Staggering levels of health spending in U.S. could be curbed by more thoughtful care
A nurse helps a senior resident with exercises at her Denver home. A local nonprofit provides free home nursing care to patients with chronic diseases, with the aim of keeping patients them out of more expensive nursing homes.
In our Slow Medicine column, we aim to steer clear of discussions on cost. Still, patterns of health spending offer insights into our health care system, at least at a macro level. Today, we highlight a wonderful JAMA editorial by Dr. Ezekiel Emanuel — with whom we have often disagreed in the past — that describes where our health care dollars go, along with suggestions about how these dollars might be better spent. His ideas make a compelling case for the slow medicine philosophy.
First, it is important to appreciate the magnitude of health spending in the U.S. Emanuel writes:
In 2015, the United States spent roughly $3.2 trillion on health care. That is a staggering, almost unimaginable amount. Indeed, this level of spending makes the US health care system the fifth largest economy in the world, behind only the US, Chinese, Japanese, and German national economies. ... To put this into another context, in 2015, the entire US Department of Defense budget was just under $600 billion. In addition, the entire worldwide information technology sector (including hardware, software, data analytics, and customer-facing initiatives) accounted for $2.46 trillion ...
Emanuel’s piece refers to another JAMA article that explains where this spending goes. Not surprisingly, the largest piece of the pie covers care for the elderly, with the highest per-capita spending among women 85 years and older, at $30,000. And of the 14 most costly conditions, 10 are chronic diseases, such as diabetes, cancer and cirrhosis.
But perhaps even more noteworthy are the ways in which this spending fails to address the most important health challenges faced by patients. According to Emmanuel, the five most significant mismatches are:
1) Inefficient spending on behavioral health: Although behavioral health spending accounts for $187.8 billion annually and represents the fourth most expensive health care sector, patient outcomes are poor. Emanuel writes that treating behavioral health conditions like depression and anxiety “is often a haphazard process,” and “that only about one-third of all patients diagnosed with severe depression have seen a mental health professional in the last year, and only 20 percent of patients with moderate depression have seen a mental health professional in the last year.” As we have described in previous Slow Medicine posts, too often U.S. clinicians rely on expensive and modestly effective pills for managing behavioral health conditions that would respond at least as well — and with fewer side effects — to simple lifestyle therapies coupled with counseling.
2) Inefficient spending on physical pain: Again, pain represents one of the top spending categories, ranking third among health conditions at $87.6 billion annually, yet the value we get for this spending is inadequate. “Patients who want pain relief often undergo surgery, even when rest, physical therapy, and nonsurgical interventions would be equally effective. These decisions are also rarely well informed, as operations for back pain, knee and hip replacements, and other types of pain relief have significant variation in both cost and outcomes,” Emanuel writes. In other words, our failure to follow the slow medicine philosophy — involving a cautious, methodical approach to medical interventions — at the micro level appears to be driving inefficient spending at the macro level.
3) Misguided public health spending: While at first blush it might seem surprising to include public health expenditures in a discussion of wasteful spending, upon close inspection, there appears to be a mismatch in where public health dollars are directed compared to where they would do the most good. “Spending priorities for public health remain rooted in a time when infections were the primary health threat,” Emanuel writes. “Today, the top 5 conditions for public health spending are all communicable diseases [the single largest of which is] HIV/AIDS, at $3.52 billion, even though HIV/AIDS ranks 75th on the list of health spending ($4.8 billion) and was the cause of death for only 6,721 US residents in 2014 ... In 2013, HIV/AIDS was far down the list of common causes of death-well below suicides, motor vehicle crashes, and smoking.”
How might public health dollars be better directed? Many of our most important health challenges stem from chronic diseases related to obesity and unhealthy lifestyles. Though spending on the prevention of infectious conditions of course remains important, we believe a greater proportion of public health spending should focus on the simple “slow medicine” therapies that we frequently advocate for. Emanuel agrees, specifically calling for more programs aimed at “changing lifestyle conditions by emphasizing tobacco control, nutrition, exercise, suicide prevention, and substance abuse” as well as injury prevention. Such spending would better meet the needs of Americans.
4) Overspending on nursing care facilities: Almost a quarter of spending among adults over 65 occurs in nursing facilities, yet we know that these dollars frequently fail to deliver high value (see Atul Gawande’s book “Being Mortal”). Again, greater adoption of the “slow medicine” approach could both improve care and reduce spending. Specifically, we would advocate for a greater emphasis on clarifying patients’ care goals to ensure they end up receiving the services they most want, such as palliative care, or the ability to live at home rather than in a nursing facility, even if these decisions are not considered “safe” by others.
5) Overspending on pharmaceuticals for chronic conditions: A whopping 60 percent of all spending for patients with diabetes goes towards pharmaceuticals, and the same pattern is also seen for many other chronic conditions, like dyslipidemia and hypertension. Yet these chronic diseases are driven primarily by lifestyle factors, to which we often pay little attention. In our frenetic, intensive health care system, it is much easier to place Band-Aids over chronic diseases with medications rather than to address the underlying issues.
Looking at our health care system from the 30,000-foot perspective underscores many of concerns we frequently describe at the micro-level through the slow medicine lens. Too often we overuse complex, invasive, and expensive services for conditions that could be much better managed with a slower, more conservative, less aggressive, more thoughtful approach. Not only would the “slower” approach frequently lead to better outcomes for patients, but we also suspect it would help curb wasteful, low-value spending.
[Photo by John Moore/Getty Images]