Stud­ies, events show U.S. health­care is a costly busi­ness

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Tot­ing up the real cost of U.S. health­care

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The past few days have brought more ev­i­dence of skewed costs and uti­liza­tion in the Amer­i­can health­care sys­tem. One glimpse came in a study in the Jan. 17 is­sue of the An­nals of In­ter­nal Medicine. A com­mit­tee of the Amer­i­can Col­lege of Physi­cians com­piled a list of what it termed com­monly overused screen­ing and di­ag­nos­tic tests.

Health ex­perts are in­creas­ingly aware that test­ing is over­done in this coun­try. Even mi­nor com­plaints can trig­ger a cas­cade of pro­ce­dures, in­clud­ing ra­di­o­log­i­cal scans and ex­ploratory surgery. Not only does this Wild West ap­proach to test­ing drive up costs, it also puts pa­tients at risk of un­nec­es­sary and pos­si­bly dele­te­ri­ous treat­ment be­cause of false alarms.

“Ef­forts to con­trol ex­pen­di­tures should fo­cus not only on ben­e­fits, harms and costs but on the value of di­ag­nos­tic tests—mean­ing an as­sess­ment of whether a test pro­vides health ben­e­fits that are worth the costs or harms,” the ACP re­port said.

A sec­ond study, in the Jan. 23 Archives of In­ter­nal Medicine, high­lighted an­other rea­son be­hind the ex­plo­sion of med­i­cal costs. Har­vard Med­i­cal School re­searchers found re­fer­rals from one doc­tor to an­other—of­ten a spe­cial­ist— in­creased 159% from 1999 to 2009. The prob­a­bil­ity that a doc­tor visit would re­sult in a re­fer­ral in­creased from 4.8% to 9.3%.

Physi­cians with an own­er­ship stake in their prac­tices or those who re­ported that more than half their in­come came from man­aged-care con­tracts posted sig­nif­i­cantly lower rates of in­creases in re­fer­rals.

Dr. Bruce Lan­don, one of the re­searchers, told the New York Times that the grow­ing com­plex­ity of medicine has driven the re­fer­rals to spe­cial­ists. But he also cited the “tyranny of the 15-minute visit” with pri­mary-care physi­cians, who lack the time and re­sources to delve into complicated con­di­tions.

This isn’t sur­pris­ing. Slightly more than 40% of U.S. physi­cians de­liver pri­mary care—pretty much the mir­ror im­age of pri­ma­rycare/spe­cial­ist break­downs in other ad­vanced na­tions. The fi­nan­cial in­cen­tives here over­whelm­ingly fa­vor spe­cial­ists, who some­times make two or more times what their pri­mary-care col­leagues earn.

De­spite the flaws, the Amer­i­can health sys­tem re­mains re­sis­tant to cost-con­trol ef­forts. In last week’s is­sue (Jan. 23, p. 6), we re­ported on the dis­mal re­sults of at­tempts to rein in Medi­care spend­ing. The non­par­ti­san Con­gres­sional Bud­get Of­fice said a study of 10 ma­jor demon­stra­tion projects in care co­or­di­na­tion and value-based pay­ment showed that most did not trim spend­ing. Ex­perts cited sev­eral rea­sons for the fail­ures, in­clud­ing the fact that doc­tors of­ten don’t talk to each other.

Set­ting prices may help. One of the pro­grams stud­ied by the CBO made bun­dled pay­ments to doc­tors and hos­pi­tals for heart by­pass surg­eries and re­duced costs by 10%.

Mean­while, U.S. costs drew in­ter­na­tional scru­tiny. Cana­dian freestyle skier Sarah Burke, con­sid­ered a 2014 Olympic con­tender, was in­jured Jan. 10 while train­ing in Park City, Utah, ac­cord­ing to news re­ports. She was flown to the Univer­sity of Utah’s Health Sci­ences Cen­ter in Salt Lake City, where she died af­ter nine days in a neu­ro­log­i­cal crit­i­cal­care unit. Her ski as­so­ci­a­tion in­sur­ance did not cover the event where she was hurt. News re­ports that her fam­ily might face hun­dreds of thou­sands of dol­lars in med­i­cal bills sparked a wave of dis­be­lief and crit­i­cism in the me­dia in Canada, where no cit­i­zen would be at risk for such steep ex­penses.

Nei­ther Medi­care nor pri­vate pay­ers have made a se­ri­ous dent in U.S. costs in re­cent years. Don’t be sur­prised when this coun­try turns to the more rigid price and uti­liza­tion con­trols em­ployed in some other na­tions.

NEIL MCLAUGH­LIN Man­ag­ing Ed­i­tor

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