Central to the discussion of health care in the United States is the difference between preventative care — which some have come to refer to as “health care” — the care that maintains you in a state of health (bear with me) and sickness care — the care you receive when you are already sick or dying. These are different things and central to the argument about the relative quality of the United States’ healthcare model and the cost to reward inherent in that model.
If you are sick and dying, the USA is the bee’s knees. As I am unaware of any international readership, if you are reading these words — if you even had the opportunity to read the title of this essay and decide it was another one that didn’t interest you, then you are already in the best place on earth to be actively dying.
It’s like a Price is Right prize…
“We’ll send you, and as many as six family and friends at any given time, to a luxury room in the ultra-modern, aseptic and welcoming St. Sebastian Hospital Inn and Resort, where you will be treated as our VIP guest for world class amenities, delivered around-the-clock for up to months on end! Our courteous, expert and professionally-trained staff will soothe your savage beast with bed baths, tube feedings and routine IV-site location changes — delivering you medications unavailable to 2/3 of the people on the planet! You’ll be our guest as we use technologies such as the Arctic Sun — which is sure to keep your precious organs at a a brain-saving 91.4 degrees Fahrenheit, while we pamper you with only the finest Made-in-America Demerol and your airway is treated to the most advanced ventilatory support known to mankind! Our staff will be available to meet you, and your family’s needs, 24 hours per day, 7 days per week — 365 days per year! All this can be yours, if the Price is Right!!”
Damn. That sounds like a pretty sweet deal!
This is the American healthcare model. You are left to your own devices right up until you check into the. St. Sebastian Hospital Inn and Resort, your first myocardial infarction behind you, the stent in your left anterior descending artery still fresh, or the sternotomy scar spanning down the center of your chest, still hidden under the patchwork of gauze and tape. The American healthcare model (I thought we were going to call this sickness care?) is profit-driven and relies on this type of care for those profits. The cost of your stay at St. Sebastian Hospital Inn and Resort for your coronary artery bypass graft surgery (CABG) is going to be north of $100k. Dr. Chris Lillis, writing for Doctors for America in 2010, put the cost between $65k and $162k. http://www.drsforamerica.org/blog/sticker-shock-740
Costhelper.com details the cost of heart surgery as $70–200k+, and heart valve surgery to be even greater, at $80–200k+. http://health.costhelper.com/heart-surgery.html.
CABG surgery requires the surgical team to open your chest with a sternotomy and to re-plumb the arteries providing your heart itself with oxygenated blood and conveniently, these arteries are on the exterior surface of the heart. Valvular surgeries are more involved and require the surgeon to actually enter the heart itself. Thus the greater cost.
The American model is built on these Hail Mary procedures to save lives. The American model relies on extremely expensive, emergency surgery and costly medications after a person is already ill. Our model relies on sick people receiving daily medications for the remainder of their already poor quality lives. If you are actively dying, the US and A is THE PLACE TO BE! We’ve got #1 locked up in this regard — globally! But we balance our global status as #1 in emergent, critical care with a total quality ranking south of 30th place, despite the exorbitant costs associated with our model.
Is it possible to both save healthcare dollars while actually delivering on the promise to provide health to the people? Can the health of a population be improved at the same time the cost to achieve that end is reduced?
Forbes.com stacked the USA model against several comparable first-world, industrial-powerhouses and found us to be dead last. http://www.forbes.com/sites/danmunro/2014/06/16/u-s-healthcare-ranked-dead-last-compared-to-10-other-countries/#5340edcb1b96. The World Health Organization places the United States in 37th place globally in total healthcare quality, and #1 — by a long margin, in total cost, as well as cost-per-unit (cost per person). The WHO describes one of their primary measures of a healthcare system as how well it contributes to the overall health of the people it serves, as measured by the actual health of those people. The US was 53rd, behind both Canada and Cuba on our continent alone. http://www.who.int/whr/2000/media_centre/press_release/en/
We’ve all met obese doctors and nurses who smoke and live on fried food. They exist, to be sure. I’ve even met several obese cardiologists. But, there are also many who walk the walk.
While waiting on my 4Runner to be serviced, I walked to City Brew to burn what I fully expected may amount to an entire day and happened upon a cardiologist I’d worked with in my first job as an RN. He’s since retired from that job and moved along to other endeavors. Dr. Ed Dean was always a physician who walked the walk. He penned a 15-page handout that was to be provided as part of his patients’ discharge instructions and was known to a fearless lecturer of patients and counselor of staff. This “how to” bible went into detail about the diet and lifestyle modifications his patients needed to pursue if they didn’t want to remain his patient on a recurring basis.
A central truth of the American healthcare model is that cardiac patients are growing in number. If you lecture one with the hard truths of their situation, they grow angry and never return, that patient will be replaced by two others. This is philosophically true, if not mathematically correct.
