Control health costs? Look in the mirror first

By Andrew G. Kadar

Most of us are happy with the medical care we receive; we just think it costs too much.

We want to maintain all the conveniences and quality we currently have, provide the same care to all the uninsured and pay less for the whole package.

Politicians hold out the promise that we can do all of this if only doctors, hospitals and insurance companies behave a bit better, become more efficient, computerize record keeping, act a little less greedy.

Patients, we the people, don’t have to change one bit in this fantasy.

If we want to get serious about reforming health care, if we want to cut costs, then we have to look in the mirror as well as point fingers.

We cannot seriously analyze any transaction, including medical care, by looking only at the supply side, ignoring the demand side of the equation.

Americans simply expect and demand more timely, more convenient, more technologically advanced and, therefore, more expensive care than people in other countries.

We don’t want to wait for weeks and months for diagnostic tests like MRIs and colonoscopies.

Once we believe a procedure will benefit us, we want it when we want it, at our convenience, not at the convenience of the providers.

In other countries, people expect and accept that there may be a long wait for tests, particularly those that involve expensive equipment.

The economic equation is quite simple: more MRI machines in a community lead to shorter waits to get tested and higher costs.

If we have enough so that people can get tested promptly, then some of the time the equipment will lie idle waiting for patients.

If the machines are scarce, then they will be in constant use while people wait their turn to be tested.

The U.S. has more than four times as many MRI machines per million people than Canada or Great Britain; Canadians perform nearly 40 percent more exams per scanner.

Since MRI machines don’t come free, our greater capacity generates higher per test expenses.

To compound the cost differential, if pricey machinery is scarce, fewer tests will actually be performed. Some people will get well while waiting; some will choose to live with their symptoms; some die before their turn at the front of the line.

American orthopedists perform far more total knee and hip replacements than their counterparts in any other country.

The incidence of knee replacements in Americans over 45 is nearly 50 percent higher than in Britons and more than double the rate among Swedes. A total joint operation costs a whole lot more than a cane.

Wealthy people, people with clout in other countries receive artificial joints at a higher rate than their poorer, less influential countrypeople.

American-style private practice medicine tends to be available only for the elite in other countries.

Total hip and knee replacements reduce pain, increase walking ability, improve quality of life.

They don’t prolong life and, therefore, don’t show up in any of the comparisons that critics of American medicine like to point to — the statistics that highlight that we spend more money on medical care but don’t have the longest life expectancy, the comparisons that ignore lifestyle differences between countries and the numbers that neglect quality of life measures and patient expectations.

Our wasteful malpractice lottery system also adds enormously to health care costs.

Defensive medicine leads doctors to order diagnostic procedures that are likely to yield very little to no useful information.

Yet if a patient turns out to have a rare problem that a low-yield test might have revealed, the doctor that neglected to order that study stands a high chance of facing a very hostile plaintiff’s attorney.

The U.S. leads the world in malpractice lawsuits by a wider margin than it does in medical technology or medical expenses.

Health care providers can surely improve in many ways, but that’s only half the story.

If we want to get serious about improving our medical care delivery system, then we have to look at the whole picture, including the demand side of the equation.

If we insist on the latest technology, promptly and at our convenience, if we permit legislators to continue to guard the lawyer enrichment program of our current malpractice system, then no matter how efficient and altruistic health care providers become, we will continue to face higher costs than people in other countries.

Andrew G. Kadar is an attending physician and an assistant professor at Cedars-Sinai Medical Center in Los Angeles.