Taking care of sick patients that need to be hospitalized is what I do for a living. These days, I am known as a hospitalist, and business for professionals like me has never been better. When I see Medicare listed on a patients chart I see dollar signs. But the cost of my services is dwarfed by those of the subspecialists I work with. Medicare pays for all inpatient procedures and things like heart catheterizations, endoscopy, radiology, and surgeries pay big bucks. But what are we actually accomplishing with all of these expensive interventions? What is the return on investment? Most importantly though, if even the wealthiest individuals in the United States would not be able to pay for these services directly, how can we as a society afford them?
When I started my training just eight short years ago, it was not uncommon to see patients from the greatest generation in the hospital. Ninety plus year olds that fought the Nazis in World War II, lived through the depression, and pioneered the space age. I recall these patients saying things to me like, “don’t worry about me doc”, “I’ve lived a great life”, “go help some of these other people”, “Ill be fine”. I would answer, “Sir, you just have a pneumonia, we will get you some antibiotics and get you better”. The health of some of these people were amazing. “I found out smoking was bad in the 50s doc, so I quit”. Meanwhile, across the hall, a 65-year-old Vietnam Veteran with bad lungs, a bad heart, and bad kidneys wants “everything done”. These patients were often unwilling to quit smoking, would not change their diet, would not take the time to learn any of their medications, but yet, wanted “everything done”. Of course there were and are always plenty of exceptions. I thank both of these groups for their service to our country and understand the hard life Vietnam Veterans have faced following the war. None-the-less, the differences in health, philosophy, and teamwork between these two populations was striking to me.
The United States National debt was 23 trillion dollars at the start of 2020 (not including unfunded Medicare and Social Security promises). This is an absolutely unfathomable amount of money to even the most intelligent humans. Medicare costs almost 600 billion dollars a year. It is the second largest expense behind Social Security and makes up 14% of our national budget. Spending that, per above, we cannot afford. And that’s just Medicare. All of healthcare in the US costs our citizens almost 3 trillion dollars a year. On our current trajectory 1 out of every 3 US dollars will soon go towards healthcare. As someone who works in healthcare, I can tell you, our dollars are not well spent. A large proportion of the money goes to health insurance companies, pharmaceutical companies, or ends up lining the pockets of healthcare executives, three groups that are likely the biggest reason why healthcare costs have spiraled out of control.
However, if you want to know the real reason why healthcare costs have become so high, look in the mirror. The number of patients I have in the hospital that tell me they want “everything done” meaning whatever procedure, intervention, or life support is necessary, always astounds me. People who cannot even tell me where they are or what year it is, getting 100,000 USD surgeries. Saying things to me like “keep me alive doctor”, “whatever it takes”. Families also drive this, often kids that have been neglecting their parents for years, subconsciously trying to make things up to them, by recommending aggressive care. The number of demented patients that don’t even know what is really happening to them, that have millions of dollar’s worth of interventions done on them in the last few years of life is appalling, inhumane, and wasteful. The return on investment, on keeping elderly demented patients alive is negative from a society standpoint, and in my opinion selfish. I also believe that these patients and their families are spending money that, as a nation, we do not have. It is the equivalent of your grandparents taking you out to dinner, racking up a 500$ bill, and leaving the table when the check comes. All these older folks, “that want everything done” are going to die in the next few years or already have. Unfortunately, they are leaving a great deficit for all of us younger folks, to the tune of 20+ trillion dollars.
This all probably sounds very harsh, especially to the untrained individual that loves their grandparents and wants them to stay alive. But keep in mind that healthcare is one of the biggest killers on the block. Healthcare, meaning doctors, nurses, hospitals, pharmaceuticals, etc. kill almost a quarter of a million people a year. Only heart disease and cancer take more lives. People must understand that medications are toxic and have side effects. Surgeries and invasive procedure damage tissues, cause frequent complications, and kill people. At some age, for every individual, the risks of modern healthcare begin to outweigh the benefits. So even though my older patients want “everything done”, many of them are actually being harmed by this strategy. They would live longer and do better if they avoided aggressive interventions, medications, and especially hospitals all together. This is supported by some studies indicating that individuals on hospice tend to live longer than individuals who were offered hospice but declined in favor of continued aggressive care. Hospice is a program for people thought to have less than 6 months to live. It shifts the focus of care away from aggressive interventions and toward quality of life and comfort.
Adults older than 65 have access to expensive and aggressive interventions via Medicare, often to their own detriment. But what about the 20-year-old girl with depression. She needs one or two medicines, a therapist, an appointment with her doctor every 3 to 6 months, and a gym membership. Annually this might cost 5,000 USD a year. Moreover, the return on investment is tremendous. With managed depression, this young lady will be able to function at work and school. She can contribute to society potentially for the next 50 years. Sadly, resources offered to such an individual often do not even exist. Many young people have limited or no access to care. Those who do have access are paying 500 - 1000 USD a month for insurance. One inpatient procedure might provide enough revenue to care for 10 young patients with mental health problems for an entire year. We are always taught to prioritize the younger generations as they are our future. Right now we are dumping on the youth and giving our old and demented the inhumane care they and their families have asked for. Meanwhile a bunch of executives, insurance companies, pharmaceutical and device manufacturers are making ridiculous amounts of money. I believe that these individuals have and will continue to add complexity to our healthcare system. This complexity makes it harder to enter the playing field as well as harder to change things. This helps lock in profits for years to come.
As a young professional I see a lot of things that make me angry. The world that I am growing up in is not the world I would have created. I hear older Doctors tell me they hate things too, but wander why they continue to put up with it. It is time for myself, my colleagues and my generation to “be the change”.
Everything is so political these days. Healthcare, the national debt, and the environment are difficult to discuss without devolving into political non-sense. Our first president said something smart that makes a lot of sense to me now. Simply put, do not have a two party political system, it is by nature polarizing, pigeonholes ideologies, and keeps people from thinking with an open mind. As such, It is time for political parties to die so that we can all think logically and clearly. Anyone who has watched the news in the last 25 years, and likely for much longer, should have figured this out on their own. It is time for the older generations to stop spending immediately. You are leaving us youngsters with a bill we cannot afford. It is time for us to stop ruining the environment and our atmosphere. We cannot live and be healthy on a dead planet. I can assure everyone that pollution has changed the compositions of our atmosphere, poisoned our water, and has caused the extinction of numerous species. These things are a matter of urgency and have nothing to do with politics. In fact they have much more to do with health than politics. That is why I am addressing them here.
In conclusion, lets start prioritizing the younger generations. Lets shunt healthcare resources in their direction and away from older folks that can no longer benefit from aggressive care. Let start protecting our planet so our children and grandchildren can enjoy it, as we have. It is time for people to start doing the right thing. Our entire species may just depend on it.
Put even more simply, lets leave behind a better world for future generations!