Wednesday, January 2, 2008

Health Care Costs... can we control them?

This image was taken in Victoria Park in Truro, Nova Scotia. I grew up in this
town that provided a great place to call home. The park is inside the town limits and worth
taking the time to visit. There are great hiking trails, and the park avails itself
to many of us who are of limited mobility.

One of the benefits of living in Nova Scotia is the outstanding health care that is available to Bluenosers. Many have heard me comment on the excellent care I had when I fought cancer for two years… care I am convinced was as good, perhaps better than in any other constituency in North America. Beyond that experience, I have accompanied a heart attack victim to hospital in Dartmouth (transported later to The QEII) and saw outstanding work done, and an excellent outcome resulted. So, through my personal observation, I can attest that the acute care situation, at least in the urban areas of the province, is very good.

Given my 30 years in the healthcare industry around the world and my personal health trials, I am a reasonably informed observer of health care. Therefore, this posting will not call on ‘data’… it is personal observation only. I want to differentiate acute care from chronic care. The former requires urgent medical treatment to stabilize a patient’s life, whereas chronic care is necessary to improve the patient’s quality of life. I want also, to refer to the various impacts on health care by the cost of providing that care, and how we might control and then reduce it over protracted periods… perhaps generations long.

I intend posting to be ‘very’ challenging to the senses! This will mostly be directed at chronic care, and in the future we will look at acute health care in our province. It seems to me that we in North America are focused on living longer lives. Longer often does not involve healthier or better lives, and as a result, we will resort to often costly treatments in order to prolong life. I would argue that in too many cases, this last period of many people’s lives is the most painful, and heart wrenching for the patient, family and friends.In effect, rather than life, we are prolonging death!

It has been established for some time that nearly 50% of all health care costs in North America are incurred in the last year of patients’ lives. A substantial portion of that cost is in fact incurred in the last 24 hours of a patient’s life! And to what avail? I plan to argue in this and future posts, that the costs do not, in any way, justify the ends. These costs, to often, leave us with memories of the pain not the gain… of the hurt, not the pleasure of the life lived and now lost.

It seems to me that in many ways this becomes a social or moral issue that we should address in the future. While I am not on one side or the other, it seems to me that it is an important function of the medical profession to be pragmatic about the options of patients who are deemed to be in the last year of their life. Perhaps we should consider some clinical studies on the prognostic capacity of the systems that provide universal health care. Once we understand the ability of the system to accurately estimate the outcome of significant (usually very costly) treatment options, we will be able to make educated decisions on whether to ‘save’ a person’s life… rather than prolong death, just spending the money anyway.

The ability to forecast the quality of life, as well as quantity might allow us to spend more money on those who have the opportunity to live longer and more comfortable, productive lives. Expensive studies on new drugs and procedures that prolong the death process of patients, often a painful prolongation of an otherwise good to great life should be contextualized with prognosis on the quality of the resulting life, so that we can tell if the new care is appropriate. I have spoken with countless terminally ill patients who just want to move on to their next stage of existence, but health care professionals and institutions can’t and families won’t allow this to happen. Remember, 50% of health care costs are in the last year of patient’s lives. Shouldn’t we be reconsidering our moral and legal positions?

Let’s look at other chronic health care issues that are costing the system, and look at ways to alleviate the cost situation. One of the most important issues seems to me to be smoking! We know that tobacco, in its many incarnations, is a major cause of several health care problems (read costs). Heart Disease, Lung Cancer, Peripheral Arterial Disease (PAD), Asthmas in children and so on, are all connected (in)directly to tobacco use. In the socialized medical system in Canada (and being considered in the USA), shouldn’t we expect that if the top three causes of death and health care cost are directly attributable to tobacco… it should be banned! Shouldn’t we consider, persons that persist in using tobacco should be excluded from coverage by the health care system. Why do we allow this substance, which would never be approved if it were invented today, to foist the ravages of such significant disease on our people... today, and in future generations. We ban guns, yet they would never kill as many people as does tobacco!

Let’s consider that obesity, particularly morbid obesity, is directly implicated in hypertension (high blood pressure), stage two diabetes, chronic joint problems and many other systemic issues. Shouldn’t we be considering programs for our children in school to teach them the fundamentals of nutrition and the implications of poor eating habits. Shouldn’t we be creating alternative activities in the schools including providing daily gymnasium time, healthy meal options in the cafeteria, education on healthy activity and so forth. At least we would then look forward to long term health (read costs) improvements. We would then need to culturally deal with the current obesity issues as a chronic disease… treating the underlying causes (education, isolation, low income, low self-esteem among the many), not the symptoms (obesity). Let's help these people who either don't know how, can't or won't work to alleviate their health challenge we call morbid obesity (> 30% over target BMI (Body Mass Index)).

