Why is American health care so expensive?

About 5 months ago I embarked on an adventure in healthcare . My healthcare. I decided to take medicine to reduce my cardiovascular risk. I recognize that my cardiovascular risk is pretty low, and when I am much older I may wish for a nice clean cardiac death before I lose my faculties. Having found a plaque in my carotid artery while ultrasounding myself, I decided that perhaps I should enter the ranks of consumers who take drugs to reduce their blood pressure and cholesterol. Astute readers made various comments, including that perhaps I should first try diet, weight loss, exercise and that I should be aware that someone of my description has a low likelihood of actually benefiting from drug treatment of these things. These were reasonable comments. It turns out that I don't need to lose weight, being at the bottom of the healthy range of body mass index, and that my exercise level is pretty optimal, my diet is as evidence based as I can make it, and although I have a low ris...

"Annie, Annie, are you OK?" Many of us learned to resuscitate a person who has collapsed using Annie, the manikin based on a death mask of a young woman who had drowned in the Seine in Paris in the 19th century. Bystander cardiopulmonary resuscitation (CPR) has become increasingly accepted and expected as the years have passed, and we have even begun to make affordable machines to deliver a life-saving shock (defibrillation) to the heart of a person who has collapsed with an otherwise life threatening heart rhythm disturbance. We lack, though, much good information about how useful the procedure is in saving lives and bringing people back to meaningful existence. A recent study completed in Denmark looked at the outcomes of bystander performed CPR and defibrillation. Denmark has been quite aggressive in training and encouraging citizens to perform CPR when a person collapses and is found to have no pulse. They have also been scrupulous about keeping records of what h...

Gilbert Welch  has written an excellent commentary on the fresh-out-of-the-printer recommendations of the US Preventive Services Task Force (USPSTF) regarding screening for thyroid cancer. Dr. Welch, a professor at Dartmouth University, has spoken out about wasteful and harmful procedures done in the name of prevention. He is a compelling writer, has written several books aimed at people who are not doctors, and has captured the essence of the thyroid cancer screening controversy in this article , published in JAMA today. Briefly, he applauds the recommendations of the USPSTF which state that there is no evidence that looking for thyroid cancer in people who have no concerning symptoms (symptoms such as a neck lump, difficulty swallowing or hoarseness) helps them. He looks at the population data on thyroid cancer, first evidence out of Finland that suggested that nearly everyone probably has a small thyroid cancer if you look hard enough, and evidence that discovering and treat...

There is enthusiasm in politics about reducing regulation to stimulate creativity and economic growth. Maybe. But reduction in oversight of medication and medical devices by the Food and Drug Administration (FDA) will probably lead to a proliferation of expensive potions and gadgets that don't actually help. This week, the New England Journal of Medicine published an article detailing the near miss associated with an injectable monoclonal antibody for Alzheimer's disease. (Spoiler alert: it doesn't work.) Authors Chana Sacks, Jerry Avorn and Aaron Kesselheim detail the saga of Solanezumab, a drug that attacks the protein in the brain that is associated with Alzheimer's dementia. A monoclonal antibody is a molecule that binds to a specific target allowing the immune system to clear it from the body. Solanezumab binds to amyloid beta protein which is increased in the brains of patients with Alzheimer's disease. Although it may help clear amyloid protein from pa...

Medicaid , the program that provides funding for adults, seniors (along with Medicare), children and people who are blind or disabled who can't pay for their own healthcare, is expensive. It is painfully expensive. The program, along with CHIP (the Children's Health Insurance Program), marketplace subsidies and Medicare is responsible for 25% of the federal budget. Total Medicaid costs in 2016 were around $532 billion per the Kaiser Family Foundation. States fund up to half of the cost of Medicaid, and in my state, Idaho, our share of Medicaid and related payments makes up about 21% of the state budget. Medicaid is a safety net that allows people who can't afford private insurance or to pay out of pocket to get healthcare. It pays for doctors' fees, preventive care services, hospital care, mental health care, the majority of women's costs for pregnancy and childbirth and costs for the impoverished elderly who are in nursing homes. It pays for emergency room visi...

Last week was a big week. Many patients. Lots of bedside ultrasound. I've blogged on and on about my undying love for ultrasound at the bedside as a part of my physical exam. It keeps being powerful. It saves peoples' lives. It keeps me from making stupid mistakes. I am eternally grateful. This week it helped with the usual things--hearts and bellies and bladders and lumps and bumps. I was able to tell patients what was going well and not so well, in real time, and show them pictures. But ultrasound of the lung needs a little advertisement. Ultrasonographers and radiologists are terrific at imaging the internal organs, even those of tiny babies. Cardiologists and echocardiogram technicians are amazing in their ability to image the heart and describe its innermost workings. Although I leverage my ultrasound abilities by using my other exam and history taking skills, I do not have the extensive training in imaging that these people do. But in the US, only clinicians suc...

I hear many of my progressive friends say that "obviously what we need is a single payer." That could work, but it is definitely not a sure thing. Overall what we want most is universal access to healthcare at a cost that is affordable. Why, some may ask, does it need to be affordable? Why can't it just be free, like in Canada? That's a wonderful thought, sort of. It also ignores the big truth that healthcare is like any other resource and is not free. It is always paid for by all of us. The difference between a single payer and multiple public and private payers, which we have now, is the degree to which we feel the pain of paying for it. Healthcare costs are paid by our employers, and thus from our wages, our taxes and directly from our purses in the forms of premiums and copays. There are problems with universal access to healthcare, too. As a nation of people with various values, it is probably safe to say that most of us want sick people to be able to go ...