Why is American health care so expensive?

Antibiotics are a miracle, killing the bacteria that might otherwise kill us. They are also dangerous, with side effects that can be fatal as well as merely annoying. They kill good bacteria as well as bad ones, disturbing the delicate balance of the bacterial communities with which we share our bodies. Intravenous antibiotics can work quickly to forestall life threatening blood stream infections and can reach high levels in the blood and penetrate structures such as bone, eventually eradicating infections that might hide out and cause chronic infection. Oral antibiotics, however, are also very powerful and are sometimes absorbed so well that they are just as effective as intravenous (IV) ones. Whether to use oral or IV antibiotics is based on several considerations, but we usually believe that infections on the heart valves or in the bone or joint or artificial joints require IV antibiotics. Long term treatment with IV antibiotics can be logistically difficult. Consider these two ...

When I went to medical school over 30 years ago I dreamed of working in exotic places, plagued with poverty, where nothing was familiar and where I could be of use. It sounded deeply gratifying. I imagined that I might escape the small fiddly problems of my privileged life by trading them for large, worthy problems. I longed for the feeling of being sure that I was doing the right thing. Not long after finishing my residency in internal medicine I took a trip to Thailand where, after being a tourist for several days, I visited a leprosy colony run by the Anglican church near the city of Chiang Mai, spending a week there watching and trying to help out. It was profoundly educational. Not only did I learn about the disease but also about all of the creative approaches the hospital there used to manage anything from chronic wounds to physical disability and patients' need to have meaningful work. The patients had illnesses that took years to heal, and they had workshops where they...

When I finished my training I was taught that the vast majority of dementia was Alzheimer's disease, with occasional cases of multi-infarct dementia as well as odd syndromes such as Kreutzfeld-Jacob disease and genetic, traumatic, toxic and tumor related syndromes. Parkinson's disease, we were taught, caused a tremor and freezing up of a person's movements and only very rarely was associated with any kind of memory loss. These teachings helped us modern doctors leave behind terms such as "senility" or "hardening of the arteries" to explain cognitive loss. We still had no useful tools to change the course of dementia, but we were more scientific in our description of it. In the last several years, however, neurologists have determined that there is a very common dementia that is associated with Parkinson's disease. Lewy body disease or Lewy body dementia was a condition that I had been taught was not only uncommon but only accurately diagnosed a...

"If there is a physician on the plane, please press your call light!" The vast majority of doctors who have flown on airplanes have heard this, and most of us are willing, if not entirely eager, to respond. What follows is usually a far from ideal encounter with inadequate information, too much noise, a cramped space to work in and little knowledge of what is expected or even possible. My experiences (I think there have been 3) were people who had become dizzy or had passed out. One of them was pretty frail, but none required that we land before our destination airport. What I learned was that: 1. More than one physician usually responds to these calls. As a general internist, I'm usually the most appropriate person to evaluate the patient (winning out over ophthalmologists, dermatologists and obstetricians.) 2. The flight attendants are very grateful, bring me an extra glass of juice and promise some kind of compensation from the airline which may or may not ma...

The price of new drugs just seems to go up. I've stopped being excited about innovative pharmaceuticals that target various hard to treat diseases and conditions, simply because they cost so horribly much. Each of these new developments looks like a classic philosophical dilemma. Do I pull the lever that makes the trolley kill one person instead of 5 or do I save the one and allow the trolley to kill 5? Do I prescribe the new drug that potentially helps my patient but may destine a whole population to lousy health care by making the overall budget unsupportable? When I was in residency in the 1980's medication that cost a dollar a pill was crazy expensive. Inflation doubles that plus a little more, so think $2.25 and pill in 2018 money. But today's expensive medication costs 10-20 dollars a pill. Or $1000 a pill for the drug to cure hepatitis C. Or, in the case of a now pretty commonly used drug for advanced cancer, $150,000 a year. This is real money. On the lower end,...

The New York Times has pointed out a very interesting coincidence. It was during the presidency of Ronald Reagan that health costs and outcomes began to diverge from the rest of high income countries with which we compare ourselves. In an article by Austin Frakt, a healthcare economist, physicist and mathematician, he points out that America began to abandon healthcare cost controls, except for Medicare, when Ronald Reagan took the helm from Jimmy Carter, who had steadfastly backed limiting public and private healthcare spending. Deregulation of many institutions followed. Regulation of industries related to health were rolled back and new regulations which helped control spending in Europe were not introduced. In the early 1980's insurance companies began to change the way they paid hospitals for their services, introducing "DRG's (diagnosis related groups). Hospitals responded to this change in payment methods, being paid according to diagnosis rather than time or...

This last week a monoclonal antibody injection for migraine was released, with fanfare and great hopes of becoming a commercial success. Amgen developed Aimovig (erenumab) and published its findings in the New England Journal of Medicine last November. It is an injection that targets calcitonin gene-related protein (CGRP), a chemical released in the brain during migraine which dilates blood vessels. The monoclonal antibody inactivates this protein for a long time, on the order of one and a half months. Migraine is often involves head pain, nausea, weird neurological symptoms including vision loss and even stroke symptoms. The combination of symptoms is frequently disabling and "migraineurs" suffer not only from their nausea and headache, but also from large financial burdens associated with the condition, on average around $6000/year for chronic migraine sufferers. The economy loses over $13 billion in lost workdays. Over 44 million people in the US have migraines, thoug...