Dr. Dean and I spoke for almost an hour on his retirement project, ichangebillings.com. His project is an integrated diet, health and lifestyle website intended to support visitors in a state of health by bringing all of the necessary concepts, tools and ideas into a single electronic location. A man who had undoubtedly earned a very comfortable living while treating the sick and dying, is endeavoring to keep those people healthy and out of the hospital in the first place.
I told the good doctor that he was on to something, and that I was extremely interested in his cause. Having recently blown a job interview for a position I’d been (lusting may actually be the right word) for, I’ve since worked on my pitch. I jumped into the conversation and told Ed that I was a Board-Certified Cardiovascular Registered Nurse, a Progressive Care Certified Nurse, a Certified Heart Failure Nurse who holds the Certified Strength and Conditioning Specialist credential from the National Strength and Conditioning Association who just happens to be graduating with a Doctorate of Nursing Practice in May and that I would be interested in helping if he ever needed it.
I was on a roll and kept going.
Continuing, (and probably shouting by this point) I added that American disease is not something that can be helped or cured by you as an interventional cardiologist. The more education I get, the more I realize that it is a public health crisis, that can only be solved by diet and exercise — writ large upon the population, not stents delivered onesy-twosy in a cath lab.
We shared a brief eureka! moment and swapped phone numbers.
People say that gym membership and eating healthy food is too expensive. Remember when we talked about that $100k+ surgical procedure above? How much does a gym membership cost? How about healthy food?
Let’s do some math. I hate math. Not my forte. Here we go…
We’re going to do this with everything measured in “premium” units, just to see how the most expensive options may compare to the heart surgery.
The most expensive Crossfit gym that has had to tolerate me as a member, was $140/month. Ouch. That hurt, I won’t lie. Now, if I were a member of that gym for 60 years, from age 20 through age 80, I would pay a total of $100,800 in total membership dues. That gets us near the heart surgery. Also, let’s say that we have to spend $200 extra per month for healthy food, so we’ll only total the difference between junk food and healthy food (you are going to have to eat something) and we’ll only account for the difference. Ouch, that stung. $144k. Diet and exercise has us at $244,800. I think diet and exercise are going to lose, aren’t they?
Wait, what about the daily medications you aren’t going to be on if you are healthy? Uh, oh. That just changed the game. By a lot. Miles, fact.
If you’re having heart surgery, you’re going to be on a cholesterol-inhibiting statin drug for the rest of your life. Atorvastatin, generic Lipitor, is ~$160/month. If you’re on a statin, you’re going to need an ACE-inhibitor as well, you know? Oh, good. Lisinopril is only $30/month. What about a beta blocker? That is standard therapy for a heart patient. Carvedilol is ~$70 month. Regular trips to see your cardiologist to see how the new plumbing is doing? Let’s just call that $1k/year. Is that fair? For 20 years. We’ll say you get the bypass at age 60 and live to be 80, though that is a generous life expectancy for anyone who’s had a bypass.
Was anyone keeping a running tally?
20 years of Atovastatin is $38.4k
20 years of Carvedilol is $16.8k
20 years of Lisinopril is $7.2k
20 years of cardiology service is $20k
The CABG itself was at least $100k, but could have been $200k+
These are very, very conservative estimates. Most heart patients are on more medications than these and they tend to be repeat customers. Twenty years as a heart patient will cost at least $182.4k, if you get the CABG at a cut-rate $100k and you didn’t require any emergency care to get from your living room to the operating room.
If the CABG cost $200k, and you had to be life-flighted from your farm in rural Montana, then the surgery suddenly cost half a million dollars.
But I suck at math.
Adopting a healthy diet and engaging in regular exercise provide rewards outside of your checkbook. There is a concept that insurers and the healthcare industry don’t like to talk about called the “Quality-Adjusted Life Year”, or QALY. If we define a year in perfect health as 1, and say that a year spent living with NYHA Class IV heart failure is only half as good as that perfect year, which would be generous (I’ve been generous all over the place to show that, even given the cheapest, best-case scenario of some of these diseases and what it takes to treat them, they still compare very poorly to expensive diet and exercise), then we can say that each year spent living sick is “less” than a year living healthy. Sick people often have this look on their faces like they’d want to die, but can’t or won’t. These aren’t quality years.
If you didn’t pull out the “Wrap it Up Box” already, I’ll do it for you. https://vimeo.com/138475766.
A life lived healthy, caring for yourself with diet and exercise will be longer, and as I’ve tried to argue, fiscally conservative. All those countries that outperform our healthcare model have well-developed primary and preventative care. They do the things that keep their citizens out of the cath lab and away from Dr. Dean’s stents.
Grab the apple, put down that Twinkie, drive past McDonald’s and find Beartooth Crossfit across the street. Surf the web, find ichangebillings.com and get to work on yourself. Our professional staff will be waiting to pamper you with amenities such as a squat rack, barbells, kettlebells, loud music…
***This blog has not been approved for weak-minded idiots***