EDITORIALS A BICENTENNIAL EDITORIAL
The Dollars for Health QUITE SIMPLY, the number of dollars available for health is and will be far less than what can legitimately be spent, whether in research, education or health care services. As time goes on this gap between what could be used and what will be available will increase. America, now entering its third century, has already found that one of its major problems is how to deal with rapidly rising and seemingly uncontainable costs in the field of health. Expenditures for health have now reached 8.3 percent of the gross national product. It is clear that sooner or later there will have to be some sort of ceiling on the dollars spent for health, and that within this limitation, not only services, but research, education and medical progress will all have to share the available dollars. As might be expected there is beginning to be some study of the subject. Some of the causes of rising costs are obvious, some are not. It has been observed that the laws of the market place which tend to control prices and costs do not seem to apply in health. A recent study' commissioned by the government and carried out by a nongovernmental research institute, found that a multitude of forces, each reinforcing the other, has pushed the health care system into ever greater emphasis on costly secondary and tertiary care, to the neglect of other levels of care which might be less expensive. The cost of labor and supplies has increased enormously and the price of inflation is added on. But there has been relatively little study of the dollars health care saves by preventing, curing or restoring productivity or, on the other hand, of the dollars it costs to maintain the chronic disability that occurs when restoration of health and productivity has been incomplete-and what, if any, might be the trade off. But there are other strong but less obvious forces at work. For instance, conflicts of interest of various kinds pervade the field of health and these cannot help but affect costs. Patients and families have one view of expenditures when illness is serious, but the public or whoever foots
the bill may have another. Even the patient or the family may have a different view when confronted with the bill. And public cost consciousness can conflict with public compassion, as in the End Stage Renal Disease program for example. Providers of care, especially physicians, find conflicts between what a patient really needs and what it takes to satisfy public accountabilityutilization controls, quality assurance and defense measures in case of future litigation. And there are costly conflicts of interest within government itself. So far the federal government has been loath to apply the same cost controls to federal health care programs that it does to programs in the private sector. It seems likely that in no other field are there so many genuine conflicts of interest impinging upon costs, and mostly adversely. Then there is a curious irrationality about health and health care. People are not always as concerned as we like to think they are. A surprising number believe "it won't happen to me" and take irrational risks. Others are unduly fearful. We know that a large number of patients do not follow their physician's advice or take their prescribed medicine even though they sought the advice and bought the medicine. Everyone knows that smoking and too much alcohol are bad for people, yet indulgence in both continues to be widespread in spite of all out efforts in education and control. It is clear that the costs of health care and the dollars for health cannot be separated from human behavior and that rational thought may not always prevail. Given the cost problems, the conflicts of interest, the inherent irrationalities-not to mention imperfections in the science and art of medicine-what is to be done? Certainly something more than the ad hoc stop gap measures of today will be needed. Perhaps it is already time for a new approach. It is suggested that many of the dollars now being spent for health are not producing that much health. Would it not be worthwhile to reassess the assumptions upon which all health expenditures are based, whether in patient care, administration, education or research, and see what kind of data or experience supports them? Have not many programs and services been carried to the point of diminishing returns for the dollars being spent? And to what extent is the THE WESTERN JOURNAL OF MEDICINE
219
EDITORIALS
friction in the system-and the cost-being increased by attempts to impose regulations and controls upon it, and is this worth the cost? It seems certain that many dollars now being spent for health could either be saved or spent more productively for health if questions such as these were asked and answered. And this is something that can be done now. In the longer range it will be necessary to face up to the ever growing disparity between health resources and burgeoning needs. Judgmental decisions involving personal goals, societal goals and contemporary ethics will need to be made at all levels of health care. These will involve doctors, patients, consumers, administrators and the public. It will be necessary to develop the means by which a broadly based consensus can be achieved at all levels of health care on where and for what the relatively limited dollars available in this field
will be spent, be they public or private dollars. It is clear that physicians will be involved in all of this. Their knowledge of what constitutes health and its disorders, their direct experience with patients and their more recent experience with the problems created as well as solved by governmental and other interventions will be essential. Their advice should be sought and listened to and they should take part in the decisions at every level. It is not too soon to begin to get some new and more realistic approaches to all of this into place, so that the dollars for health care can both be conserved and used more efficiently and effectively.
