Why is American health care so expensive?

One of the most exasperating things about the Affordable Care Act (otherwise known as health care reform) is the fact that its many provisions don’t just start immediately, but rather are phased in over a really long period and at seemingly random intervals. As a physician, I often hear my insured patients say things like “I can’t afford a colonoscopy right now” or “how much will a mammogram cost me?” I tell them that with the health care reform legislation they won’t have to pay for either one of these things. Unfortunately, my response has been a misleading oversimplification. It is true that one of the most welcome parts of the Affordable Care Act is that recommended preventive care services will be paid for in full, without co-pays or cost sharing. But when? Medicare and Medicaid programs will begin covering preventive care services at 100% on January 1, 2011. The services included are at this link: http://www.healthcare.gov/law/about/provisions/services/lists.htm

The Food and Drug Administration (FDA) has made two bold steps in the last month. They have asked the manufacturers of pain medications containing the mild opiate propoxyphene (Darvon) to voluntarily take these products off the market, and they have removed from the market all generic forms of the drug colchicine that is used to treat gout. Initially, this all seems ridiculous. Both of these drugs are nearly ancient, with a track record of successes, failures and side effects that goes back decades.  On further examination, it still seems pretty stupid, though quite a bit more complex.

Since Medicare, the single payer health insurance program for citizens age 65 and over, was signed into law in 1965, medical care for seniors has become more universally available and increasingly expensive. Since Medicare insurance looked to doctors and senior citizens like a blank check, services offered to older Americans rapidly expanded as did their unit cost and consumption of those services. The American government has tried various schemes for reining in spending, none of which have been popular or effective. In 1998, we decided to try the "sustainable growth rate" formula to control costs. Under that law, Medicare expenses were allowed to rise a certain amount, that which was considered to be a sustainable amount, based on inflation and other costs, and if those costs rose by more than the target, reimbursement for services under medicare would be reduced for the next year to an extent that the target of reasonable cost increases could be reached. In 2002, Medicare

A year ago I decided to shed my company health plan and buy an individual plan with a high deductible for my family. The cost of my employer plan had reached nearly $900 for my family of 4 who never use health insurance, and the deductible was $1000, which meant that any care we have received in the last 10 years would have been unreimbursed. I found a plan with a deductible of $7000, which I could combine with a Health Savings Account for $481 a month. How clever, I thought. I have really bucked this system! I just got my bill for the health insurance plan that Premera Blue Cross decided to provide for me in place of the plan that I signed up for a year ago. A few weeks ago I had received a glossy color sheet describing how my plan was changing, due to health care reform. My new plan would cover all health maintenance with no charge to me out of pocket, but would no longer have any coverage for various alternative medical services or eye care services. The overal

The New York Times has taken note of Abraham Verghese's efforts at Stanford University School of Medicine to revive the art of examining patients. One gets the idea in this article that most medical schools have let the entire subject slide, which is not true. Nevertheless, enthusiasm for the hands on aspect of data gathering has declined somewhat. When I was in training about 25 years ago, my clinical teachers took the subject of teaching us how to identify pathology in a patient seriously. Johns Hopkins medical school was at that time held up as a model of a clinical teaching institution, so training medical students and residents in the arts of examining hearts, blood vessels, livers, spleens, bones and joints was clearly going to be part of the curriculum. Many patients who moved through the clinics and hospitals associated with Johns Hopkins donated important pieces of their time and dignity in the service of teaching what would be generations of physicians how best to do this

Quite a number of perfectly adequate and hard working doctors have been invited to go to Washington to dine with Newt Gingrich. Most of us have decided not to go, though the tenderloin did sound tempting. But now that we aren't going, and health care reform is most likely a done deal, what is left for us to do? We are the Champions of Medicine, so are we just supposed to throw our capes over our shoulders and ride off on our white horses? "My job here is done..." I will say, as the music starts and the credits begin to roll. Despite our hard work over the last harrowing year, there are still some problems with the American Health Care System, as it is sometimes called. It is too expensive, costs are rising and people are suffering because they can't get the care they need. What have we gotten with the Affordable Care Act? We have funding for various projects aimed at making medicine more cost efficient and we have payment methods, public and private, that will mak

