A surprisingly large amount of the world’s gross national product—approximately 5 percent—is spent in the U.S. healthcare system. This enormous amount of money, now in excess of the gross national product of France, has progressively increased from approximately $100 billion in 1960 to approximately $1.9 trillion in 2005. Engendered by costly new technology, a defensive response to adversarial litigation, unfunded government mandates, demographic pressure, and increasing patient expectations, healthcare cost inflation creates a substantial societal dilemma.
Some form of healthcare rationing often is the primary focus of governmental and market-force strategies to restrain escalating expenses. Such rationing is enforced by expanded managed care, diminished entitlement programs, stringent certificate of need regulations, diminution of end-of-life expenses and a rigorous economic physician credentialing process.
Alternatively, medical healthcare costs may be controlled by improving healthcare efficiency. Improved efficiency may be fostered by malpractice reform, increased outpatient care, the rigorous employment of economic factors of scale, and pursuit of less expensive yet effective healthcare modalities.
Many physicians perceive little incentive to decrease global healthcare costs because they lack appropriate healthcare cost information and are overburdened with regulatory requirements and bookkeeping details. Unfortunately, minimal physician involvement in healthcare cost containment strategies exacerbates cost escalation. The absence of the physician, arguably the most knowledgeable participant in the U.S. healthcare system, logically flaws progress toward appropriate cost restraints.
This unwelcome physician disconnection is reflected by the minimal attention that issues related to healthcare cost receive in medical literature. In neurosurgery, outcome analysis has focused upon mortality and morbidity rates and measurable physiological and radiographic parameters, neglecting healthcare cost parameters.
To assess such inattention, a review of English literature addressing standards of care in neurosurgery was done through PubMed for the years 1980–2005 (Figure 1). In the late 1990s there was a moderate increase of published articles focusing on this matter. Since the year 2000 there has been a substantial increase in the amount of activity concerning standards of care in neurosurgical publications. Nonetheless, articles containing such information constitute only a small percentage of the overall body of literature.
Further, a PubMed search using “costs in neurosurgery” as the keyword was performed upon worldwide neurosurgical literature between 1985 and 2005 (Figure 2). Among the 64,418 cited neurosurgical articles, neurosurgical costs were referenced in only 750 articles (0.85 percent). Between Jan. 1 and Nov. 1, 2005, only 35 of 2,676 neurosurgery papers discussed economic issues (1.3 percent). Other surgical subspecialties, while showing corresponding publication dynamics, were somewhat more sensitive to economic issues. For the same 20-year period, costs were mentioned 691 times in the 8,911 orthopedic articles (7 percent), and 3,325 times in the 126,379 cardiovascular articles (3 percent).
Using a more specific methodology, the 946 articles which appeared in the journal Neurosurgery between 1995 and 2003 were individually reviewed. Approximately 4 percent of these articles contained evidence of economic assessment in their outcome analysis. Twenty-five articles made some reference to work status and eight articles made diffuse qualitative remarks about economic issues, while seven articles mentioned outcome in dollar terms. Only one article compared different treatment modalities in terms of direct dollar costs and benefits.
As a relatively static number of neurosurgeons attempt to secure their place in an evolving and increasingly expensive American healthcare system, an improved knowledge of treatment costs is imperative. The paucity of economic assessment in published neurosurgical outcome data implies a disinterest in the custodianship of the nation’s healthcare dollar. A proactive, physician-led treatment assessment that routinely considers cost issues offers the best mechanism to protect patient welfare against ill-conceived, bureaucratically directed cost restraints.
Joe Sam Robinson III, Cemre Sevin, Konstantinos N. Fountas, MD, Carlos H. Feltes, MD, Leonidas G. Nikolakakos and Joe Sam Robinson Jr., MD, are in the Department of Neurosurgery, Medical Center of Central Georgia, School of Medicine, Mercer University, Macon, Ga.
For Further Information
• Ausman JI, Pawl RP: What neurosurgeons should do to succeed in tomorrow’s scientific and socioeconomic environment. Neurosurg Focus 12(4):Article 9, Epub 2002
• NHE Projections 2005–2015, www.cms.gov > Research, Statistics, Data and Systems > National Health Expenditure Data
• Pear, R: Health spending rises to 15% of economy, a record level. The New York Times January 9, 2004: 3.
• Report Estimates Health Care Cost Increase at $621 Billion Since 2000, USA. www.medicalnewstoday.com/medicalnews.php?newsid=19866
• Smith C, Cowan C, Sensenig A, Catlin A: Health spending growth slows in 2003. Health Affairs 24(1): 185–194, 2005
• United States Spends More on Health Care Than Any Other Country, www.newstarget.com/009839.html
• U.S. Health Care Costs Rise to 15.5 Percent of Gross Domestic Product, www.newstarget.com/z006015.html