4.13.2009

The high price of keeping you sniffle-free

The art of medicine consists in amusing the patient while nature cures the disease.
- Voltaire

Megan McArdle was apparently given the daunting task of explaining why health care costs so much over at The Atlantic. While I think the question probably requires more than a blog post can provide, her explanation is pretty good. I have a couple of things to say. First, the quibble:
[D]rug industry profits were a tiny portion of healthcare spending. If we eliminated all profits--hell, double it to account for the much maligned "marketing costs"--we'd possibly push down expenses by another 0.5% of GDP. But as with insurance administrative costs, it's more complicated than that. Without profits, no one would do R&D--and on net, drugs save us money, because they often replace expensive procedures. Years of statins are still cheaper than one hospital stay for a heart attack or stroke. And about half the marketing cost is free samples, which most people would agree are a good and useful device for letting patients see whether a drug works for them.
Well, I don't know about most people, but I am pretty ambivalent about free drug samples. Sure, they're useful for letting patients see how a drug works for them, but often they are expensive "me, too" name-brand drugs, which are no better than older medications that are available as relatively cheap generics. It doesn't help bring down health care costs to start patients on free samples and then prescribe the medication for long-term use. Free samples are given out because they make money for the pharmaceutical industry, and are a mixed blessing at best.

However, what I really wanted to mention is Megan's second of three reasons we pay more:
2) We consume more services. Americans get shiny new facilities--my British colleagues once derisively commented that American hospitals are "like hotels". American hospitals don't have open wards for almost anyone. They staff at very high levels. Doctors conduct an inordinate amount of tests. We use an expensive machine rather than watchful waiting. And often, those expensive machines catch conditions that never would have turned into anything, which we then treat.
This is, frankly, true. Speaking as just one provider, I feel a lot of pressure much of the time to Do Something when some kid is sick. It is hard to explain to distressed parents with an ill child that there is probably not a heck of a lot to be done, and the little guy is just going to have to get better with time. I know the axioms I was taught in medical school about not ordering tests unless there is some specific question to be answered, with an impact on anticipated management. (In other words, don't order tests just because you're shooting in the dark, but only if they're actually going to make a difference in what you're going to do.) But it's hard to tell people to ride things out, and some people are more tolerant of this answer than others. Ordering "screening labs" or chest x-rays gives the impression that you're intervening in some way, even if the expectation is low that there is anything to be found.

This also applies to prescribing medications. People don't like to feel bad, or to have their kids feel bad. And they want you to Do Something about it. While I'm having some success with delaying antibiotics for ear infections, for example, this approach doesn't work with everyone, and it's a hard, hard conversation to try to talk people out of their expectation of leaving the office with a prescription to fix things, even if no such prescription exists.

I think the pressure to Do Something, with its attendant expectations that we should live lives free of every cough, sniffle, ache and sneeze, accounts for much of our health care costs. Add in the mortal fear that most physicians have of missing that subtle finding that revealed the insidious disease, and getting sued back to the Pleistocene by a vengeful patient or family, and you've got a lot of unnecessary tests. Unfortunately, the solution lies in changing people's attitudes about illness, and that's a lot harder to do than vilifying drug companies.

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