Why is American health care so expensive?

David Blumenthal and others recently published a paper  in the New England Journal of Medicine entitled "Health Care Spending--a Giant Slain or Sleeping?" In it they look at the ongoing, and rarely discussed, phenomenon of slowing of healthcare spending, which has persisted over several years. Health care spending grew remarkably after the establishment of Medicare and Medicaid in the 1960's, resulting in the fact that health care costs now equal about 18% of our gross domestic product (GDP) when they were only 5% before these programs were introduced. This was no coincidence. A third party payer, even one we expect to value frugality such as the government, will increase utilization of services because they are already paid for, and will increase prices for the same reason unless the prices are negotiated. In Europe, prices for procedures and medications are frequently  negotiated, but in the US powerful drug companies and device manufacturers successfully resist this,...

Today in the mail I received a letter from my private health insurance company informing me that my current policy, which was being cancelled because it didn't meet minimum standards of the new healthcare law, would actually be available to me next year. In other words, I could keep my plan. There has been a big kerfluffle about a presidential promise to allow people to keep their health insurance plans if they liked them, which turned out not to be true under the health care law. Having read the law I thought that was pretty clear. I figured that my plan wasn't compliant and I would therefore find myself signed up for some more expensive policy by my health insurance company when 2014 rolled in. I am not entirely sure why the president told people they could keep their non-compliant policies, and apparently he has been spanked soundly for saying it. The "Keep your health plan act of 2013" passed the house in November, but I cannot find anywhere that it passed the...

Rural medicine, I guess, can be defined as health care that happens in places that aren't big cities or referral centers. The vast majority of the populated earth's crust that has any health care at all is served by rural practitioners. I have done a little bit of rural medicine in Haiti, in Mexico and now a bit more in South Sudan. I have also worked in a rural health care system in Idaho for nearly 20 years.  People benefit hugely from health care delivered to them in their less densely populated home turf, despite the fact that health care in such locations lacks technology and specialist services that are often available cities or university medical centers. In the US, most rural health outposts are within an hour of a major medical center, either by ambulance or helicopter, so transfer to a high tech center is usually possible when there is an indication. In developing countries people are often grateful for any medical care that can be provided and transfer to a highe...

Two days ago I got back from Old Fangak, a tiny town in Jonglei province on the banks of the Zaraf River, a branch of the Nile. Because I am on a self proclaimed sabbatical, and because I have wanted to visit my friend Jill Seaman who treats tuberculosis and Kala Azar in South Sudan for years, I just took off and went there, and now, many mosquito bites later, I am back. South Sudan is the newest country in the world, having achieved independence July 9, 2011 after decades of civil war in the Sudan. The politics of independence are complicated, involving routine marginalization of the sub-Saharan population of the south by the Arab north. There are also rich oil reserves in South Sudan which may help fund infrastructure improvements eventually. I visited Juba, the capital city, briefly and spent the vast majority of my time there in the town of Old Fangak where the hospital and medical clinic are located. Two weeks and a bit and basically one small town do not make me a South Su...

I just finished taking an exam for the American Registry of Diagnostic Medical Sonography. Having passed it, I can now put RDMS after my name, standing for Registered Diagnostic Medical Sonographer. The RDMS is a credential that many ultrasound technicians carry, and occasional physicians, especially those who make ultrasound part of their practice. So now, should I ever be at loose ends, I can potentially get a job as an ultrasound tech. To take the ARDMS qualifying test, one must first satisfy various requirements, which fit into categories meant to include ultrasonographers of great experience, ultrasonographers who have gone through a training program (usually 1-2 years) physicians who studied ultrasonography extensively during their medical school and residency training and physicians whose experience includes extensive review of hundreds of scans by experts. Proving experience requires letters from a supervising teacher. The exam is a proctored 5 hour test, 3 of which is i...

Statins made the news in a big way this week. The American Heart Association, in collaboration with the American College of Cardiology, just released recommendations that should change the way we prescribe medications called statins, including drugs like Lipitor and Crestor and their generics, Atorvastatin and Rosuvastatin. The headlines say stuff like "More Americans may be Eligible to Receive Cholesterol Lowering Drugs!" Boy howdy, aren't we all in for a treat? Big Money: I am a bit, or more than a bit, skeptical of news about statin therapy because Lipitor, before it went generic, was responsible for over 6 billion dollars in revenue for Pfizer and since it went generic, Astra Zeneca is raking in more revenue than they did last year for their cholesterol drug, Crestor, at about 1.6 billion dollars. This kind of market influence is associated with significant influence on the attitudes of both physicians and patients through advertising and research support. I thi...

I just got back from the Haitian island of La Gonave (lagonav in Creole) after 8 days there visiting people who work on projects we help to fund. I'm glad to be home, because this is where I live and I missed toast with jam, my dog, and not being sticky sweaty all the time. Still, it was a wonderful trip and full of things to get excited about. I first visited Haiti in 2010, about 3 months after the big earthquake hit the main island and killed 250,000 plus people, primarily in Port Au Prince. I went to La Gonave, 35 miles off the coast of Haiti, on a trip that was planned before the earthquake and which had nothing to do with the acute worsening of misery associated with the widespread destruction of the main island's marginal infrastructure. La Gonave was definitely affected by the earthquake, but nobody was killed, mainly due to the fact that there were very few large buildings and very few people inside in the late afternoon in the few places that did collapse. Poorly c...

I frequently throw away the American Journal of Medicine (the "Green Journal") without reading it because it is not one that I actually ask for and it doesn't address questions that I find interesting. Lately, though, the quality of the material is better and I am more likely to pick it up and page through the articles. Today I found that there were two editorials on the use of handheld ultrasounds, specifically the Vscan, the little pocket model that I have used for the last nearly 2 years as a diagnostic tool at the bedside. One article , by Julie Kim MD and colleagues from Northwestern University in Chicago, IL presented the opinion that these devices should only be used as part of clinical trials or for evidence based indications. They based this view on a review of the literature which showed few prospective trials showing improved patient outcomes. The following article , by Roy Ziegelstein, MD and David B. Hellmann, MD points out that "wise use of hand-c...

I just read an article in the Journal of Patient Safety by a NASA toxicologist and patient safety advocate, John T. James PhD, which addressed the question of medical errors in hospital settings. Dr. James evaluated the results of 4 studies of patient adverse events (PAE's) and extrapolated the results to estimate that 400,000 deaths yearly are associated with preventable patient harms. The Harvard Medical Practice study which reviewed records from several New York hospitals in 1984 estimated that deaths due to medical error numbered about 98,000 per year, and that number has been quoted widely and embraced as the truth by the Institute of Medicine, a nonprofit organization which seeks to advise patients and decision makers about important issues in medicine. This current article uses different methods and suggests that the number may be much higher. After reading the article about the article on a public interest site on the internet, I perused the comments, which were primar...

A 100 year old woman is brought to the emergency room by a concerned friend because she can no longer get out of bed to get food or go to the bathroom. Other than being unwashed and a little confused, she is fine. Her electrolytes are pristine, her electrocardiogram the definition of normal, her blood count and chest x-ray perfectly mirror the expected physiology for her age. Even her urinalysis is normal. She takes no medications and hasn't been to the doctor for a decade. She has no living family and her friends have their own lives and problems. She can't go home because she has just gotten too old. What shall we do with her? When the law establishing Medicare was enacted in 1966 as title XIII of the Social Security Act during the presidency of Lyndon Johnson only half of seniors had health insurance and many had no access to healthcare because they couldn't afford it. Now nearly all seniors in the US have insurance coverage for both ambulatory and hospital care. M...