Scrubbing In: Good health care doesn't come cheap

When I asked my diabetic patient recently how well he had controlled his blood sugar over the last few months, he let out a deep sigh. If only he could check his blood sugar a reasonable number of times, he told me, he would have better control.

But his insurance covered only enough test strips for him to check a few times a week - instead of several times a day. He hoped that the insurance appeal, which his primary care doctor had launched, would soon help.

I muttered to myself in disbelief: Why must a doctor appeal to an insurer to get the proper number of test strips for a diabetic patient? Shouldn't the first prescription suffice? If minimizing health-care costs were the goal, wouldn't the insurer do better by spending $50 on test strips instead of $20,000 on a hospital stay?

How to spend health-care dollars - from test strips to CT scans - is a crucial issue these days in Washington. President Obama wants to trim the fat from wasteful health spending, which threatens to swamp the federal budget. Cutting costs, he argues, is necessary for the future stability of our health system.

But a leaner medical system may not necessarily create a better one. Cost cuts have to be smart cuts, and should not harm patients the way rationing test strips does.

Researchers say that up to 30 percent of Medicare expenditures are wasteful. If we can trim such excess, health care will work more efficiently for more people. There are an estimated 50 million uninsured patients to cover, and the money has to come from somewhere. Obama vowed not to raise taxes on middle-income Americans, so it has to come from our already fiscally troubled health system.

The most convincing argument that excess exists comes from provocative research at Dartmouth, cited recently by Harvard surgeon Atul Gawande in the June 1 New Yorker magazine.

The article chronicles the story of McAllen, Texas, the town with the country's second-highest Medicare expenditures per person (after Miami). McAllen's doctors, Gawande concludes, are products of a system that rewards quantity over quality. They are sophisticated entrepreneurs who treat patients as revenue-producers, which results in a slew of overtesting and overtreatment.

This spending would be less objectionable if McAllen's seniors were living longer, free of pain and disease. But the opposite seems true, suggesting that Medicare is spending more money and getting less in return.

Now the Obama folks think that McAllen, a Mexican border town with high unemployment, lots of crime and no medical school, is a microcosm of the country.

Is it? I'm skeptical. Most doctors I know order tests based on years of training and experience, not on how much money they can eke out of the system. If we order extra tests, it's from the fear of lawsuits. Doctors err on overtesting rather than risk a run-in with the trial lawyers.

Richard Cooper, a University of Pennsylvania physician, also challenges this core belief that less is more. He says the Dartmouth researchers limit their analysis to Medicare, neglecting the effect of overall health spending. States with more total health spending have better quality care, Cooper found.

A cornerstone of the new system is a public plan option that would supposedly run without the excesses of McAllen. Similar to Medicaid or Medicare, it would be government-run and cost less than private insurance. But would the services be as good as private insurance?

I recently saw a patient in the Wills Eye ER who had decreased vision in both eyes for a few weeks. I wanted to send her to a specialist for more sophisticated testing.

But her New Jersey Medicaid HMO was limited. To even get to our ER, she had to petition her insurer because Wills isn't in New Jersey. Then to find a specialist who would see her on an ongoing basis, I searched all over New Jersey - as patients were stacking up in our ER - and finally found someone in Newark.

She arranged medical transport up there, only to be turned away after a two-hour ride because the receptionist couldn't find her electronic referral. "Having this insurance is like having no insurance," she told me.

Why didn't anyone take her insurance? Public plans like Medicaid reimburse so little that many doctors just say no. The same is true to a lesser extent of Medicare.

Will doctors do the same with Obama's new plan?

Of course, consumers will be able to choose this public plan as presented and opt out if it underperforms. But the reformers have to be careful. Good health care is not cheap, and cheap health care is not good.

Rachel K. Sobel, a second-year resident

of the Wills Eye Residency Program at Thomas Jefferson University, writes about her experiences

every other week.

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