Venous Thrombosis
tributed in the United States, has been of greatest value in clinical investigation, where it has provided objective data on occurrence rates. Its most important contribution so far has probably been the trial and proof of low dose heparin as a prophylactic agent in postoperative patients.3'4 Labeled fibrinogen scanning will undoubtedly continue to be valuable as a surveillance method, but its greater application in clinical practice may prove to be as a diagnostic measure in patients in whom a preformed venous thrombus is suspected to exist, even though the technique is less sensitive with established thrombi than when employed as a screening procedure and administered in advance in high risk cases. Recent noninvasive additions to the diagnostic armamentarium, such as plethysmographic techniques,5-7 appear to achieve their highest degree of accuracy in detection of major thrombi in the femoral and iliac veins, which are probably the source of most serious pulmonary emboli. Therefore, they are promising methods for confirmation of a clinical impression based on swelling and tenderness in the thigh. Their advocates claim that, if they give negative findings, they can provide comforting assurance of a minimal hazard of major pulmonary embolism.8 However, these techniques are essentially blind to thrombi in the calves, and this point must be kept in mind in considering their clinical applicability. The litera-
FROM TIME TO TIME, new technology provides both the impetus and the means for a dramatic gain in our ability to cope with a serious disease. So it is with venous thromboembolism. The recent renewal of interest in this familiar problem can be traced largely to the development of improved diagnostic methods. Sensitive and objective techniques now available have led to an appreciation of the prevalence of thromboembolism complicating the postoperative state and occurring in nonoperative patients; they have provided increased understanding of the natural history of the disorder; they have underscored the insensitivity and unreliability of diagnosis when based solely on clinical criteria, and they have afforded investigators a means of generating solid data in studies of prevention or treatment. Radiographic phlebography and scanning of the lower limbs for uptake of labeled fibrinogen have been particularly influential. The former procedure is at present regarded as the ultimate standard for showing the presence of venous thrombosis in the lower extremities of living patients, when carried out by modern techniques."2 Although invasive and not without morbidity, it is superior even to routine autopsy in its sensitivity. The latter method, available for general use now that 1251-labeled fibrinogen is commercially dis-
220
SEPTEMBER 1976 * 125 * 3
-MSMW REFERENCE 1. Trends Affecting U.S. Health Care System. Commissioned by DHEW and prepared by the Cambridge Research Institute. DHEW Publication No. HRA 76-14503. Washington, DC, Government Printing Office, Jan 1976
The Dollars for Health QUITE SIMPLY, the number of dollars available for health is and will be far less than what can legitimately be spent, whether in research, education or health care services. As time goes on this gap between what could be used and what will be available will increase. America, now entering its third century, has already found that one of its major problems is how to deal with rapidly rising and seemingly uncontainable costs in the field of health. Expenditures for health have now reached 8.3 percent of the gross national product. It is clear that sooner or later there will have to be some sort of ceiling on the dollars spent for health, and that within this limitation, not only services, but research, education and medical progress will all have to share the available dollars. As might be expected there is beginning to be some study of the subject. Some of the causes of rising costs are obvious, some are not. It has been observed that the laws of the market place which tend to control prices and costs do not seem to apply in health. A recent study' commissioned by the government and carried out by a nongovernmental research institute, found that a multitude of forces, each reinforcing the other, has pushed the health care system into ever greater emphasis on costly secondary and tertiary care, to the neglect of other levels of care which might be less expensive. The cost of labor and supplies has increased enormously and the price of inflation is added on. But there has been relatively little study of the dollars health care saves by preventing, curing or restoring productivity or, on the other hand, of the dollars it costs to maintain the chronic disability that occurs when restoration of health and productivity has been incomplete-and what, if any, might be the trade off. But there are other strong but less obvious forces at work. For instance, conflicts of interest of various kinds pervade the field of health and these cannot help but affect costs. Patients and families have one view of expenditures when illness is serious, but the public or whoever foots
