The Cost of Dying, 60 Minutes, November 22, 2009

60 Minutes presented an outstanding program that tells the story in human terms about how our country manages to waste so much money while not properly caring for those we love at the end of life. If you missed the program, take 14 minutes of your time to watch this outstanding piece of excellent TV journalism.

The Cost of Dying, CBS TV 60 Minutes, November 22, 2009

$ The cost of Health Care reform

You've probably heard it said by critics that health reform will cost taxpayers at least a trillion dollars. This sounds scary, which is the intent of the critics, but it turns out not to be true!

The quoted figure is not a trillion dollars a year, but rather a trillion dollars over 10 years. On a yearly basis, the cost equals approximately $140 billion dollars. To put this in perspective, the Part D Medicare Drug plan passed during the Bush presidency is about 600 billion dollars for drugs alone.

$140 billion dollars a year still overstates the cost, however. That is because other parts of the reform plan result in savings for Medicare, such as the reduction of subsidies to private insurers, reform of payment rates for doctors and a decrease in payments to hospitals for providing "free care" to the uninsured. When all of this is taken into account, the net increase in government spending for health care will likely be about $100 billion a year, which is a one-time increase equal to less than 1 percent of US national income, which has historically grown at an average annual rate of 2.5 percent every year.

While criticizing, right wing critics have stood against ideas to improve care and lower costs. For example, a plan to fund research which gives doctors, patients and health plans better information on what works and what doesn't, Republican critics have claimed a sinister plot to have the government decide what treatments you will get. Using this kind of perverted logic, a proposal that Medicare pay for counseling on end-of-life care is transformed into a secret plan for mass euthanasia of the elderly. There are many other examples.

Please, don't take hysterical criticism at face value. The truth is more complicated, but also reassuring.

The need has never been greater

My grandfather was a physician in general practice at the beginning of the last century, before the Flexner Report revolutionized medical training and brought medical education into the scientific age. His office was in the bottom of the family home. My grandmother would open the door, folks would come in, and the agenda was whatever was on the mind of the person who came. There was no phone interuption (there were no phones!), record keeping was easy (20 years on one 3 by 5 card), and most modern therapies had not yet been invented.

Today, many physicians in primary care continue to practice in the same basic style as my grandfather. They wait in their office to see what comes, and are only paid for this visit "piece work". It is as if the telephone was never invented, much less the Internet! They do not manage their patient panel in such a way as to improve their overall care, because they do not have the tools to know how the group is doing, and indeed, they may not even have thought about it.

Recently, Dr. Kevin Grumbach, professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, has renewed the call for a thorough "Revitalization of Primary Care". He correctly notes that the traditional model of primary care has not been very well supported by payers, purchasers or government agencies, and that people are turning away from it. In a recent article, he is quoted as saying, "This model of 19th-century practice -- of the doctor in the office and patients coming in -- is not going to work in the 21st century. We have come to the proverbial fork in the road." He identifies physician payment reform as one of the first steps we must take in revitalizing primary care, to provide the personal medical home. This is the work that we have been engaged in at Family Care Network.

Dr. Grumbach notes that the worsening shortage of primary care physicians is fueling "medical homelessness," which leaves patients without adequate access to primary care services and patient-centered medical homes. This is particularly tragic, since the ratio of primary care doctors to the population is the only statistic that has ever been shown to correlate with both improved health care quality and decreased cost of care. We must change now. The need has never been greater.