Reining in Costs

The recent economic woes of the U.S. government, the midnight hour in raising the debt ceiling, the downgrade of U.S. credit, and the political complexity of fiscal policy-making reminds us that along with social security, health-care expenditures will need to change. Raising taxes for the wealthy, increasing revenues, and cutting costs elsewhere simply won't be sufficient. As health care consumes more and more of the GDP, it becomes more and more unsustainable and harder to change. The recent events remind us strongly that we need to act now to change the system. What frightens us is the idea of shifting the burden of healthcare costs from the government to individual families. Health - good health - is so expensive that no one can afford it: individuals, companies, and now not even the government.

I don't have great solutions to this problem, and I know little of health care economics. But I think we might have to start proposing the ugly words no one wants to hear. Is it time for rationing? I've written about this in the past and I'm sympathetic to the concept that health care should not be rationed - that it would be ideal not to have a limit on how much a patient can get. Who's to say which medications or surgeries or visits should be covered and for which patients? But now that we are stuck between a rock and a hard place, these ideas are going to resurface. It's time to become practical.

For example, what if I raised a highly controversial idea: changing the gestational age of premature infants who we resuscitate. Depending on the hospital, preterm infants around 23 weeks are the youngest to be resuscitated. If a woman delivers a fetus prior to 23 weeks, then the fetus is not resuscitated; if the gestational age crosses the threshold, then resuscitation can be pursued. Here are the statistics:
From this graph, newborns resuscitated at 22-23 weeks had a 73.8% chance of mortality within 28 days. Those that do survive are likely to have a lot of morbidity from such an early birth. Overall, these patients have some amount of cost to a system's resources. What if as an overall standard, we decided that premature infants before 24 (or 26 or 28) weeks not be resuscitated. This decision would in essence say that the costs of resuscitating infants before that gestational age outweigh the benefits, especially since pre-existing morbidity and mortality is so high.

Now I want to be clear: I'm not proposing or advocating this. It is fraught with moral and ethical issues. It doesn't take into account changing technologies that may allow more effective resuscitation and care of premature infants. It would stimulate outcries from mothers whose premature babies are doing wonderfully, and perhaps mothers whose premature babies are not. I'm hardly an expert in this subject; I haven't done pediatrics for two years. But I only raise this point to show that if we are to control costs, one possible approach is to identify populations of patients, medications, or interventions whose health care costs outweigh the benefits they reap. I apologize to anyone who may be offended by my example.

Image of neonatal mortality by gestational age 1995-1997 is shown under Fair Use, from UpToDate, adapted from Alexander et. al, Pediatrics 2003.