Why is American health care so expensive?

I practice primary care internal medicine in a group that consists of a few family practitioners, a few nurse practitioners and 7 internists, two of whom are also specialists. (An internist is defined as a physician who specializes in the detection, prevention and treatment of illnesses in adults.)  My office is across the state line from our primary office and has consisted of 3 internists and sometimes a nurse practitioner. I see patients in the office 4 days a week and also take care of  hospitalized patients.  The hospital is a very good but small (25 bed) facility, with cool features like an MRI machine, fully staffed emergency department and rooftop helicopter pad for transferring very sick patients to larger centers, and is a 20 second walk from my office. I think, right now, that mine is about the best job a person could have. In two weeks, the third internist in my small office will be moving to another state.  He has been very productive and has been doin...

Amount of pressure

A hot topic in medicine is the "impaired physician". There was a whole series in the throw-away journal Pain Medicine written by a doctor who spectacularly screwed his life up by getting addicted to opiate pain medications, then overprescribing those same drugs to patients and defrauding Medicare and Medicaid by charging for procedures that he didn't do. He proceeded to run off to various foreign countries where he managed to keep himself fed and housed until finally returning to the US to serve his time and probably not practice medicine. The articles he wrote were luridly exciting, definitely not in the category of "there but for the grace of God go I." Most of us in medicine have had contact with a colleague who has some kind of a substance abuse problem. I personally have had 3 colleagues with whom I worked closely who had trouble with both drugs and alcohol to the extent that their work was affected and they had to take time off, do a treatment program a...

I just got back from 2 weeks on the Haitian island of La Gonave. We have a longstanding exchange established between our community in Idaho and several communities there.  Last year, a few months after their earthquake, I visited for the first time, carrying medical supplies and planning on delivering care to the injured and ill. In fact there were very few injured and ill, partly due to the fact that La Gonave is very rural and few houses were occupied at the time of the quake. The other important fact was that this part of Haiti, with few if any medical providers, does not support sick or injured people very well and so they either die or recover. This visit was primarily to study their medical resources, beliefs, health concerns, and to advocate for better sanitation practices and water antisepsis. I was unable to resist bringing medications and supplies, and also stuffed my suitcase with condoms to hand out like candy. Community organizing around effective ways to use their...

I just read an article in the New England Journal of Medicine by Sean Palfrey MD, a professor at Boston University School of Medicine in the department of pediatrics.  Dr. Palfrey dares to state the obvious, in a world in which the telling it like it is can be the kiss of death.  Dr. Palfrey writes: Every participant in our health care system must focus on ways to optimize health while decreasing cost, at every step of the process. We need to change the financial incentives currently embedded in health care reimbursement systems that reward the use of tests, procedures, consultations, and high-cost therapies. And finally, the legal system needs to be more restrained about pursuing lawsuits when a difficult diagnosis is missed or a treatment fails, to diminish the pressure on health care providers to practice expensive, defensive medicine at every turn. These are major changes, but today we are far from providing good care for all our citizens and far from achieving ...

It is very common for patients to complain that they don't get to spend enough time with their physician, or that their questions don't get answered.  This is more true now than it was 20 years ago, and is a direct result of the fact that physicians are paid, not for taking care of patients, but for seeing patients, not for solving their problems but for spending time, even a very small amount of time, physically in an office with them. Physicians are not paid for talking on the phone with patients, for e-mailing them, for discussing their case with learned colleagues, for evaluating their complex medications with pharmacies or for coordinating care with specialists, caregivers or family members. What we do get paid for, and often well paid for, is office calls. The other day I read an article published in a trade journal called the American College of Physicians Internist reviewing suggestions made by Dr. Neil Baum, a urologist in New Orleans, in a session of the Medical Gro...

Very recently a new drug came out which is significantly better than the drug it seeks to replace. Every year many new drugs are marketed, and most of them offer no improvements over what is already in use, but confuse physicians and patients with false choices, and contribute to increased drug costs. Dabigatran, or Pradaxa (its brand name) is a drug which prevents the blood clots that can cause strokes or other serious mischief, and may eventually replace warfarin (Coumadin) which has been in use for decades. It has several very significant benefits, including the fact that frequent blood test monitoring is not necessary and bleeding risk is reduced. Some background may be useful. Warfarin (coumadin) was originally introduced as a rat poison because it reduced the little guys' vitamin K levels and thus prevented the production of a few proteins involved in blood clotting. With no available vitamin K rats would bleed to death from minor injuries. Not long after its release as a...