Wednesday, July 18, 2012

Let's Look at Some Numbers

     Today a patient told me she went to the hospital last month, had some tests, spent a night, and was discharged.  This morning she got her Medicare statement in the mail:  $70,900.
     How can one night anywhere cost that much?  Wouldn't you imagine this might be the price to fly to the moon and back, if we had passenger spacecraft to take us?
     "Why did you go to the hospital?"  I asked her.  I always feel like a failure when patients go to the emergency room or get admitted.  My job as a family doctor is to be available to them so they won't need the ER, and I'm supposed to prevent the problems which require hospitalization.
     " I had chest pain and they ran that tube in me, but they couldn't put in a stent because the blood vessel was kinked, so they took it out."  She had had five stents placed many years ago.
     "Mama," her daughter corrected, "You know they put that dye in you too."
     "But why would any test with or without dye cost so much?"
     "I don't know," the patient said, shaking her head.
     "Beats me," her daughter chimed in.  "You doctors are expensive."
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     If a patient has an appointment with me and I recommend a stress test, chest x-ray, echo and some labs, the total cost will be around $375.  I'll get a lot of information that day.  I'll have a chance to do a complete physical with the patient in a gown, and I can ask a lot of questions.  Before the patient leaves I'll have a pretty good idea what that patient is likely to die from, too, and when, and how I might be able to prevent or postpone his death. (Family doctors, it has been shown, are better than actuaries at predicting life expectancy.) 
     At the next visit ($100) I'll go over the patient's lab test results, explain which lifestyle changes are a matter of survival, and prescribe medicines, herbs or vitamins, based on the patient's wishes and needs.  There will be plenty of time for questions, and the patient's personality and values  will become important factors in treatment.  It's unlikely that this patient will go to the hospital for anything.
                                             *                   *                    *
     Two months ago a sixty-year-old woman told me the following story.  She was about to undergo elective surgery, but developed breathing troubles and, diagnosed with congestive heart failure, spent a week in the hospital.  Lots of tests were done, and some IV medications were administered.  Her heart failure got better.  On the seventh day a CT scan was performed.  Afterward, doctor hastened to her hospital room and asked with great perturbation, "What's going on here?  You have a penis!"
     "Yes," she said.  "So what?"
     Turns out her elective surgery to be for a sex-change operation.  She had been living as a woman for forty years and had finally been able to afford the surgery to make her anatomy coincide with her self-identification as a woman. 
     "Didn't they do a physical exam when you arrived at the hospital?"  I asked her.
     A physical exam had been the sine qua non for hospital admission when I was in medical training.  Every square inch of a patient's body was supposed to be examined.  "A finger or scope in every orifice," was the instruction, and I never forgot it.  
     "No one ever touched me," she said.  
     I wonder what a physical exam is these days?  It must have changed since I was in medical school.
     "I hardly ever saw the doctor," she went on.  "At least that "cat-scan" brought him into the room!"-- and, mercifully, she laughed.
     Congestive heart failure is preventable.  When it occurs, it's easy to treat most patients in the outpatient office.  I have not had to send a patient to the hospital for heart failure in fifteen years.
     The cost for her heart failure week in the hospital?  $700,000.

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