Got a cite on the end of life care thing?

The culprits I understand are:

1) Higher prices across the board - meaning drugs cost more, doctors get paid more, procedures cost more. Some of this is difficult to address (it's not so easily to just pay doctors less in a country with high income inequality, you'll get less doctors) and some of it is because the government doesn't have the power to drive down costs that it does in other countries.

2) Administrative costs. For example, How Large a Burden are Administrative Costs in Health Care?

A 2011 study found that 39% of the cost difference between Canadian and US hospitals were administrative. A 2014 study likewise found that hospitals in the US spent twice as much on administration as in countries like England. This is because of the complexity of the US system. For example:

And the work done by staffers may be an underestimate, as many doctors shoulder this burden themselves. For example:

Getting costs down in the short-term is one thing, but due to increasing medical advancements the rising costs will continue to eat up an ever larger share of GDP until increasing expenditures becomes untenable. The U.S. might hit that threshold first sans any changes, but others will soon follow.

OK? Like, agreed, more or less. So what? That's definitely not in the picture as a major explanation of why the US spends so much more right now (though it probably is a minor factor).

The very first study you cite has numbers like this:

39% of 1589 difference, ~650, which is less than 10% of $7,290 per capital overall spending.

What the study doesn't say is a lot of US administrative expense is due to overlapping state and federal regulations. The higher level top down view is just that US spends ~5-10% (depending on how exactly you define and what datasets you use) of healthcare spending on administration. Even the most expansive definitions would put the figure at ~15% at most. Even if you completely eliminated admin expense (not possible), it still would only chip away 5-10% (not using the most expansive definitions that would make the number ~15%)... or ~12% to 20% of the difference between where we should be (on the plotted straight line) and where we are. If you just brought it to the 3-5% typical of other countries, we're looking at ~9%-12% of the difference eliminated, and that's without adjusting for America's totally bonkers healthcare/insurance reg regime.

Those anecdotes are nice but they are no replacements for actual numbers. Of course, doctors will tell you they want to spend more time with patients. Those are billable hours whereas admin hours are not. I'd be particularly dubious of surveys conducted in the last 5 or 6 years. CMS is in the midst of a massive drive to push EHR out and a lot of doctors are resisting the modernization efforts.*see footnote

If you purely focus on admin costs, you can probably bring the US back in line (or very close to it) just by eliminating the carve-out to allow states to regulate insurance companies and regulating healthcare/insurance companies only on the federal level. It would basically eliminate more than half of the insurance companies' compliance office within a year or two.

*Funny story. VA, by virtue of being biggest system and by virtue of the fact it operates under its own rules (bypassing a lot of state regs) and by virtue of it being by far the largest system without a research arm attached, actually got an open source standard for EHR (VistA) that was getting rapid industry acceptance then DoD decided to pick up Cerner, eventually forcing the VA to adopt Cerner too. The VA/DOD basically went from free (nearly on the margins) internally developed open standard to what's now destined to be something close to a monopoly in healthcare EHR. **** like this is why I am suspicious of government's ability to control costs.

Agreed that administrative costs aren't some kind of magic wand. I'd expect you could achieve something on the order of a 10% reduction, generously, in overall spending by cutting administrative costs. It doesn't sound like you disagree that the problem there is "complexity", broadly speaking.

I'm not an expert and haven't looked through studies but my suspicion is that the cost of administration is underestimated if anything, simply because it's so difficult to quantify. Take doctors who do a lot of their own administration, for example. How are you going to quantify that?

It's just not that much. For an old project, almost 10 years ago (7? 8? I really don't remember), because I wanted in on the EHR money (CMS and some states were offering money to doctors to get EHR), I literally followed doctors around to figure out what they did every minute. They consistently overestimated the amount of time spent on admin, and by a lot.

A very typical overestimation is they universally counted the time dictating while walking to the next exam room as admin time. But that's bogus because they have to walk anyway. They also almost universally insisted some of the time spent with patients is inputting forms but in practice, all the experienced doctors are typing as they speak and waste very little time on forms. And to the extent time could be saved, it was more just "here is a standard list of questions you should let your nurse ask before you even see the patient."

The venture didn't take off because after we gathered data on how much time we could realistically save the doctors vs. what they think they could save had such a huge divergence we decided it would have been too difficult and expensive to get a viable product out that could scale before the field got flooded.

We get VA patients transferred daily to us because they can't handle any number of problems, especially after 5p or on a weekend (topic for another rant, I suppose) - and the patient invariably arrives with their entire medical record printed out. This sounds good, but it's actually a ginormous pain in the nuts - I'll accept a guy with a bleeding ulcer spewing blood all over the floor because the VA can't hire any GI docs to work past 4pm, and I have to page through a ****ing phone book that includes notes about the time he sprained his dick jacking off too hard in 1971. And as far as I can tell, they have some technique for assembling the pages completely at random, so you get to play find the ****ing current problem every goddam time. They DO manage to keep their patients medications up to date, assuming you can find the current list, which is very helpful.

It's actually hilarious, as long as I'm not trying to save some guys life.

MM MD

We looked at this a few years ago because we were going to a scribe system (another ****storm entirely) and we paid some premeds to follow us around and figure out how much time we actually spent on patient care vs. other stuff.

On average, in the main department, I spent 9 minutes actually talking to/examining/reviewing results/explaining plans/giving discharge instructions to a patient. I spent about 15 minutes ordering stuff, talking with consultants, reviewing results, and preparing the medical record. We use a voice activated system (which sucks) and I averaged four to five minutes dictating per patient. (I don't use scribes, for a bunch of reasons, but I'm not against them)

I see 16-18 patients a shift - the rest of my time is spent drinking coffee, taking a leak afterwards, staring into space, discussing the occasional difficult case with my partners, teaching residents/students, and interacting with nurses.

We don't do our own billing - we pay (a lot)_ for a company to do it. As I understand it, a large portion of admin expenses lies in the fact that you have to deal with multiple insurers, with multiple forms/requirements, all with different paperwork/computer systems. This stuff probably shouldn't be done by doctors anyway - Gets pricey, for obvious reasons - it's insanely inefficient.

MM MD

I'm not an expert and haven't looked through studies but my suspicion is that the cost of administration is underestimated if anything, simply because it's so difficult to quantify. Take doctors who do a lot of their own administration, for example. How are you going to quantify that?[/QUOTE]

There are all sorts of admin costs that aren't obvious from the outside.

I was chief of my group for 8 years. I got paid 60 hours a month (by my group) at our going rate to handle all sorts of admin stuff - interfacing with the hospital, dealing with problems/concerns with other departments, occasional patient/doctor complaints.Had to show up at hospital and health system board meetings on a regular basis, and prepare for those meetings. I had about 15 hours of meetings a month dealing with quality and similar stuff that the hospital wanted me at (and those meetings are required for the hospital to do, if they want to keep their permit to operate from the state). I did a fair amount of media stuff for the hospital, and we had some bad stuff occur in our area while I was chief, so I was on TV a lot (a lot of you probably saw me)

Etc. etc. - this stuff has to be done by someone (for either political or statutory reasons)

MM MD