Today I received an invitation to an election day party from Newt Gingrich himself! Apparently I have “made the cut” as one of the 2010 Champions of Medicine and will receive a handsome certificate at an election day party at the historic Ronald Reagan Building in Washington D.C. Newt has confided to me that he has worked tirelessly of the course of his career for health care reform. He understands that I have faced challenges during the Obama administration's first two years and that this year has been especially difficult for me with the “Democrat held Congress essentially dismantling the world’s greatest healthcare system and replacing it with the failed model of socialized medicine.” Newt wants me at the party mainly because he wants to be surrounded by the best and brightest this country has to offer on the “night we set the wheels in motion to repeal Obamacare and replace it with real, meaningful reform.” Wow. I would love to go! I would have absolutely n

It is not uncommon for comments about cost effective medicine to be met with mistrust by patients.  Saving money is fine, but not if it means that when I, personally, as a patient, am in pain or sick, will have to wait for relief, get suboptimal care or be denied a life saving treatment. I, as a doctor, am also a patient, and can fully sympathize with this opinion. When I envision cost effective medicine, I mainly see an absence of cost ineffective medical interventions.  Without these big yellow lemons of common medical practice, there will be more time and money to provide care that is meaningful. So what are the top shelf worst and most cost ineffective practices? It would be beautiful to see a well funded study of this question, but I haven't seen such a thing, so I will dip down into my well of 25 years of medical experience and pick out several of the things that I, as a patient, don't want to happen to me. These are things that are costly, common and have very little v

This week's JAMA presents an article by Samuel Sessions MD of Harbor UCLA Medical Center and Allan Detsky of Mount Sinai Hospital in Toronto suggesting that teaching medical students to be aware of cost when learning to treat patients.  They recognize that physicians have an ethical responsibility to pay attention to the fact that medical expenditures are increasingly threatening America's economic viability and point out that training in cost-effectiveness needs to start in medical school. A few years ago I let my membership in the American Medical Association lapse since I felt that the did not represent me as a primary care physician and a socially responsible human being. During the debate around health care reform, they have not demonstrated leadership in helping American medicine move in the direction that will result in reducing costs and improving access for people who need medical care. They have, however, published articles in the Journal of the AMA by many thoughtf

Obstructive sleep apnea (OSA), that is snoring with episodes of not breathing, probably affects more than 1 in 20 people.  It is most common in older men, though certainly not limited to this group. Risk factors include obesity, large neck size and limited room for air passage in the back of the throat.  When a person has OSA he or she may wake up hundreds of times a night as breathing is stopped by floppy tissue in the airway and the drive to breathe arouses them enough to take an effective breath.  This loud irregular snoring and snorting also interrupts the sleep of a partner in the same bed. People with sleep apnea have a lousy quality of sleep, rarely reaching the lower sleep levels and are less productive during the day than healthy sleepers and often fall asleep in meetings, movies and while driving. Years ago we discovered that application of a mask to the nose which applies a constant air pressure to the breathing passages can improve nighttime breathing and nighttime sleep. T

Last night I realized that I actually do like having a computerized medical record system. I have had a love hate relationship with our computerized medical record system since we adopted it in January of 2007.  We decided to make all of our records and billing electronic in 2006 and tried out several systems before deciding on General Electric's Centricity product.  It was expensive, over $100,000 for our 9 physician group, not including the loss in production as we learned how to use it, and not including many of the laptops and desktops and printers and other hardware. When the system "went live" we all slowed our history taking and record keeping to a snail's pace and were hard pressed to see half as many patients as we had before the system was in place. We all stayed late and came in early. Eventually we adjusted to it, and after a year, we were not as fast, but almost as fast as we had been before. We lost 2 physicians who really couldn't deal with it and

