Why is American health care so expensive?

Cuba has achieved a life expectancy approximately equivalent to the US, despite a long standing embargo on food and medical supplies and despite spending a small fraction of the amount of money per person on health care than we do. A Stanford social sciences researcher, Paul Drain, has studied Cuba's medical system and has identified a few factors that may be responsible for their success.  Cuba completely subsidizes medical training.  After high school, students who are interested in medical school and qualify for it attend 6 years of combined college and medical training, complete with a stipend for living expenses and then 3 years of postrgraduate training in primary care medicine.  Many do rural health residencies either before or after the postgraduate training. After becoming family practitioners, 35% of them do further specialty training and the rest remain primary care doctors.  There are many multi-specialty clinics which provide care in citi...

In the last year vitamin D has been making headlines. It is not a new vitamin. It was first synthesized in the 1920s and deficiency of the vitamin was known to be a cause of rickets, a bone deforming disease, associated with reduction of sun exposure with the movement to crowded living conditions with inadequate sun exposure during the industrial revolution. It is important in regulating absorption of calcium in the gut and deposition of calcium in bone as well as having a role in  supporting the immune system.  Vitamin D2 can be made by plants and was added to milk and cereals in order to prevent rickets in children starting in the late 1920s. Vitamin D is available in relatively small amounts in various foods, especially fatty fish and beef liver. Normally these food supplement the vitamin D made in the skin when we are exposed to certain wavelengths of sunlight.  Dark skinned people are less efficient at producing vitamin D from a given amount of sun exp...

Pending huge cuts in Medicare make headlines yearly.  “Doctors sweating bullets: Medicare spending due to be cut by 21%!”  In the medical rags we hear that “this year the cuts will really occur and then no doctor will provide care to patients on Medicare.” But then, sure as spring follows winter, the cuts are forestalled. Does this seem silly to anybody else? This week’s New England Journal has an article that addresses this problem clearly.  I read the article, written by Dr. Bruce Vladeck, as saying that we are stuck in a legislative bind with regard to medicare spending, both because we spend too much on medicare, mainly due to the fact that we overspend in general without adequately supporting primary care, and also due to rules we established years ago regulating overall expenditures for the Medicare program.  The rules were good, if a bit optimistic, and required that we curb overall outlay for Medicare year by year.  Each year that we...

Lately I have been attending various administration level functions at our hospital, as the doctor who has ideas about reducing costs.  I suspected, when I began rabble rousing, that the hospital administration would passively or even actively oppose open discussion of where money was being wasted, since most of that wasted money seemed to go directly into the hospital's accounts.  Apparently the hospital associations have been reading the writing on the wall for some time, and have realized that there will be cuts in their revenue. The administration was already interested in cost transparency when I began to push for it, and the CEO as well as members of the board have been very receptive to various ideas that would improve quality and efficiency, even to the point of considering options for providing a health care package to our whole community. In a meeting lately, a representative of the corporation that owns our hospital spoke, during a talk I gave, on the...

When I first started to the hear the mantra "the problem is fee for service" in the discussion of health care reform, I couldn't quite wrap my head around it.  What exactly did this mean?  I had worked for an HMO, received a salary, and now that I no longer work for a salary, and make money based on the amount of work I do, I feel more free to practice the way that works best for my patients, me, my family and my friends. Sure, higher performing systems like the Mayo Clinic work with salaried physicians, but doesn't that take away those physicians' incentives to provide the best service? The problem with fee for service is that the services for which I charge a fee are not the services which are of value to my patients.  What patients want, mostly, is good health with a minimum of time, effort and money spent to get it. What I charge them for is face to face time in the office.  What I spend most of my time doing is solving problems in a context tha...

This article, in the New England Journal, offers some truly innovative ways to deal with the fact that suing for medical malpractice rarely serves the purpose of compensating the injured party or improving the dysfunctional system or practitioner. I intend to propose an institutional "disclose and offer" option at the hospital where I work, since it seems unlikely that a better option will replace medical malpractice as it now exists, at least during my lifetime. Here is the article, in full, because it is all good: by Michelle M. Mello, J.D., Ph.D., and Thomas H. Gallagher, M.D. In February 2010, the Illinois Supreme Court ruled that the state’s cap on noneconomic damages in medical malpractice cases violated the Illinois constitution. 1 This development has contributed to growing pessimism about traditional approaches to medical liability reform. In some quarters, interest is shifting to innovative reforms that can be implemented by health care institution...

Who would have thought that the Journal of the AMA would be an agent of positive social change? The AMA has, for me, symbolized the most frighteningly powerful aspects of organized medicine, and its trade journal, the JAMA has been one of the big 3 (with the New England Journal and the Annals of Internal Medicine) vehicles for presentation of relevant cutting edge clinical research. But since health care reform has been in the news the JAMA has offered many well considered opinion articles about how best to make American medicine serve the people. The lead article this week presented research in the area of surgical treatment for spinal stenosis.  Spinal stenosis is a common and disabling subset of what people think of as "a nerve pinched in my back".  Patients with spinal stenosis have bony growth or disc protrusion into their spinal canal in such a way that the spinal cord is crowded, leading to pain down a leg, or both legs, with exertion or in certain postures.  It ...