Whatever it costs, it’s too much

There is an old Jewish joke [because there are no young Jewish jokes] in which a wife asks her husband if he would give her the moon. The husband immediately replies “of course”. The wife then asks the husband if he would give her the stars. The husband immediately replies “of course”. The wife then asks if the husband would give her the shirt off his back. Without delay, the husband says no. The stunned wife asks how it can be that the husband would give her the moon and the stars but not a simple shirt. The husband retorts “because a shirt, I actually have”.

I once heard a beautiful Dvar Torah on the meaning of giving a wife an article that is valued at a “pruta”, or basically the lowest possible monetary value which was available at the time of the ancient rabbis. It is with this nearly valueless item that the husband seals the accord with his new wife, such that they are now both bound by all of the rules and privileges of marriage. The ktuba, or prenuptial agreement, can speak to very significant sums of money in the event of a divorce. But this is a totally isolated feature in the marriage ceremony from the actual linkage that transforms the two individuals into a husband-and-wife.

The obvious question is how can any pact between man and woman be considered binding when it is valued at the equivalent of a penny. One would say that the very fact that such a low monetary value was assigned to this transaction, indicates the lack of seriousness of either side of the pact.

The response to this is beautiful. The ancient rabbis recognized that marriage has two components. One component is the romantic element. It is that component which we attribute to love and passion. When one looks at a young couple under the chupa, one is struck by their positive anxiety and excitement. They truly look like two Angels waiting to enter a new paradise. This, and the hors d’oeuvres, are the primary reasons people love to go to weddings. The second component of a marriage is a very emotionless, businesslike transaction that involves the agreement accepted by both regarding the responsibilities and benefits of the marriage. Taking on these responsibilities has nothing to do with the feelings of either member of the marriage. This could very well be a marriage of convenience which is devoid of any love. Nevertheless, the husband and wife exchange promises that may very well follow them for the rest of their lives. This part sounds quite unromantic, and truthfully, it is.

If the husband was to present to the wife an object that had any real value, it would be far too easy for the onlooking public to say that the husband values the wife according to the object presented. Therefore, if the husband gives the wife a beautiful chandelier, worth thousands of dollars, it would appear to everyone that this husband values his wife far more than another husband who gives his wife only a candlestick. Therefore, the rabbis decided that the universal value for the object being presented to the wife be of the lowest possible value. The fact that in most cases, the object is worth much more has no significance from a Jewish legal perspective. One could easily argue that the husband should always initially present the wife with a piece of string to wrap around her finger, to clearly indicate that there is no connection whatsoever between the value of the object and the meaningfulness  of the new connection between the husband and wife. The piece of string could then later be exchanged for a much more valuable wedding ring. But the actual marriage ceremony would be founded on nothing more than a piece of string and a promise to share the married couples lives together.

There is a similar concept when, G-d forbid, an individual passes away. Jewish law tries very hard to eliminate any distinctions at the time of burial. It seems that transformative moments, such as marriage and death, are seen as equalizing moments in Jewish law. I personally very much like this attitude and approach.

Why this long introduction? In a recent edition of the New England Journal of Medicine, two articles appear that have to do with measuring the value of health care. The first article is called “Value Based Cancer Care” and the second is called “The Value of Prescription Drugs”. It seems that even thousands of years after Jewish law dealt with the valuation of marriage and death, modern-day medicine is still dealing with the same issue in regards to medications and treatments.

A relatively recent example, brings this discussion to bear. Published studies found sofosbuvir (aka Sovaldi — the effective, but expensive hepatitis C drug) “acceptably” cost-effective (i.e., $50,000 to $100,000). The problem is that already strained health budgets cannot easily expand to accommodate several million Americans in need of the medication.

What does one do in this situation? The United States already has a national debt on the order of $19 trillion. From this perspective, what does it matter if one adds a couple of billion dollars more to it. Contrarily, add up enough of these billion-dollar programs, and they do start getting close to $1 trillion themselves. The ultimate question that gets asked in these scenarios is if it is appropriate to put a dollar value on the life of a person. Unfortunately, it is not only appropriate, but effectively, universal practice.

I know the case of a senior physician effectively demanding an upgrade to a basic service being provided in a health care center. His superiors informed him that the budget simply did not allow for such an upgrade. And to put things in perspective, this upgrade would have cost many tens of thousands of dollars – a very expensive proposition. Who’s right? The physician who is fighting for better medical care or the management that has to balance all the budgets so that the health care service does not go bankrupt? The appropriate answer is that compromises have to be made. Hopefully, both sides are focused on providing the best possible care within the real-life limitations that they face. If this is true, then the compromise really will be the best possible outcome for the patient.

This particular story is still even more complicated. Who decides that the more advanced upgrade will actually improve quality of care? Is this decision based on a single personal impression? Is it based on a study that was performed by the company that manufactures the upgrade? Even if there is an improvement in quality of care, will it be so small as to be not noticeable? And last but not least, what else will not get funded if money is directed towards this upgrade?

I want to slightly change the topic and discuss the valuation of physicians. It might sound a bit strange to put a price on the head of the doctor. Of course, the most obvious valuation of any physician is his or her salary. Their salary is meant to reflect, to some extent, their worth to the medical institution they work for. But what happens when one doctor uses a great many tests to evaluate a given set of patients, while another doctor uses very few tests to evaluate a similar set of patients? One could have a situation where the salary of the first doctor is significantly less than the salary of the second. Nevertheless, the first doctor ends up costing the healthcare system far more, because of all of the extra testing and procedures that he or she performs.

At my previous place of employment, I once designed a system that used all of the clinical data we had to value the entire performance of a physician. Without going into detail, we had a classic example of two doctors who differed dramatically in salary, tests done, rate of referral to the hospital and many other parameters. In the final analysis, the doctor who salary was literally twice that of the other doctor, cost the healthcare system far less than the cheaper doctor. This was a perfect example of how subtle and difficult it can be to place a price on health care.

The only way to truly dissect out the cost of every component and individual  within a healthcare system is to have data on every element of the health care. If a doctor takes longer to record the medical record on the computer, this translates into cost of care. If another doctor inappropriately sends home patients who will develop complications, this also translates into a higher cost of care. In this case, though, one has to follow the patients for an extended period of time to know the true cost.

Financial analytics will become a major area of interest in health care. In the past, there was very little oversight on medical care. If a doctor deemed that something was necessary, then it was done. This will not be the case in the future. And in order to determine what is the most appropriate type of care for each person, the financial aspects will have to be considered as well. Doctors are not accountants. More so, they often become insulted when the cost of their care is challenged. This attitude will have to change. The end result has to be the welfare of the patient. But unfortunately, there are a lot of egos and politics standing in the way. It will be a fight. But it will be a fight we have to win in order to keep health care affordable to all.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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