By Joyce Frieden, News Editor, MedPage Today
“Despite the increases in resources devoted to healthcare, multiple health metrics, including life expectancy at birth and survival with many diseases, shows the United States trailing peer nations,” Hamilton Moses III, MD, of the Alerion Institute in North Garden, Va., and colleagues wrote online Tuesday in the Journal of the American Medical Association.
People in the U.S. also are sicker than their counterparts in other countries belonging to the Organization for Economic Cooperation and Development (OECD), they continued, with cardiovascular disease, perinatal disorders, respiratory diseases, and infectious diseases such as HIV accounting for 75% of the deviation.
Although the U.S. lags on these indicators, in 2011 healthcare expenditures stood at $2.7 trillion, or 17.9% of GDP — double the percentage in 1980 and 4.2% more than the average for the other members of the OECD. Overall healthcare costs increased 2.9% a year between 2000 and 2010 and prices of hospital care, healthcare provider services, drugs and devices, and administrative costs accounted for 91% of those cost increases, rather than increases in demand or the aging population, the authors noted.
In addition, they continued, changes are taking place in the way care is being paid for. There has been an 83% drop in personal spending for physician services and drugs, with the slack taken up by government programs and private insurers, which together pay more than 90% of hospital and doctor costs and 80% of nursing home care.
Chronic illness costs for those under 65 make up 67% of healthcare spending, underscoring the need for “more sophisticated and better coordinated approaches to common conditions,” they said.
The cost landscape also has been affected by the move toward consolidation. Hospitals have been buying up competitors as well as physician practices and insurers have been buying up competitors. “The most striking example,” Moses and colleagues wrote, “in all but five states, the top one or two insurers have market shares of more than 50%, and in 18 states they have shares higher than 75%.”
Marketplace consolidation may decrease physician independence and cause doctors to become frustrated, the authors suggested. On the other hand, patient demand for easy physician access has brought on the growth of concierge medicine with its independent physician groups. “In response, some states (e.g., Massachusetts, Oregon) have considered discouraging growth of concierge medicine via regulation and physician licensing laws.”
In addition to other changes in the marketplace, more resources are being put into the adoption of health information technology, although those investments have yet to bear much fruit aside from automated drug interaction monitoring, they wrote.
But, although healthcare costs have tripled in real terms over the past 2 decades, “in the last 8 years, the trend in cost has moderated. … A general drive to measure and manage for value and accountability, for outcomes, and for spending has emerged, and it appears to have sustained momentum,” according to the authors.
They posited a number of possible causes for the poorer outcomes performance of the U.S., including different cultural norms on health-related issues such as gun ownership, unprotected sex, drug use, seat belts, as well as differences in obesity and risk of trauma. “Other [causes] are directly or indirectly attributable to differences in care, such as delays in treatment due to lack of insurance and fragmentation of care between different physicians and hospitals.”
And they noted that resistance to change may prove to be a problem in continuing the moderation in cost increases, particularly if patients decide not to challenge decisions by their health plan. “The medical profession has spent decades discouraging medical paternalism in all its manifestations,” Moses and colleagues suggested. “To have it reemerge in another form would be unfortunate and counterproductive.”
But there is hope, they wrote. “Physicians and advance practice nurses, spurred by a new, younger generation, might prove highly receptive to altered incentives, bring new objectivity, and embrace broader measures of success, such as those that reflect the value of their clinical judgment and their ability to engage patients in decisions having major gravity. Physicians and nurses, not ‘Big Med,’ ‘Big Pay,’ or the government, could become the main sources of service innovation.”
The authors called for “a new discussion — ideally out of the political arena and with self-interest held at bay — among all of the involved constituencies,” aimed at making better choices concerning healthcare delivery and financing.