Medical schools are the intellectual fountains from which the POEM assumptions spring forth. For a variety of reasons they are dominated by ologists and most have blatant anti-family medicine cultures. The bank accounts of the medical schools are filled by fear. The more medical schools can scare people into believing a long list of dreaded diseases is lurking in the shadows and for just a few more dollars their professors will find a cure, the more dollars pour in from donors and state and federal governments.
Hospitals are the single largest cost category in healthcare, about one-third of all costs. They are big and complicated and live in a very complicated regulatory and financial world.
Hospitals tend to be well-supported local institutions, particularly the non-profits. In the competition between hospitals and managed care insurance companies in the 1990s, the hospitals won. Partly as a result, bed costs per day in American hospitals may be three times as expensive per day as some European hospitals: $1,850 per day vs. $653 per day in 1999.
In fairness to the hospitals, their general revenues have to cover a lot of costs such as bureaucratic unfunded mandates and all the uninsured patients who show up at their ERs. As a result, hospital charges are like Pentagon charges. The charge their allowed to bill have little to do with the actual cost of providing the service.
The two most overriding ways hospital contribute to expensive healthcare is that 1) they aren’t rewarded for being efficient by keeping people out of the hospital, and more important 2) they are incentivized to buy and charge more for the latest expensive technologies.
THE AMERICAN MEDICAL ASSOCIATION AND THE OLOGISTS
The American Medical Association has only about 15% of the U.S. physicians as members, but it is still the leading voice of all physicians to the rest of the country. Its first problem is its House of Delegates is about 80% ologists, which is why if there are ever times when the needs of primary care conflicts with ologist care, ologist care wins.
My primary gripe with the AMA is it has done nothing to acknowledge the role doctors play in driving up healthcare costs. It develops policies under the assumption that doctors should order all tests and treatments they feel are “medically necessary” with no restrictions based on costs or other societal needs. The AMA essentially assumes health only comes from the formal healthcare system and doesn’t recognize that other aspects of society contribute to health. The AMA has not fostered a discussion with the rest of America on what the role of the healthcare system should be balanced against other societal needs.
NON-PROFIT DISEASE ADVOCACY GROUPS
Yes, I’m talking about groups such as the American Cancer Society, the American Heart Association, and others. These well-meaning groups contribute to expensive healthcare in their single-minded pursuit of fighting their target diseases. Like the AMA, I don’t see them sponsoring discussions on limits of testing or treating diseases (At what point does chemotherapy become to expensive to justify?, for example). I see them typically scaring people into donating more money to their organizations, because we’re this close to a cure.
Is there a disease it’s acceptable to die of that doesn’t need to be fought with fundraisers, 5Ks, t-shirts, and ribbons?