What is behind high costs in medical care?

Rinckside 1992; 3,3: 7-8.

n most societies, there is a consensus that human life has to be preserved and protected and that every effort should be made to help ailing people. Life and health occupy the top position of the scale of human values today.

The method and extent of preservation available today were unthinkable one hundred, fifty, even twenty years ago. In most instances preservation is possible because of the dramatic medical progress achieved during the last 200 years, particularly in the late 19th through the 20th century.

I only mention some randomly selected key words: vaccination, antibiotics, pacemakers, transplantations, radiation treatment. These, and many other developments, have contributed to life expectancy doubling during this period.

But medical progress has not been limited to therapeutic techniques. New diagnostic methods have also been invented and perfected since the 19th century. Modern diagnostics such as ultrasound, computed tomography, magnetic resonance imaging, as well as advanced laboratory methods, can reveal disease at a stage where it is still accessible to therapy and, in many cases, allow a restitution ad integrum.

But along with the tremendous growth in medical care, the number of complex operations, dialysis patients and histological examinations increased. As some basic health problems have been conquered, others have developed; as once fatal diseases have almost disappeared, others just as deadly have arisen.

Physicians and medical researchers constantly face new challenges. By the time a recently developed technique – be it therapeutic or diagnostic – becomes part of a clinician's daily routine, another one is under development.

The general public is usually not engaged in this process. Most are not even aware of it, nor of the difficult journey it involves. Their first contact is through the headlines of a news story announcing a new hope, another promise. And then, not surprisingly, the hope turns into a demand by the public: we want to benefit from this new development.

Little thought is given to what goes on behind the scenes. Hardly anyone thinks about the work, let alone the cost, that makes medical dreams a reality.

   Better diagnostics and therapy are extremely expensive. Beyond the costs of developing new techniques lie the costs of bringing them to the public. Today's factory-like hospitals require special building structures, air-conditioning and particle cleaning, a vast supporting infrastructure, sophisticated equipment and pharmaceuticals, as well as a highly trained staff, usually topped by a gargantuan administration.

Only about one percent of the overall health costs are created by high-technology diagnostic methods. The cost of MR imaging, for instance, drowns in the noise of other costs [*see remark below].

The main contributing factor to high costs are medical personnel. Nursing is not done by nuns for the love of God any more. Every time there is a salary increase, health costs go up. Between two-thirds and three-quarters of all health expenses are a result of personnel costs. Shorter working hours add to them.

In addition to direct procedures costs, there are other expenses to be calculated. Pacemaker patient now live to an age when they may get diabetes, coxarthrosis, or Alzheimer's disease, which again keep physicians and the entire healthcare system busy. Patients dependent on an artificial kidney cause costs of up to US$ 100,000 per year; they also need dental care, new glasses, orthopedic shoes, etc.

In many cases we seem to have preserved life in purely quantitative terms. Now we must work on improving the quality of these additional years.

   With the help of modern medicine and physicians, people can now live much longer. But longer does not necessarily mean healthier. And, thus, to the costs of lengthening life one must add the costs of treating the ailments suffered by those whose lives have been extended. In light of this, we can see that the cost of healthcare and of the healthcare system in general, will continue to increase.

A commonly held belief is that the high cost of medical care is the direct result of physicians demanding enormous salaries and the medical industry wanting to make tremendous profits – at the expense of people's illnesses.

Many see the medical care field as the heaven of the money-makers, as a money-making machine. In fact, techniques like MR imaging are only developed in those countries where the medical industry makes a profit. Purely socialist countries where individualism in thinking and working is punished or not allowed have neither developed new medical techniques nor pharmaceuticals. Usually the medical care offered in these countries is insufficient or at best delivered after long waiting periods. But their costs are not lower.

   On the other hand, it would be naïve to ignore the fact that a certain degree of profiteering takes place. It is only human and only open societies can (could?) stop it where it happens. The irresponsible creation of unnecessary costs as well as the superfluous expenses created when techniques are not properly used must also be brought to attention and controlled. In many instances, the latter is more due to lack of knowledge and education among physicians and less due to malevolence. Quality assurance in high-technology is but one way to achieve better and cheaper utilization of high-technology medical modalities.

Stopping the exponential increase in medical-care costs, however, will require that our societies change their attitudes. Preserving life for the sake of giving more time should not be the goal. Quality of life – however long – should be the focus. This implies that preventive medicine must be emphasized and rewarded, and not only by the medical profession. The general public should be made aware of and responsible for their own health.

The promises of the social welfare state during the last fifty years included everlasting youth and health. Increasingly, the absurdity of this kind of wishful thinking has become obvious. There is an unmistakable tendency that the solidarity of the society or the state are not being able to cover the financial burden any more. Politicians do not dare to voice this because it is unpopular and they do not want to lose votes (and financial sponsorship from companies of all sorts). It is easier to blame certain relatively small groups in society such as the physicians than facing the problem at its roots.

Who talks about cost increase or increases of expenses in the legal system? Who talks about the increase of expenses in leisure and holiday travels? It is all part of the better quality of life which is part of our societies – and to enjoy this better life we must be ready to pay the cost. Or we must accept returning to where we were not so long ago: very few could take a holiday at a nice beach resort and a great many were dying of tuberculosis at the age of 35.

However, this will not happen. People will continue taking holidays and spend billions of dollars on them. And physicians will continue developing new methods to help the sick. That this is costly is not their fault. Cutting down expenses by attacking physicians, in particular those in high-technology disciplines, will not solve the problem.

And, if salaries will not decline, healthcare costs will increase in the future.

   * PS, 20 years later: Within a few years, this has changed. Medical imaging expenses have risen by several hundred percent and constitute a major part of medical expenses.

Citation: Rinck PA. What is behind high costs in medical care? Rinckside 1992; 3,3: 7-8.

A digest version of this column was published as:
What is behind high costs in medical care?
Diagnostic Imaging International 1992; 8,5: 7,53.