The following essay addresses the present tendency of scientific medicine to rely heavily on studies which address the effects of treatments on populations rather than individuals.  It has been clear, always, before and after various large scale studies of the effectiveness of estrogen, that hormone therapy is good for some people and not good for others. Nevertheless, at great cost to patients in money and time and quality of life, we have at various times pronounced estrogen to be good either for everyone or for no one. When the Woman's Health Initiative study was stopped in 2002 due to increase heart attacks and breast cancer in the women treated with estrogen and progesterone the non-medical press circulated the story extremely effectively, and within a year very few women did not know that the estrogen they had been prescribed and told would save them from all sorts of misery was actually toxic and evil.  It was a bad year for estrogen. In the 8 years since then doct

Last night I attended a program put on by the hospital about health care reform. The first speaker had clearly spent a great deal of personal time and energy working with folks who really didn't want the health care reform bill to pass. He had a good ole boy presentation style, peppered with sarcasm and full of predictions of imminent doom for the world as we now know it.  The only saving graces for his talk were that the food was excellent and that he used so much insurance and benefits jargon that the majority of the audience quit listening to him. The second guy was more balanced.  He identified himself as a moderate republican, and though he didn't particularly like the health care bill as a whole, he presented a pretty balanced review, and looked at ways we could allow it to improve health care. His major points included the fact that "accountable care organizations" (ACOs) are likely to become a dominant way to deliver health care, with their foc

We had our 4th meeting of doctors and staff interested in improving access, cost and overall quality at our hospital. It was well attended, but mostly by staff and board members rather than physicians. I guess we doctors think we are too busy to talk about health care reform. We had me, an internist, a psychiatrist, a radiologist and and emergency doc. Thinking was clear and focused, and the meeting was productive, as much as talking can be. We came up with several items needing action, and discussed several items that are moving solidly in the right direction. 1. My Own Home: an organization is being born which provides all sorts of resources to older folks wanting to stay in their own houses rather than moving to retirement homes.  It will be supported by grants and will require membership payments. It will probably really start functioning in the next year. It is moving in the direction of getting up and running as fast as is practical. 2. Direct or prepaid medicine: there is qu

The New England Journal of Medicine this week published two articles on imaging technology.  The first was about the safety of CT scans and the second was about the indiscriminate use of radiological imaging of all kinds. Imaging of the human body is big business and important in the progress of diagnosis, but once a machine or technique is invented, its use is mostly unregulated and largely up to our discretion, without supporting scientific evidence of usefulness. CT scans do cause cancer. This is because ionizing radiation causes cancer and CT scans carry lots of that. Every year 10% of Americans get a CT scan, and many people have multiples. Each CT scan carries 100 to 500 times the radiation dose of a standard chest x-ray if done properly.  If an error is made, much more radiation can be delivered. Sometimes a patient might find out about such an error, but most often there would be no symptoms and no recognition. CT scans also do save lives.  They detect problems that would r

The training that leads to becoming a physician is long, taxing and requires academic stamina and intelligence to complete. Nevertheless, most of what we eventually learn is practical: how to take care of patients in sickness and health. This is as it should be, since that is what we mostly do. Nevertheless, because we take many many hours of science related classes, most physicians consider themselves to be scientists. And that we, mostly, are not. In my years of training I have learned how to construct a hypothesis, test it and use my data to make a conclusion. I know how to document my data, and I know how to perform simple statistical analyses.  I know how to interpret statistics I read in other peoples' work, for the most part. But because I am always looking for ways to use the science I read to help me in patient care, I often make inferences that are speculative and probably just plain wrong.  It works for me, though. I need to plug the science I read into the craft of me

The American College of Physicians has created an initiative to reduce costs and increase quality.  It is called the High-Value, Cost-Conscious Care Initiative, and was launched at the annual meeting in April.  They plan to focus on overuse and misuse of ineffective tests and treatments, of which there are many.  The congressional budget office estimates that 700 billion dollars yearly is spent on tests and treatments that do not improve health.  I suspect they underestimate that significantly. At the same meeting the college revealed plans to lobby for changes in health care policy not quite adequately addressed in the health care reform package, including prolonging salary bonus for primary care doctors treating patients on medicare and medicaid. This is good! Even great. Why did this take so long? I expect that part of the problem has been that it is difficult to find consensus in changing a system when there is considerable concern about loss of income and loss of respect.  I

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 cities, and small p

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 exposure, which p

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 fail to live by the for

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 corp

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