Why is American health care so expensive?

On June 28, 2012, the Supreme Court of the United States voted to uphold most of the disputed provisions of the Affordable Care Act, allowing the legislation to stand. I read the syllabus and some reasonable portion of the opinions. The link is here:  http://msnbcmedia.msn.com/i/msnbc/Sections/NEWS/scotus_opinion_on_ACA_from_msnbc.com.pdf The two issues considered by the court were: 1. Does the constitution allow the government to withhold Medicaid funding from states which do not choose to participate in expanding Medicaid to citizens who sit below 133% of the poverty line? 2. Can the government require citizens to buy health insurance? There was lively discussion. Chief Justice Roberts argued that it is not constitutional for the government to take away Medicaid funding as a way of forcing states to comply with Medicaid expansion. Justice Ginsberg felt that this could be construed as amending the Medicaid program and was within Congresses legislative prerogative. Eventually...

Pulmonary embolism is a condition in which a blood clot that forms somewhere in the veins of the body moves with flowing blood into the right heart and then out into the lung (or lungs.) It is a common cause of sudden death, since a very large clot can cause the heart to fail and reduce the oxygen level in the blood. The blood clots that cause pulmonary emboli usually form in the deep veins of the legs, sometimes in the large veins of the pelvis and rarely form in the heart. Some people with pulmonary embolism have symptoms that are vague, like dizziness, cough, chest pain or shortness of breath. When they are evaluated they usually have an increased pulse rate, often a low-ish oxygen level, and occasionally report coughing up blood. A person who has a small pulmonary embolus may have really mild symptoms and then flip a very large clot later which can be devastating, so we evaluate many people for pulmonary embolism who have very atypical symptoms. We have a blood test, the d dimer, w...

The other day at my home hospital (which I love and think does a great job of controlling costs and treating patients appropriately) I was sitting around with the intensive care unit nurses and discovered some more irksome facts about how much things cost in hospitals. I had just learned how to place a PICC line (peripherally inserted central catheter) from a nurse anesthetist. When a person is critically ill it is important to have access to the blood stream in such a way as to allow lots of fluid to go in quickly or to make sure that medications that can be irritating to small veins (like potassium and blood pressure support medications) get where they are going without causing damage. That means that a catheter (an IV) needs to go into a central vein. It can go by way of a large vein in the neck or upper chest (the internal jugular vein or subclavian vein) or it can start in a smaller vein in the arm; that catheter is a PICC line. PICC lines can get clotted off, because they are lon...

Today I met a man whose liver is failing. He drank way too much alcohol for many years and quit in February when he finally realized his liver was toasted, pickled, scarred, hardened, cirrhotic. He had begun to build up fluid in his belly that had to be drained with a needle because the medicines designed to help reduce it didn't work and made him feel terrible. Because the liver clears toxins created by metabolism, and his didn't, he began to be loopy and tired all the time. Today the fluid had built up again and when over 8 quarts of it was drained from his belly he was too weak to walk and had to stay in the hospital. The single solution to his problem, barring the invention of a time machine so he can go back and not drink so much, is liver transplantation. He is not insured for a liver transplant. We talked about this and about his prognosis with the technology available to him, which is terrible, while he struggled to keep his eyes open. I am pretty certain he will reme...

I really loved doing primary care, taking care of patients in my community in a medical office and in the hospital when they needed that. I practiced primary care internal medicine for over 20 years, first as part of a health care cooperative and then in private practice, and it was very gratifying, never boring and fed my soul. This last year, across the country, almost no internal medicine residents chose to go into primary care. Graduates of family medicine residents were more likely to go into primary care, but many of them, too, chose specialties or hospital medicine. Though family medicine residency positions mostly did fill, over half of them were taken by foreign medical graduates who traditionally are less competitive for residency slots. Why? An article in the New England Journal of Medicine discussed some of the challenges of being a primary care doctor and some of the changes in reimbursement that are expected to ease the shortage of those absolutely essential regular doc...

Two articles in today's New England Journal of Medicine address waste and rationing. Rationing in health care is an emotion fraught term meant to awaken visions of long lines of people waiting for loaves of bread in grainy black and white photographs, but bearing the faces of sick loved ones instead of long dead strangers. Arrrgh. The first article, entitled "From an Ethics of Rationing to an Ethics of Waste Avoidance" is written by Howard Brody MD, an infectious disease specialist who was in clinical practice for many years and now is known as an ethicist. He makes the point that we need to pull ourselves away from the issue of rationing truly valuable medical care to focus on realizing that the procedures and treatments that we do that are truly not helpful are not only expensive but harmful and therefore unethical. He further suggests that using population studies to decide what works or does not work for an individual is inherently in error, and that if we successfull...

My Advanced Cardiac Life Support (ACLS) certification expires in June of this year. At least that's how it used to be. Now my card says that June 2012 is the "recommended renewal date." These re-certification dates always sneak up on me, and if I go over two years between certification I need to take a two day class rather than a one day class, which is more expensive and time consuming. ACLS is a protocol based set of guidelines published by the American Heart Association to standardize the treatment of cardiac arrest, heart attacks, strokes and heart rhythm disturbances. The first guidelines were published in 1974 and have been updated 6 times since then, most recently in 2010. ACLS is meant to help physicians deal with situations that require very quick action in order to have good outcomes, sort of like soldiers used to need to be able to take apart and reassemble a rifle quickly. ACLS often follows bystander cardiopulmonary resuscitation (CPR), also known as Basic ...