the bill may have another. Even the patient or the family may have a different view when confronted with the bill. And public cost consciousness can conflict with public compassion, as in the End Stage Renal Disease program for example. Providers of care, especially physicians, find conflicts between what a patient really needs and what it takes to satisfy public accountabilityutilization controls, quality assurance and defense measures in case of future litigation. And there are costly conflicts of interest within government itself. So far the federal government has been loath to apply the same cost controls to federal health care programs that it does to programs in the private sector. It seems likely that in no other field are there so many genuine conflicts of interest impinging upon costs, and mostly adversely. Then there is a curious irrationality about health and health care. People are not always as concerned as we like to think they are. A surprising number believe "it won't happen to me" and take irrational risks. Others are unduly fearful. We know that a large number of patients do not follow their physician's advice or take their prescribed medicine even though they sought the advice and bought the medicine. Everyone knows that smoking and too much alcohol are bad for people, yet indulgence in both continues to be widespread in spite of all out efforts in education and control. It is clear that the costs of health care and the dollars for health cannot be separated from human behavior and that rational thought may not always prevail. Given the cost problems, the conflicts of interest, the inherent irrationalities-not to mention imperfections in the science and art of medicine-what is to be done? Certainly something more than the ad hoc stop gap measures of today will be needed. Perhaps it is already time for a new approach. It is suggested that many of the dollars now being spent for health are not producing that much health. Would it not be worthwhile to reassess the assumptions upon which all health expenditures are based, whether in patient care, administration, education or research, and see what kind of data or experience supports them? Have not many programs and services been carried to the point of diminishing returns for the dollars being spent? And to what extent is the THE WESTERN JOURNAL OF MEDICINE
219
EDITORIALS
friction in the system-and the cost-being increased by attempts to impose regulations and controls upon it, and is this worth the cost? It seems certain that many dollars now being spent for health could either be saved or spent more productively for health if questions such as these were asked and answered. And this is something that can be done now. In the longer range it will be necessary to face up to the ever growing disparity between health resources and burgeoning needs. Judgmental decisions involving personal goals, societal goals and contemporary ethics will need to be made at all levels of health care. These will involve doctors, patients, consumers, administrators and the public. It will be necessary to develop the means by which a broadly based consensus can be achieved at all levels of health care on where and for what the relatively limited dollars available in this field
will be spent, be they public or private dollars. It is clear that physicians will be involved in all of this. Their knowledge of what constitutes health and its disorders, their direct experience with patients and their more recent experience with the problems created as well as solved by governmental and other interventions will be essential. Their advice should be sought and listened to and they should take part in the decisions at every level. It is not too soon to begin to get some new and more realistic approaches to all of this into place, so that the dollars for health care can both be conserved and used more efficiently and effectively.
Venous Thrombosis
tributed in the United States, has been of greatest value in clinical investigation, where it has provided objective data on occurrence rates. Its most important contribution so far has probably been the trial and proof of low dose heparin as a prophylactic agent in postoperative patients.3'4 Labeled fibrinogen scanning will undoubtedly continue to be valuable as a surveillance method, but its greater application in clinical practice may prove to be as a diagnostic measure in patients in whom a preformed venous thrombus is suspected to exist, even though the technique is less sensitive with established thrombi than when employed as a screening procedure and administered in advance in high risk cases. Recent noninvasive additions to the diagnostic armamentarium, such as plethysmographic techniques,5-7 appear to achieve their highest degree of accuracy in detection of major thrombi in the femoral and iliac veins, which are probably the source of most serious pulmonary emboli. Therefore, they are promising methods for confirmation of a clinical impression based on swelling and tenderness in the thigh. Their advocates claim that, if they give negative findings, they can provide comforting assurance of a minimal hazard of major pulmonary embolism.8 However, these techniques are essentially blind to thrombi in the calves, and this point must be kept in mind in considering their clinical applicability. The litera-
FROM TIME TO TIME, new technology provides both the impetus and the means for a dramatic gain in our ability to cope with a serious disease. So it is with venous thromboembolism. The recent renewal of interest in this familiar problem can be traced largely to the development of improved diagnostic methods. Sensitive and objective techniques now available have led to an appreciation of the prevalence of thromboembolism complicating the postoperative state and occurring in nonoperative patients; they have provided increased understanding of the natural history of the disorder; they have underscored the insensitivity and unreliability of diagnosis when based solely on clinical criteria, and they have afforded investigators a means of generating solid data in studies of prevention or treatment. Radiographic phlebography and scanning of the lower limbs for uptake of labeled fibrinogen have been particularly influential. The former procedure is at present regarded as the ultimate standard for showing the presence of venous thrombosis in the lower extremities of living patients, when carried out by modern techniques."2 Although invasive and not without morbidity, it is superior even to routine autopsy in its sensitivity. The latter method, available for general use now that 1251-labeled fibrinogen is commercially dis-
220
SEPTEMBER 1976 * 125 * 3
-MSMW REFERENCE 1. Trends Affecting U.S. Health Care System. Commissioned by DHEW and prepared by the Cambridge Research Institute. DHEW Publication No. HRA 76-14503. Washington, DC, Government Printing Office, Jan 1976
