Why is American health care so expensive?

The bacteria that live in our healthy guts are a garden of cooperating and competing species that help to determine our intestinal health. When we take antibiotics, we kill countless bystander bacteria in our guts and sometimes develop changes in our digestion which can be severe. Clostridium Difficile infection is one of these conditions, a superinfection with a bacterium which is pretty resistant to antibiotics and causes infection of the colon with diarrhea, sometimes fever, nausea and vomiting and occasionally death. We treat Clostridium Difficile (C. Diff) diarrhea with a couple of antibiotics to which it is sensitive, but they don't work very well and some patients become chronically infected. What does work for C. Diff, when all else fails, is a fecal transplant, that is to say taking stool from a healthy person and putting it into the gut of a person who has the infection. This is a stinky procedure in which genuine human poop, from a human who has been tested for disea...

First a disclaimer: People often receive compassionate, considerate and effective care at hospitals. They have countless interactions which impart the miracle of human caring and enrich their lives. It is also institutionally prevalent to have haphazard care with poor communication, near misses and avoidable misery. I have been working at a university hospital emergency room as part of a mini-fellowship in bedside ultrasound.  It is the first time I have spent significant time entirely dedicated to an emergency room since I was a medical resident about a quarter of a century ago. As an internal medicine physician who works in hospitals, I have spent one or two hours at a time relatively often in emergency rooms taking care of patients who were admitted to me on their way to the medical floor, but that is not the same as staying there, seeing the more and the less ill, the folks who may go home and may get admitted, watching the rhythm of the department over time. People come ...

Harlan Krumholz, a Yale University professor of cardiology and public health, just published an article in the New England Journal of Medicine entititled "The Post-Hospital Syndrome--An Acquired, Transient Condition of Increased Risk." In it he points out that, not only are there many under-recognized complications of hospitalizations, mostly the same things I mentioned in my previous post , but these things lead to a very vulnerable period for patients after they are released from the hospital. Patients, especially elderly ones, often come back, sick, to the hospital with a new condition that was not directly related to what got them in trouble in the first place. Instead they come back with new issues, related to the fact that they were in the hospital, being unfed, un-exercised, treated with medications, and stressed in a myriad of ways which have consequences later on. I notice a few things that relate to this, in my job as a hospitalist and primary care internist. Fi...

Hospitals are very focused on avoiding harming patients lately. They have been moving in that direction for a long time, but with health care reform legislation, payments are on the line, which makes something that was a very good idea into an imperative. In the year 2000, the Institute of Medicine, a non-profit organization that monitors various aspects of medical care, reported that 44,000-98,000 people died each year due to medical errors. This began a nationwide focus on patient safety that has had some, but not enough, impact on outcomes. Hospitals already do not get paid for care of a patient who gets a blood stream infection from their central venous catheter or a urinary tract infection from their bladder catheter, so they have to eat the costs associated with these things. When a hospital is paid a lump sum for a diagnosis (say a patient is admitted with appendicitis) and the patient gets some complication that makes their care longer or more expensive, the amount of money t...

I just finished another week of hospitalist shifts at a small hospital in Alaska. It was a good week. People worked well together, the patients were well served and seemed to feel good about their care and, since I had been at this hospital for several weeks, I noticed some of the things that really worked. The hospital is a member of the "Planetree Alliance" which works with member hospitals to make them more sensitive to how patients experience things, and also works to increase efficiency so energy and money can be directed in the right way. I read some things about this group. Apparently it was started by a woman after she had a terrible dehumanizing hospital experience and now started an organization to make hospitals less unpleasant. In some places it works, and in others it does not. It sounds like that has to do with whether the nurses are genuinely overextended. Planetree hospitals look better, with fish tanks and waterfalls and nice lounges, and have services l...

I just read in a recent issue of "Aequanimitas," the newsletter of Johns Hopkins Osler medical service, a brief interview with J. Mario Molina, the CEO of Molina Healthcare, an organization which coordinates managed care for recipients of Medicare and Medicaid for several states. It looks like he must have been one of my senior residents when I was an intern. It sounds like he practiced for a few years before taking on the leadership of his family business. He expressed his firm belief that medical care would soon be moving away from paying physicians for the individual services they perform and, instead, paying them for keeping patients healthy. Since it will be organizations, not doctors, who are paid for care, it will quickly become clear that paying for anything that prevents dire illness with its astronomical associated costs will benefit the whole. Medical institutions may find themselves in the business of making their communities healthy. This is not foreign to larg...

Colorado and Washington state have legalized the recreational use of marijuana. I thought this would take longer to legislate, especially with the recent backlash from the federal government about medical marijuana. Eighteen states (including California, Alaska, Vermont and Oregon) allow marijuana to be used for medical reasons, but have restrictions on which conditions can be treated with it, which don't necessarily correlate perfectly with the diseases for which it is effective. I have worked in a state which doesn't allow legal marijuana use for anything, but have seen patients from neighboring states who did use medical marijuana and have tried to stay abreast of the laws and issues surrounding use. Marijuana is relatively nontoxic. Nobody has ever died of overdosing on marijuana, though it is theoretically possible. Combining marijuana with other drugs can lead to overdose death, and combining marijuana with driving or other activities which require fast reaction time ha...