Alcoholism has a tremendous direct impact on health care costs. It is directly implicated in heart and liver disease, hypertension and several cancers. These are chronic costs that can be significantly reduced when cessation programs are delivered. Shouldn’t we immediately identify those who need help and provide proactive treatment for these patients who are today ignored, shunned or mis-diagnosed. Further, shouldn’t we be working in the schools to teach the students about the implications of abusive consumption of alcohol and some drugs. This education could impact our health care costs a generation down the line… health care costs which, unchecked, will bury our ability to absorb in our provincial, state or federal budgets.

The issues of bad behavior and the financial costs of health care foisted on society by people who insist on hurting others by erratic driving of various vehicles or physically attacking or abusing other humans, should be addressed. These costs are not being considered in the courts of our society. If we don’t want to put these people in jail, we should at least require them to pay the health care costs we (society) incurs as a result of their actions.

The point here is that we have a very good health care system in Nova Scotia. We want to sustain it, but we don’t seem to want to take the hard steps of understanding the causes of the cost of good health. Yes, we need new treatments. A larger need however is to minimize the costs we currently have in the system. A very large portion of the costs are incurred in disease states that are behavior caused. Modification of current behavior, and education could have a far greater impact on health care costs than reducing coverage, raising taxes and insurance premiums and so on. In fact, it likely is necessary that we do these in parallel since we already spend close to 10% of our total Canadian GNP on health care (13.5% in the USA... amounting to nearly $1.4Trillion) and the savings in educational processes will take generations to reap.

It will take leadership in our health care sector and in government in order to initiate and sustain the societal and moral issues at the core of our health care problems. While I personally don’t believe that the leadership is here… clearly the need is here. We need a change in our current attitudes and thinking… and we need to engender the fortitude necessary to sustain an attack on health care costs. At the current rate of cost increases, we will double our health care bill every seven to ten years. Do you have any ideas about from where it will come. I hope you will comment, and get this dialog started.

Please also remember that this is a day-to-day issue and each…



Anonymous said...

Hi Bruce,

Very thought provoking. As I read the blog I considered a couple of things:
1. Would society support actions in this area?
2. What are the barriers to getting desired results?

In terms of prolonging death I agree that considerable costs could be saved by taking a different approach. That said, families and society in general would likely never support any decision, no matter how reasonable, if it meant a loved one were denied any sort of treatment that could keep them around for a little longer. Death brings out a person's selfish side. They want to hold onto that person just alittle longer for their own personal reasons. They ask the person to bear the pain in order to avoid dealing with their loss. That is a tough one to overcome.

On the other hand, tackling child obesity should be met with real support. So should a ban on smoking. So what are the barriers to achieving both? If we can identify barriers we can plan ways around or through them.


Bart said...

Talk about thought provoking: a retired politician during a guest lecture stated that "Not only do we need more baby cribs, we need more coffins as well".

There is more than meets the eye: This is an abstract of a 2006 paper from Brian S. Armour and M. Melinda Pitts on Smoking: Taxing Health and Social Security. "While the health risks associated with smoking are well known, the impact on income distributions is not. This paper extends the literature by examining the distributional effects of a behavioral choice, in this case smoking, on net marginal Social Security tax rates (NMSSTR). The results show that smokers, as a result of shorter life expectancies, incur a higher NMSSTR than nonsmokers. In addition, as low-earnings workers have a higher smoking prevalence than high-earnings workers, smoking works to widen the income distribution. This higher tax rate could have implications for both labor supply behavior and Social Security system funding.

Anonymous said...


The issues you describe are well known, but remain unchecked after years and years. It seems that too many have a vested interest in maintaining the status quo. Real change will only occur when incentives change. That's my two american cents.

BTW - my sales territory covers the Western US and Canada. For the past 3 years I have wandered back and forth across the border with my bag of wares. It has been quite an education, learning to pitch new technology to the socializers of the north AND the enterprizers of the south! I have learned a lot.


Ponderling said...

I want to respond to the three comments here above... This issue of health care in Nova Scotia is a critical one. We are not being strategic in our approach by the government... incremental change will not fix it anymore than a band aid on a broken bone. It is not a matter of lowering costs... complete change in the approach to care will be necessary... we do not have enough disposable government budget available to continue on the road we are today. None of the political parties have a real strategic approach to health care. This has to change!

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Grad. Saint Mary's University, 1975, got into the medical device business initially in sales, then various management positions up to president, all in Medical Devices. I prefer therapy products over diagnostic, but they are all fun, and in a way have defined my life. I have now evolved, with help from my 35 year partner Lynnda with whom I now share every hour. I am into staying healthy, photography, kayaking, bicycling, gardening and two books a week. I wish I had gotten to this stage earlier!