Why is American health care so expensive?

I have been working almost exclusively in hospitals for the last 17 months and I often get a chance to rub shoulders with the 1%, that is to say the people whose poor health puts them in the position to spend more healthcare dollars than the other 99% of the US population. At the opening speech of the American College of Physicians annual meeting a few weeks ago Ezekial Emmanuel, an adviser to the US Office of Management and Budget and head of the department of Medical Ethics and Health Policy at the University of Pennsylvania gave some interesting statistics. In the United States, 1% of patients at the highest level of medical spending are responsible for 22% of healthcare costs and the bottom 50% of healthcare utilizers use a little over 3%. I looked at the article , from the Agency for Healthcare Research and Quality, and found that this percentage is relatively stable over many years, and, in fact, the costs are slightly less concentrated in the upper 1% than they were in 1996....

I first picked up an ultrasound transducer 17 months ago, at Vicki Noble MD's emergency medicine ultrasound course at Harvard University. I had just barely heard about using ultrasound as a clinical tool and was vaguely interested. The course was 3 days long and cost a little under $700 and changed my life forever and made me a better doctor. Emergency physicians have embraced the use of ultrasound at the bedside for many years and the vast majority of physicians who complete emergency medicine residencies are competent in using ultrasound for procedures and diagnosis. In bedside ultrasound, the doctor who examines the patient also does the ultrasound, often with a small portable machine, checking out the heart, lungs and other internal organs as part of the physical exam.  Internal medicine physicians have been very slow to pick up this technology, probably mostly because the equipment has been a little too large to be convenient and training to wield the probe and interpret t...

The American College of Physicians is an organization of internal medicine doctors, about 133,000 of us, which had its inception in 1915 with the aim of promoting the science and practice of medicine. It is the second largest doctors’ group in the United States, and has members and chapters  throughout the world.  The college has representation in the American Medical Association and influences government health policy.   The ACP had its annual meeting this year in San Francisco, which is a wonderful place. It was located at the Moscone Center, a big convention hall with gorgeous architecture, and the weather was spectacular. It was right near Chinatown, so I didn't have to eat the overpriced pastries and coffee from the convention vendors, or sell my soul to the devil by eating what the industry sponsors supplied in the hall of evil advertisers.  I went this year because I was receiving my fellowship in the college. If an internist has been doing me...

Medicare has been costing the government a scary amount of money for many years, and the very popular program, established in 1965 under President Lyndon Johnson to pay for health care for seniors, has undergone many changes since its inception. Because the government funded program was a very deep pocket from which the sick could pay hospitals and doctors, it influenced the cost of medicine and the volume of health care in a pretty profound way. In 1983 Medicare began to pay hospitals for care of patients in a way that was felt to be likely to reduce unnecessary and expensive care. This was the Inpatient Prospective Payment System, the IPPS.  Instead of paying a hospital for everything that was done to a particular patient, which would potentially encourage higher costs and higher utilization of services, Medicare began to pay hospitals a certain amount for each kind of sickness. These categories of sickness were called Diagnostic Related Groups (DRGs). If a patient had a part...

I know what I want, in healthcare, that is. I want it to be efficient, effective, thoughtful and inexpensive. I want it to create healthy people who don't need very much health care. I want it to involve elegant solutions to problems that take less time, money and effort. I want it to be so much easier and less expensive that taking care of all of our people uses even less resources than taking care of only some of them, as we do now. But the healthcare industry in America is bigger than me, and bigger than all of the doctors who work in it, even if we could all agree on what we want. So what does it want? Is it even reasonable to think about healthcare as an entity? I propose that it is, that this way of looking at it makes the direction it has taken much more understandable. We observe that bureaucracies grow, even though we complain about how they should shrink and become more efficient. Agencies beget more agencies, and attempts to reduce bureaucracies often don't w...

My son, who is 19, wanted a nice jacket and his genome for Christmas this year. He had found out that a company called 23andMe  would tell him about his genetic susceptibility for diseases and his ancestry for only $99. 23andMe is a private company that started doing direct to consumer genetic testing in 2007 and has progressively lowered their prices and increased the amount and sophistication of information they give clients since then. My sister bought my son the genetic kit and the padded envelope was under the tree for him on December 25th. He opened up the little plastic tube inside, spit in it and sent it back. In a couple of months he had all sorts of interesting information. He was most interested to see what parts of the world his ancestors sprang from, but also got information about scads of other things including his sensitivity to caffeine, ability to recognize bitter tastes, whether his muscles were predominantly "fast twitch" suggesting he would be a good s...

An article  from Sweden was recently published showing that in a very large group of women, over 60,000 of them, followed for 19 years as part of an also very interesting study of the effectiveness of mammograms, women who get more calcium, in their diet or as supplements, had a higher risk of dying of anything, but especially of heart attacks. It is unclear why this would be true, but there are various theories. Further, the study showed that this risk was more pronounced if the calcium was taken as supplements, but still present in women who got their calcium from the food they ate. The highest level of risk was in women who got more than 1400 mg of calcium a day, and an intake of 700-1000 mg a day did not particularly increase risk. The women with the lowest average calcium intake were not at any increased risk of death, which was a surprise to the researchers. Information about calcium intake was taken from the subjects' reports of diet and supplement use, which was further...