Why is American health care so expensive?

I am in the African Republic of Tanzania. This year I have again accompanied a group of medical students from University of California at Irvine who will be teaching bedside ultrasound to clinical officer students at a medical school in Mwanza, the second largest city in this East African country. We will also be looking at the utility of ultrasound in diagnosing schistosomiasis, a parasitic disease which is endemic here. Mwanza is on the coast of Lake Victoria, a huge body of water also bordered by Kenya and Uganda. Much of the commerce here has to do with the lake, both relating to tourism and fishing. Schistosomiasis is a water borne disease caused by a fluke that lives in the lake, harbored by snails. The snails are infected by the schistosomiasis miracidia and shed cercaria capable of infecting humans into the beautiful blue water where they penetrate the skin of mammals that swim in the lake. The flukes move through the lymphatic system, penetrate...

"They should make an ultrasound probe that plugs into your laptop. It could just hook into a USB port." Ultrasound technology has become progressively more accessible to doctors who aren't radiologists. During my training, some obstetricians imaged the bellies of their pregnant patients to quickly see how the baby was lying in the womb and assess its progress. Other than that, ultrasound resided in the realm of the radiologists, who lived in dark rooms and interpreted blurry pictures for the rest of us. Since ultrasound is not expensive and has many potential applications, far beyond just seeing fetuses, other specialties have adopted it and doctors in resource poor countries where there are no radiologists have come to rely on it for all sorts of information. Trauma surgeons and emergency physicians can use it to rule in or out life threatening conditions, and internal medicine physicians like me can improve on the accuracy of our physical exams and sometimes avoid t...

A health research company just released a list of the 100 top drugs in America according to sales. 29th on the list, with sales of over 1.8 billion, is the cholesterol lowering drug ezetimibe, brand name Zetia. This drug was released over 10 years ago because it worked really well in combination with statin drugs such as Zocor (simvastatin) to lower LDL cholesterol levels. It was released as a single agent and combined with simvastatin as Vytorin. The only problem was that in 2008 a study  of the ezetimibe/simvastatin combination compared to simvastatin alone showed the combination did not improve measurements of arterial wall thickness which correlates with things like heart attacks and strokes. Although cholesterol levels were lower in the combination arm, simvastatin was just as effective in achieving the more meaningful outcome. Ezetimibe appeared to increase cancer risk in another study , evaluating patients with aortic stenosis. A study which compared adding niacin or...

A friend sent me a link to a New York Times article on the ridiculous amount that insurance company executives and hospital administrators make. So the reason that American healthcare is so expensive is not because doctors earn too much, or drug companies charge too much or device manufacturers are making ever more expensive devices with ever expanded indications. Except that it is all of that and more. Hospital administrators and insurance company executives do make lots of money. They make more than I ever will, unless I do their jobs. But it's also pretty easy to make a comfortable living as a physician working for a hospital or even a nurse practitioner in one of the specialty or acute care areas. By "easy" I mean that it is easy to make money, not that the job is easy. The creation of the Affordable Care Act has set into motion some mechanisms for decreasing costs, but it doesn't come close to dealing with the fundamental dynamic that makes health care expen...

I've been hearing about the VA (Veterans Health Administration) scandal recently. A traipse through the high quality media coverage available on the internet has brought me up to date. Apparently in 2012 a physician at the VA in Phoenix began to call attention to the fact that her hospital was providing inadequate care, specifically that her emergency department was overcrowded and dangerous. In the primary care arena, reports that veterans had to wait ridiculously long times for appointments were investigated by the General Accounting Office and a report was released in 2013 that found that documentation of wait times was inconsistent, but that it appeared that veterans had to wait an unacceptable amount of time for appointments. Later in 2013 another doctor from the Phoenix VA reported that wait times were unacceptably long and that patients were dying because they were waiting so long to be seen. Numbers I've read on the internet include 6 weeks to even be called back ab...

People have smoked tobacco for centuries, possibly thousands of years, and cigarettes were first machine made in France in the 1880's. In the US, smoking peaked in the year 1965 when 50% of men and 33% of women smoked, with a per capita consumption of over 4000 cigarettes per year. When health effects of smoking began to be widely publicized, particularly its association with lung cancer, cigarette smoking began to decline. Nicotine, the psychoactive ingredient in cigarettes, is addictive , producing a withdrawal syndrome that is at least partially relieved by nicotine replacement. Cigarette smoking, though, also has cultural meaning, which has contributed to its popularity. For decades therapeutic nicotine replacement has been available to people who want to quit smoking, first only by prescription, but now over the counter since the 1990's. The first product, a nicotine chewing gum, was released in the late 1970's, followed by a patch, a nasal spray and finally an inh...

For about 2 years now a tiny ultrasound machine has been part of my standard physical exam tools as I take care of patients in the hospital and in the outpatient clinic. In November of 2011 I first picked up an ultrasound transducer in a continuing medical education course on bedside ultrasound for emergency physicians. I am an internist, not an emergency physician, but I was interested in bedside ultrasound and it was the emergency physicians who were giving the most interesting course. It was transforming for me. I was able to see internal anatomy and physiology and eventually, with lots of practice, I was able to make diagnoses more quickly and accurately. I bought a pocket ultrasound machine so I could make bedside ultrasound a seamless part of my practice It was an unexpected and welcome bonus that my patients and their families loved it. I would share the moving ultrasound pictures with them, often having them hold the machine so I could point out how beautiful their internal...