Why is American health care so expensive?

A few nights ago I attended a dinner and lecture at the local dining venue where they   served huge hunks of prime rib and sauteed snow peas from some far away place where it's Spring, and chocolate mousse and wild rice. Global warming increased just slightly due to our excess consumption, but my portion would have been wasted had I stayed home. Beside the food, I was curious to see what the healthcare lobbyist who spoke had to say about where healthcare reform is headed. I was surprised to find that he was almost entirely positive about what was going on and that in general he said things that I agreed with. How could this be? Healthcare lobbyists generally want the industry they represent to get as much money as possible. I generally want the healthcare industry to rein in its excesses and be more conscientious and efficient. Clearly there is some agenda here that I don't understand. Either that or efficiency and reining in excesses is beginning to align itself with the s...

Last month I spent 2 weeks in a small hospital in South Sudan and probably did about 100 bedside ultrasounds. The whole experience was very moving, and encompassed so much more than doing ultrasound, even though I had intended the trip to be primarily for teaching ultrasound applications. It turned out that I also had to learn as much tropical medicine as my aging brain could hold and clean up spider webs and feed people and put goop on rashes and sew up gashes and learn to say hello in Nuer and a number of other things which will occupy an important place in my heart for years. But as an ultrasound nerd, there were many exciting nerdy moments. These were the moments that most ultrasound nerds experience when we realize, again, that this technology is totally cool and that we wish everyone could do it. I have spent the last 2 years practicing hospital medicine and a little bit of primary care and doing thousands of bedside ultrasounds. I have taken classes and tests and spent fre...

In 1950 Ernst Wynder MD and colleagues began to produce convincing data that cigarette smoking caused lung cancer. Over the ensuing many years evidence has arisen linking cigarette smoking to many different cancers and conditions, chronic lung disease and heart attacks. In 1964 the surgeon general reported that cigarette smoking was the most important risk factor for development of lung cancer and that quitting smoking reduced that risk. Since that time a concerted effort to reduce tobacco smoking has been one of the most important public health agenda items for the medical profession. Since this is the 50th anniversary of organized tobacco control, the Journal of the American Medical Association has devoted an entire issue to the subject of tobacco and health . Articles include a survey of smoking prevalence around the world: US residents smoke less than people in Europe, especially Eastern Europe. Although many Africans smoke, they don't smoke much, Women generally don't...

Doctoring is a practice based in science, but at its best, attempts to treat whole complex humans to achieve goals such as health and happiness which have no good scientific definition. Good doctors practice outside of boxes, and our success or failure is scrutinized closely according to very subjective criteria by our patients and colleagues. It is nice, in this situation, to have aspects of our work be based on clearly measurable variables; blood pressure, for instance. The concept of high blood pressure as a clinical diagnosis began to be accepted at the beginning of the last century, correlated with the invention of the blood pressure cuff. It turns out that the pressure of blood in the arteries, when elevated, can lead to heart attacks, strokes, aneurysms and kidney failure and can be an indication of other serious medical illnesses including tumors of the adrenal gland and pituitary as well as narrowing of the blood vessels to the kidneys. Controlling the blood pressure has b...

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...