Joseph Cramer, M.D.: As a nation, what do we value in health care?
There is much chatter about value in health care. An equation defines it: V = Q/C. Value equals the quality of care over the cost of that service.
In America, we have ignored both quality and cost for too long. What is the cost of a total hip replacement or a visit to the emergency department? The patient does not know, and the provider for the most part does not care.
What is the quality of a doctor, clinic or hospital? What is the rate of wound infections after surgery? How many times are patients given the wrong medicines or are subjected to an imaging study or lab test that is not necessary? How many times do we physicians misdiagnose or do so too late?
Quality and cost are critical for the financial salvation of our country from the expanding burdening price of health care. The good news is that quality is beginning to be measured. There is the metric of successful outcomes of surgeries or cognitive care. There is also asking the patient or their surrogate their view of the total package. Where staff respectful? Did the physicians explain things to their understanding? How was the food?
There is, however, a greater question to the equation of value. That is what do we value as a nation? In our current fee-for-service environment, money measures worth. Physicians and institutions that perform and sell procedures earn more coins; hence are valued more.
Specialists demand and receive payments that are usual and customary. It makes sense. The physicians who perform procedures are highly trained and skilled at what they do. There is no fault in that. An ill patient goes to his primary care physician, an internist, family doctor or pediatrician. This doctor diagnoses a disease. If the treatment is only a prescription there can still be an enormous bank-busting price to the medicines, but the doctor is compensated only for an office visit. That, too, is reasonable.
On the other hand, if the person is overweight with diabetes, high blood pressure and chest pain and the primary care physician consuls on nutrition, sugar management or exercise, the doctor is either not compensated or is paid relatively less.
I must stop here with a disclaimer. All physicians in America are wealthy compared to the rest of the world. When we weigh our earnings to the income of others on earth, we earn more than 99 percent of our brothers and sisters.
The problem is, we compare with the other guy down the block. This is not a justification for pride, but it does draw into question what we value as a society when we read of sports figures living like kings and financiers living like gods. Can they cure cancer? Can they soothe a troubled, tired mother?
Skip people. Measure what we pay for war. Is there a value equation for bombs? One GPS or laser-guided weapon built to take lives is a lot more than the cost of emotionally saving them.
We need to talk more about values and not just value. If we treasure children, then a value of dollars should be attached to those who care for them. If we focused on health and not health care, we would shift our attention on those who teach nutrition, provide tools for better mental health and exercise more than those who repair or bypass the vessels that are damaged by the lack of that teaching.
This value of fairness needs to be added to the medical equation. A family doctor will comfort a family in mourning, wake up in the middle of the night to stitch up a wound or spend time counseling a troubled teen. They are not motivated by greed. They may not do more or better with extra cash, but there would be a greater feeling of satisfaction knowing society values their sacrifice.
Therefore, when we speak of value in health care, this country needs to have a conversation also on our values.
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