Getting the most for the medical dollar

Commentary. By Eric Anderson, MD, amednews contributor. Oct. 9, 2000.

COMMENTARY

Observations on the state of medical practice and medical life

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Massachusetts produced some figures that hit the press like fireworks this Fourth of July -- figures that were not exactly an American celebration.

The news? First, that the number of those on state welfare had reached a record low. Second, paradoxically, that rising Medicaid costs were straining the state budget.

The details seemed clear enough: The number of people collecting welfare benefits in Massachusetts had fallen from a high of 348,000 in March 1981 to a low of 99,150 in June 2000. Meantime, the Medicaid program had become the single largest item in the state budget, consuming, according to the Boston Globe, a full 20% of the state's $21.3 billion spending plan and increasing so fast it was "starting to crowd out other public investment choices that legislatures and governors like to make."

Those first figures in July can be explained by the strong economy, which helped some to get off welfare. The second numbers are up probably due to a factor that every physician and patient, but not politicians or the nation collectively at large, is aware of -- namely that medical care, even the no-frills variety, is very, very expensive.

Health care is now so costly that someone somewhere in this country should be making hard choices about how much medical care we can afford in our future. Society should decide, not doctors or patients.

If the decisions are left to, say, research scientist physicians, they might say: "Let's do more in utero surgery and more research into brain transplants." If the judgments were left to individuals, we'd all say: "Save our child and damn the costs."

Indeed, that was the conclusion in a study done 20 years ago when subjects were polled and asked: How much should society spend on the treatment of a single child with an incurable condition? Many persons dropped out at $100,000, but others declared it was OK and appropriate for the figures to climb into the millions.

But because we don't have the spare millions, what are fair uses of our finite resources?

Vaccine development to stop disease in its tracks would be great for starters. Even Alzheimer's disease may respond to that -- and not before time, if 18% of America's population will be over age 65 by the year 2025. Vaccines to prevent HIV infection, as another example, would make a huge impact here and in other parts of the world. Immunological attacks on infectious diseases, and on metabolic ones like diabetes, would not only benefit patients but also ultimately save the country a lot of money.

The development of better drugs for common serious conditions would come next. Rare diseases are another matter. True, one can judge a civilization by how much time and money it devotes to culture and the arts and how it looks after its less-fortunate people. But our future society may decide -- if the cost of producing a specific orphan drug becomes prohibitive -- that research should be continued only if, as a byproduct, it will benefit many others with different diseases, or if a private philanthropist picks up the bill.

Money for diseases should be allocated according to the seriousness of the disease and the numbers afflicted. We should all be spared the consumer activism and political posturing that has created huge discrepancies between the small amount of money spent by government agencies on serious diseases affecting many Americans compared with the vast funds allocated for other diseases (with fewer patients) merely to mute more shrill and discordant voices.

But are funds being spent wisely at this turn of the century to help us afford our future health care? Don't hold your breath. The immediate problems with managed care take priority.

We shouldn't expect the political talking heads to be addressing these issues in a practical way. After all, they're not doing all that much about other pressing problems like our declining fossil fuels, nor are they addressing our global warming problem -- even as the National Weather Service reports that heat now kills twice as many Americans as floods. Those problems are not presidential fodder as we head for the November roundup.

Dr. Anderson is a semiretired family physician in San Diego.