Pricey medicine and its price

October 12, 2010 

— I always wonder when people will make the connection between the prices we pay for medical care and the fact that their health premiums continue to go up every year faster than inflation.

We celebrate the new heart center, the new speciality practices, the new drugs and technologies. But, in classic American fashion, at the same time many of us still complain bitterly about the skyrocketing cost of health insurance. And that, after all, is the way we pay for all this neat stuff, whether it works very well or not.

Pediatricians and family physicians, living in the cost-cutting world of primary care where actual salaries are unlikely to approach even half the size of the recently reported $335,000 pay raise for UNC Hospitals' sole heart transplant surgeon, are likely to look askance. And they should. We all say we value our family doctor and primary care as our most visible and important connection to our health system - but that value isn't reflected in the relative salaries we pay.

To be fair though, this isn't about UNC Hospitals. It's how we've set up the game of health care in our country. The heart surgeon's raise just highlights the major problems we face with the price of care.

Start with the way we train specialty physicians such as cardiac surgeons.

First we make it make it much more lucrative to go into speciality care than we do primary care. So people want to become specialists.

Then - unlike in most other countries - we expect our would-be doctors to go into debt, often hundreds of thousands of dollars' worth, just to get a medical education.

Finally we set up a reimbursement system that pays so much for speciality care and so much less for primary care and everyday care that large hospitals feel they must be able to deliver these speciality services in order to compete and stay in business.

The result is a $335,000 raise for a heart surgeon who, if he was operating on me, I'm sure is worth every penny. However, from the policy side of the equation, I deplore the health system we've set up where such disparities and payments exist.

The opportunity health reform brings us is for hospitals, doctors, insurers, patients and others in the health system to work together to reduce costs. It's worthwhile to note that the UNC Hospitals' CEO, Dr. Bill Roper, who approved this surgeon's raise, was and continues to be one of the most influential voices pushing for comprehensive health reform, including dealing with the way we pay for health care. However, as this example shows, even the most committed advocate for change faces daunting barriers that will make such changes enormously difficult.

It isn't going to be easy to reduce costs if health systems continue to feel they must outbid the competition for specialists when the amounts required are measured in multiples of $100,000.

What about other wealthy countries? We are at or near the top in what we pay our specialists. No surprise. Despite this, those other wealthy democracies are still delivering world-class care.

Yes, it's just as good as what we get here, so there's probably some leeway in the salaries we pay in our health system. However, we can't just focus on a cardiac surgeon.

We spend billions on drugs just because of the brand name - think Nexium - and billions more on new medical devices - think knee replacement - with little evidence they work any better than older models. Any discussion of medical costs has to include areas like this too, or the changes will never work.

In the end, this raise isn't at all about UNC Hospitals. It's about our responsibility as a nation to come together and address the difficult question of costs in our health system. We have the framework to do that thanks to our new health reform law. The rest is up to us.

Adam Searing is director of the N.C. Health Access Coalition, part of the N.C. Justice Center.

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