MORE REFLECTIONS ON THE HEALTH
CARE DEBATE IN WASHINGTON
Dr. René Menguy
I am increasingly depressed by the realization that no one in Government appears to understand why health care has become so expensive
The bills being considered to solve a multi-facetted societal problem with social, moral, scientific, religious and economic considerations suggest that nobody has grasped its root cause.
Certain entities in Western civilizations resist change. Health care in our country is one. It has evolved in stops and spurts and lately, its evolution has accelerated to keep up with scientific progress,. It’s doing so because that’s the way we are; always striving to make things better. We can no more stop it or slow it down than we can reverse the Atomic Revolution. The genie is long out of the bottle
During the first half of the last century, a surgeon worked with his eyes, ears and his hands. He listened to a patient’s story, took notes, listened to sounds made by the heart and abdominal organs, collected information from X-rays when applicable and made a diagnosis based on his training. If appropriate, he operated. His tools: needles, silk thread or catgut, a good source of light and an assortment of forceps that would barely fill a briefcase. The bill: whatever he thought his time and skills were worth.
Until the late nineties, the treatment of a patient with a pancreatic cancer was as follows. If a CT scan or an MRI showed that it had spread, something would be done to relieve the symptoms. The cost: around $500. The patient would then receive chemotherapy for about 6 to 12 months.
On the other hand, if the imaging studies were negative, I’d perform a “Whipple procedure”. My cost: around $1800 from the local HMO. The 6-7 days of hospitalization, @ about $800. per diem, plus anesthesiologist’s fee and the use of the operating room brought the total cost to $9,000, for a potentially curative operation.
Today, a patient with an inoperable cancer might be treated with a “Cyberknife”, a machine capable of aiming a concentrated beam of ionizing radiation at a tumor. There are about 150 such machines in the world; a 100 of them in the US. The machine itself costs 3 million dollars. The bill for a treatment with it ranges from $50,000 to $100,000. The available clinical studies don’t show any survival benefit over previous therapeutic modalities. The late Patrick Swayze, who recently died of pancreatic cancer, was treated with a Cyberknife.
On the other hand, let’s assume that the work-up of a patient with a Pancreatic cancer indicates that the tumor is operable.
“That’s great news doc. Could you send me to that Dr. Rene something? Heard he does that Whipple operation.”
“Sorry, no can do. The guy’s retired to a beach in Florida. I’ll do you one better. I’m calling Dr. Sewgood. He does the Whipple operation with the Da Vinci robot.”
“That’s a wow. I’m so relieved.”
How quickly we’re forgotten. Anyway, this Da Vinci machine is a marvel to behold, which explains its 1.75 million dollar cost. The surgeon sits at a console, and looking through a 3-D camera, controls robotic arms introduced into the patient’s body through tiny openings. The arms carry instruments that cut and sew. Its use has penetrated all of general and specialty surgery. In 2007, the first robotic Whipple operation for pancreatic cancer considered “the most demanding” abdominal operation, was performed. In 2001, a surgeon in New York removed a woman’s gallbladder in Strasbourg, France.
Progress comes at high cost. The hospital costs, about $8,000 for a Da Vinci gallbladder, far exceed the $6,000 for a conventional cholecystectomy. The surgeon’s fee must also be factored in.
These two methodologies involve only a fraction of the medical care landscape. However, isn’t it worrisome that, despite their higher costs and lack of impact on outcomes, they’ve been widely adopted? Small wonder that the HMOs have not reduced medical care costs. Scientific progress is a Juggernaut against which Legislation is impotent. There is hope, however.
In 2006, an unmanned robot performed a cardiac operation on a 47 year old man. This successful event was a harbinger of the future. In another 10 to 20 years, robots will replace at least half the surgeons in existence. The training of those remaining will be shorter. Finally, health care will become more efficient and less expensive.
In the meantime, don’t even think about asking Surgery to give up its Da Vinci robots.