Analyzing the factors behind America’s expensive yet ineffective healthcare system.

The US spends more money on healthcare than any other country in the world at $3.5 trillion, or 18% of the US GDP. What makes the situation utterly irredeemable is that this spending does not translate into the US having the best outcomes or highest life expectancy worldwide. In fact, in the 2016 Global Burden of Disease study, the US healthcare system was ranked only 29th in the world, and, in 2017, the CIA ranked US life expectancy as only 43rd in the world. The problem lies in the US healthcare system. Healthcare reimbursement is set up so that sick care is valued over health care: the US mops the floor instead of shutting off the faucet. Moreover, doctors’ concerns about upsetting patients and potential resulting legal repercussions lead to expensive, unnecessary care with overtesting, overdiagnosing, and overtreating. America’s healthcare system is broken. Imagine that every person in the US crosses a bridge that hangs over a fast-paced stream daily. The walls of this bridge are relatively low, so people occasionally fall into the stream. Once in the stream, a professional fishes them out, or at least tries to. Often, the same person falls off the bridge, again and again, and needs to be rescued from the stream, again and again. In a nutshell, this is the current US healthcare system where intervention takes precedence over prevention. Instead of building higher walls on the bridge or installing a safety net, the US healthcare system focuses primarily on downstream interventions. We treat symptoms rather than addressing the root causes. Indeed, the Pareto Principle explains how 20% of patients account for 80% of healthcare costs because these patients keep coming back to the ER with the very same chronic diseases that are treated but never healed.

The Bridge of Healthcare
(Image: Fight to Rescue American Healthcare [Video file]. (2012). Retrieved from https://tubitv.com/movies/300834/escape_fire_the_fight_to_rescue_american_healthcare?autoplay=true &utm_source=google-feed&tracking=google-feed)

Primary care physicians (PCPs) are perhaps the most significant specialty in the entirety of medicine as, after all, they are the base of the pyramid of healthcare. Indeed, they are the vanguard of preventive medicine, but our current healthcare system does not permit them to properly do their job. The US government and insurance companies alike do not sufficiently emphasize preventive medicine as they reimburse these PCPs based on the number of patients they see, not the outcomes they produce. Therefore, to merely stay afloat, PCPs must rush through patient visits, unable to properly take a history or give patients the quality time and care they deserve. Many PCPs thus feel as if they cannot help their patients in a truly meaningful way, contributing to widespread disillusionment and burnout. From a patient’s perspective, the experience is perhaps even more harrowing. After waiting for sometimes hours on end, partly in the waiting room and then partly in the examination room, the frenetic physician finishes the visit in perhaps fifteen minutes, leaving little time to answer the patient’s questions. Often times, these patients are just referred off to a specialist because the PCP genuinely does not have the time to dig deeper, to diagnose and address the underlying issues as they are trained to do. This problem is only accentuated with the acute PCP shortage the US is experiencing as more and more new doctors become higher-paying specialists. Many patients in the US have also never seen a PCP. The failure or inability to interact with this first line of defense against disease often results in these patients arriving in the emergency department with severely exacerbated conditions that could have been caught and treated in the condition’s earlier stages. Furthermore, the goal in the emergency department is almost always reduced to merely intervening to relieve acute symptoms. Heart attack? Put a stent in the coronary artery to relieve the chest pain and then send the patient home. In the emergency department, time is rarely put towards prevention, towards empowering the patient to live a healthier lifestyle to, for example, prevent heart attacks in the first place. Therefore, that same patient may very well come back to the emergency department a few months later with yet another heart attack because the underlying issue was never dealt with it. The US healthcare system is much more comfortable with employing drugs and surgeries instead of the low-cost but extremely effective lifestyle changes.

