Eliezer Nussbaum, M.D. is one of America's most respected doctors, having founded the Miller Children's Hospital Pediatric Pulmonary Center at Long Beach Hospital in California and one of the first Pediatric Intensive Care Units in that state. He has just recently released his latest novel, American Greed.
Like most M.D.s, he's outraged by the high cost of medical care. I spoke with him about the best ways to cut costs in order to improve our ailing health care system:
What's the first and most important thing we can do to reduce health care costs?
We need to minimize the "defensive" practice of medicine by hampering the ability of patients to bring unjustified lawsuits. Because physicians can so easily be sued for malpractice, they have adopted a defensive posture, with many ordering expensive and unnecessary medical tests and surgical procedures in order to avoid having their treatment plans faulted. If a patient fails to improve, the physician can then say that every available option was tried.
A better way to handle this situation would be to create a professional review board of physicians and attorneys who will review these cases and minimize malpractice awards. At the same time, those patients and their families who bring unjustified lawsuits -- perhaps in the mistaken belief that a disappointing patient outcome equates to malpractice -- should be obligated to pay a penalty. This will have the effect of discouraging unwarranted lawsuits.
One added side effect of reducing the practice of defensive medicine would be to shorten hospital stays -- since unnecessary tests and procedures will no longer be performed -- and that will further reduce health care costs as well.
So unnecessary care is the worst culprit?
Yes, it is. There also needs to be increased scrutiny of the health care provided for patients at the end of their lives. Too often, the family is not adequately informed and they agree to medical interventions that only prolong the patient's suffering, as there is no longer any hope of renewing his or her quality of life. Take, for instance, the example of a 95-year-old grandfather with terminal, metastasized cancer who develops respiratory failure. In the Intensive Care Unit, he is intubated and forced to breathe mechanically with a respirator. For all practical purposes, he has already passed away, yet he continues to breathe with a machine. In my opinion, this is a waste of medical resources. We need to know when it is time to end a patient's medically-prolonged suffering.
Does bureaucracy also play a role in inflating costs?
At present, there are hundreds of medical reporting forms in active use by insurance companies and government agencies -- Medicare, for instance. Completing these forms requires an army of trained medical secretaries, and paying for their clerical services represents a huge expense. There is no reason why a single, all-purpose electronic form can't be developed, thus eliminating a wasteful expense for physicians, insurance companies, and government agencies.
Are there any other administrative changes that could be made?
It's been my experience that those in health care administration seem highly overpaid for work that does not always add value, and certainly has nothing to do with the real work of the hospital, which is treating patients. Of course, I know we need people to run the hospital business, but it's hard not to be outraged by the fact that a hospital CEO with an MBA earns five times what the best cardiothoracic or neurosurgeon makes after more than 15 years of expensive medical training. An in-depth evaluation of the administrative level of health care institutions could easily reveal where the waste is, and the steps that need to be taken to curtail it.
I'd also like to recommend that physicians and perhaps other health care professionals have the same degree of influence and input as administrators with regard to such administrative bodies as the hospital's board of directors. We provide the health care, after all, and deserve to be heard and to have a say in the way the institution is managed.
You've written quite a bit on your blog about the effects of lifestyle choices such as unhealthy eating, alcohol abuse, smoking, etc. Is there any relationship between those kinds of habits and the high cost of health care?
It may come as a surprise to many that a very small percentage -- about 5 percent -- of the American population consumes just under half of the overall cost of health care. Further, that miniscule percentage doesn't, as you might expect, represent those patients with life-threatening medical conditions that are no fault of their own. A large segment of that percentage represents patients who choose not to participate in their own preventive or wellness care. For one reason or another, they persist in pursuing such health-robbing habits as smoking and the abuse of alcohol, poor daily nutrition, and a sedentary lifestyle devoid of healthy exercise.
As a result, they suffer from a wide variety of medical conditions that are primarily of their own making. These often include obesity resulting in Type II diabetes, various cardiovascular illnesses, early onset arthritis, a shortened life span, and depression. All those secondary illnesses are preventable. And as I said, treating the conditions caused by these unhealthy choices eats up nearly half of the overall cost of health care each year.
Here's my suggestion: Why not motivate those who refuse to take responsibility for their own health (by refusing to follow their physician's recommendations) with an increase in their health care insurance premiums? After they quit smoking or lose weight, their premiums would decrease, thus providing a financial incentive to continue with a more responsible, healthier lifestyle. Of course, for those who suffer from a thyroid condition that has led to obesity, this would not be appropriate.
What about doctors who have these kinds of vices?
I believe that it is our responsibility to "model" good lifestyle choices, and be healthy, fit, and maintain a normal weight ourselves. In other words, we need to practice what we preach.
I have seen a morbidly overweight physician and nutritionist lecturing an overweight asthmatic patient with obstructive sleep apnea about the importance of an optimal BMI (body mass index) in treating his conditions. The irony of this situation seemed not to occur to either of them.
So I'd like to suggest a turnaround in the health care industry. If professionals like these won't take responsibility for their health -- after being given the opportunity to change their lifestyles -- then they ought to leave health care. Not only do they project the wrong image and the wrong "message" to patients, but they also pose a future financial burden for their employers, since they can expect to develop all the conditions about which they lecture their patients. However, the pressure for this change may have to come from physicians and other professionals themselves, since hospital administrators fear lawsuits for discrimination.
If these cost-saving measures were put into practice, I believe that our annual health care expenditures would gradually be reduced by as much as one half. By any measure, they seem well worth implementing.