. Necessary care? Not necessarily.
• Keeping up with the Joneses – Many years ago, a hospital CEO wanted my practice to lease an office in a monument he had built to healthcare excess. He wanted our front door to be across the lobby from a two-story waterfall surrounded by custom stonework. When I told him ‘no’, that I didn’t want our patients to think their co-pays were paying for his extravagance, he thought I was an idiot. I wasn’t; access trumps excess every time.
• Kicking cans down the road – Politicians kick cans down the road; it’s key to re-election. They have known since the early 70s the ‘pay it forward’ basis of Medicare and Social Security was collapsing under societal trends and medical advances. What have they done?Kicked the can down the road. At 61, I figure both will be there for me, but I know neither will exist for my children or grandchildren unless critical, albeit unpopular, decisions are made.

That’s how we got here. Where do we go from here? I am not sure.

Rationing is a bad word, but I think it has a place in our future provided tort reform goes hand-in-hand.Not to be trite or glib, but “we” kept my dad alive five years past his ideal ‘sell by’ date. Hundreds of thousands of dollars were spent keeping him with us in an ever-declining but always-in-pain state. I love Dad and miss him, but I also know it was a huge waste of money.

National health insurance? Possibly. We need to take a hard look at what value health insurance companies bring to the table, particularly given their staggering profits. Perhaps it is time to turn everything upside down and start serving patients rather than stockholders.

I am throwing spaghetti at the writing on the wall. I know. Nothing will happen until Congress unites to address the issues. Wait, I just saw a pig fly overhead. Made you look. Congress is incapable of putting our country ahead of reelection, bipartisanship, and fealty. I know. So do you. But as soon as I advance from knowing the causes to knowing how to fix the problem, you will be the first I call. Promise.

Lucien W. Roberts, III, MHA, FACMPE is a semi-retired practice administrator and long-time writer for Physicians Practice and Medical Economics. In his semi-retired kind of life, he is fortunate to be part of an infusion center with a simple measure of success: one happy patient at a time.