The Extent of the Primary Care Physician Shortage
(Image: Shortage of primary care physicians [Image]. (n.d.). Retrieved from https://theleadingphysiciansoftheworldblog.wordpress.com/2017/03/22/infographic-shortage-of-primary -care-physicians/)

The US spends an unaffordable amount of money on healthcare, and unnecessary care helps to explain these out-of-control healthcare costs. In short, more is not always better. However, doctors, not wanting to risk legal repercussions may overtest, using the latest, but expensive, technology without regard to the guidelines. For instance, despite the American College of Radiology recommending against imaging patients with uncomplicated headaches, CT and MRI scans for headaches have steadily been on the rise, from 5% in 1995 to nearly 15% in 2010. Moreover, the patient often values the doctor who does something over the one who does nothing, even when that something is entirely unnecessary. Besides the additional radiation exposure associated with unnecessary CT scans, overtesting also results in expensive overtreatment. In a piece in the New Yorker, author and endocrine surgeon Atul Gawande compares overtesting to a “fishing expedition,” and “since no one is perfectly normal you tend to find a lot of fish.” The problem is that these fish, in particular, are nearly always medically irrelevant, yet they must be investigated and perhaps treated to avoid purported medical negligence. Overtesting and overtreatment do not generally improve outcomes; they just increase healthcare costs. The economics of healthcare also wrongly encourages physicians to simply do more. Surgeons, for instance, are paid for each surgery they perform. The economics does not care whether the patient actually needs the surgery, whether the benefits outweigh the costs, or whether the patient is better off after the surgery than before. After all, a surgeon does not get paid the same for dissuading a patient from surgery, even if that is in the best interest of the patient and the healthcare system as a whole. The US healthcare system creates this problematic mismatch of incentives between physician and patient. In Less Medicine, More Health, Professor Welch at Dartmouth compares cancers to “rabbits that you want to catch before they escape”; the fast-moving and malignant cancers are more similar to birds while the slow-moving and completely-asymptomatic cancers are more similar to turtles. These turtles are inconsequential and should just be monitored and observed, but if found, they are often removed, either at the surgeon or patient’s insistence, for absolutely no benefit. Considering that medical error and hospital-acquired infections are one of the leading causes of death in the US, unnecessary care is likely worse than not beneficial; unnecessary care is downright harmful.

Atul Gawande’s New Yorker Article on Healthcare “Overkill”
(Image: New yorker: “Overkill” [Image]. (n.d.). Retrieved from https://occtegrity.com/the-collateral-damage-of-unnecessary-medical-care/)

In its current state, the US healthcare system is, unfortunately, a disease care system. Interventionist medicine supersedes preventive medicine so that symptoms remain under control while the underlying cause is hardly ever addressed. Unnecessary care harms patients and skyrockets healthcare costs, which, in a significant part, must be paid by the American taxpayer. Only when society as a whole begins to reward preventive medicine and improving outcomes over doing more simply for the sake of doing more can we truly reform healthcare. This goal will require a revolutionizing of US government priorities when it comes to healthcare. This goal will require a revolutionizing of medical schools to emphasize prevention over intervention. This goal will require a revolutionizing of patient expectations when going to the doctor’s office as patients will need to be empowered to take their health back into their own hands. Together, we can work to mend the broken US healthcare system.

References

American health care: Health spending and the federal budget. (2018, May 16). Retrieved June 27, 2019, from Committee for a Responsible Federal Budget website: https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget Escape fire: The fight to rescue american healthcare [Video file]. (2012). Retrieved from https://tubitv.com/movies/300834/escape_fire_the_fight_to_rescue_american_healthcare?autoplay=true &utm_source=google-feed&tracking=google-feed Fullman, N., Yearwood, J., Abay, S., & Abbafati, C. (2018). Measuring performance on the healthcare access and quality index for 195 countries and territories and selected subnational locations: A systematic analysis from the global burden of disease study 2016. The Lancet, 391(10136), 2236-2271. Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30994-2/fulltext Gawande, A. (2015, May 4). Overkill. Retrieved June 27, 2019, from The New Yorker website: https://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande New yorker: “Overkill” [Image]. (n.d.). Retrieved from https://occtegrity.com/the-collateral-damage-of-unnecessary-medical-care/ O’Donoghue, G. (n.d.). [Our Healthcare System has a Finite Number of Workers]. Pendick, D. (n.d.). Most headache-related brain scans aren’t needed. Retrieved June 27, 2019, from Harvard Health Publishing website: https://www.health.harvard.edu/blog/headache-related-brain-scans-arent-needed-201403197080 Shortage of primary care physicians [Image]. (n.d.). Retrieved from https://theleadingphysiciansoftheworldblog.wordpress.com/2017/03/22/infographic-shortage-of-primary -care-physicians/