What Matters Most
The American Medical Association (AMA) among many medical societies recommend that we deliver value-based care. Value based care is defined as:
Much of the discussion today revolves around the denominator (bottom number of the equation) total cost of care. This includes interventions around transparency in pricing, insurance company overhead, predatory billing practices, and addressing outlier physicians. These interventions are important but are likely to impact less than 10% of healthcare expenditures. The actual cost of care (over 90% of healthcare costs) lies in the numerator (top number in the equation) outcomes that matter most. These are the everyday decisions of how we clinically manage medical care based on patient preferences and values. For example, an 80-year-old patient with torn rotator cuff would not benefit as much from shoulder surgery when compared to a teenager athlete.
The reason that we do not focus on the outcomes that matter most is nuanced and overly complex. It takes time and trust to discuss clear expectations for their medical care. Patients might receive conflicting recommendations from different doctors about their healthcare. Being able to foresee long-term improvements and complications is impossible and based on our best guesses. For example, knowing whose back pain will improve with surgery is like predicting the Bears to win the Superbowl before the season has started.
I remember my first run in with back pain. It was one of those blustery Chicago days and I was out shoveling snow. I slipped on ice and fell backwards. Adrenaline kicked in fast, and I was able to get up and finish the job. Three hours later, the pain began to hit. It was a throbbing ache, and I noted shooting pains all the way down my right leg. I could barely sleep that night. Getting around the next day was impossible. I begged my wife Rene to take me to the Emergency Room.
In the Emergency Room, I was surprised that the ER was treating me like the rest of the ‘back room’ patients. The nurse sent me to a non-emergent room. They gave me a muscle relaxant and X-Ray and told me that I should be okay. I wanted an MRI, and I wanted to see the pinched nerve so the surgeon could fix it. I was certain I would be back in a week with the pain not improved. Luckily, the pain did slowly improve, and I was able to see my primary doctor the next week. He showed me the X-Ray and sure enough I had a slipped disc in my lower spine.
The next step in this type of back pain is to undergo physical therapy to stretch the hamstrings and strengthen core muscles. Subsequently, the surgeon might recommend a laminectomy if the pain does not improve. A laminectomy is a surgery where they remove a part of the bone that is pinching on the nerve root. Most people feel better after the surgery. In the end the pain usually comes back. The total cost of the management is about $75,000. For the same $75,000, you can get a gym membership with a personal trainer, two weeklong vacations to an all-inclusive with massages FOR THE NEXT FIFTEEN YEARS. Which of these two choices would you opt for?
I opted for the third choice. I decided I needed to get into better shape. I am probably the last person to join a meal plan. They sent me a weekly box of single serve freeze-dried meals; I would just add water and viola’. I also joined a gym where my trainer stretched me 3 days a week and got me to start jogging to engage my core. I lost around twenty pounds and increased my endurance dramatically. Since then, I have completed a 200-mile segment of the Appalachian Trail and two sprint triathlons in just over 2 hours. The pain still flares up at times and I manage it with capsaicin cream, a small TENS unit and Ibuprofen. I might need around five muscle relaxants a year when the pain gets severe.
Fifteen years into this journey, I am an active scuba diver, mountain climber, skier, swimmer, and kayaker. The picture was taken this year and is of Rene zip lining and jumping into a Cenote in Mexico. And the journey all began with back pain.