POLICY/QUALITY: Why does Health Care in the USA cost so much? Over-utilization is an important factor by Walter Bradley

Walter Bradley has not only written the shorter piece today, but has sent me a longer piece citing over-utilization as a cause of high health care costs in the US. I'm inclined to agree with him even if Anderson doesn't. It's a longer more academic piece and I've buried most of it behind the fold.

Introduction

The United States (US) invests a higher proportion of gross domestic product (GDP) on health care than all other developed countries, despite which the US population suffers poorer access, a higher individual financial burden, inefficient care and a higher medical error rate than people in most other developed countries.

 

The US expenditure on health care in 2004 was 16.0% of the GDP ($1.9 trillion total or $6,280 per capita), and this is forecast to rise to 16.5% ($2.2 trillion) by 2006 and 20.0% ($4.0 trillion) by 2015.¹ The annual rate of inflation of expenditure on health care 2002-2004 was about 8.4%, which far exceeded the rate of inflation for all other items in the US economy. ^1,2 By comparison, in 2001, when the US expended 14.6% of GDP on health care,  the next highest percent of national GDP spent on health care was Switzerland (11.1%), followed by Germany (10.7%) and Canada (9.7%); the United Kingdom spent 7.6% of the GDP on the National Health Service. ³ 

Despite this high expenditure in the US, the 2005 Commonwealth Fund International Health Policy Survey of sicker adults from six countries (Australia, Canada, Germany, New Zealand, United Kingdom and US) found that “(t)he United States often stands out with high medical errors and inefficient care and has the worst performance for access/cost barriers and financial burdens.” ⁴ The US lags behind many other countries in indices of quality of care. In 2006 the US ranked 43^rd among the world’s nations in infant mortality, with 6.43 infant deaths per 1,000 live births, behind the top performing nations such as Singapore (2.29), Sweden (2.76), France (4.21), Canada (4.69) and United Kingdom (5.08), ⁵ and was 29^th among developed countries in maternal mortality. ⁶ Schoen et al. (2006)⁷ found that the US lags behind other countries on indicators of mortality and healthy life expectancy, with the US performance relative to a benchmark of 100 being 51 for efficiency and 66 across all domains, the lowest for any comparable country. A 2006 survey of primary care physicians in Australia, Canada, Germany, New Zealand, the Netherlands, the United Kingdom, and the United States revealed “striking differences in elements of practice systems that underpin quality and efficiency. ….. U.S. physicians were among the least likely to have extensive clinical information systems or incentives targeted on quality and the most likely to report that their patients have difficulty paying for care.” ⁸

The US public is becoming increasingly concerned about quality of health care, rising proportion of premiums and charges that fall on employees in employment-based health insurance, timely access to urgent care, availability of physicians and rate of medical errors. ^{4, 8-11}

Several elements of the current US health care system have been suggested to be responsible this high cost, including bureaucracy and administration, malpractice insurance and defensive medicine, high cost of goods and salaries of health care workers, and over-utilization.

Administrative costs absorbed 31% of total health care expenditures ($1,059 per capita, or $294 billion total per annum) in the US in 1999 compared to 16.7% ($307 per capita) in Canada.¹² Medical malpractice premiums have increased greatly in the last two decades and the direct cost of malpractice losses incurred in the US amounted to $6.5 billion in 2001. ¹³ Fear of litigation leads physicians to practice defensive medicine, including doing unnecessary tests. Studdert et al. (2005) ¹⁴ found that 92% of practitioners in high-risk specialties practiced defensive medicine. Extrapolation from their data suggests that defensive medicine may increase the medical (physician and hospital services) element of health care expenditure by at least 30%.

On the other hand, Anderson et al. (2003) ¹⁵ stated that “It’s the Prices, Stupid”, arguing that the high cost of health care in the US results from the price of goods and services (salaries of those that work in the health system, pharmaceuticals etc.) being much higher in the US than in other countries. They later presented evidence that supply constraints and cost of malpractice claims are not major factors in the high costs. ¹⁶ 

 

Over-utilization in the US health care system

Though there is little reliable information about the extent of over-utilization in the US health care system, informal discussions between physicians from the US and other developed countries leave no doubt that, for the same diagnosis, US patients with health insurance receive many more medical services than those in other countries. US physicians tend to order many tests to rule out unlikely or rare conditions, while those in other countries tend to be more cost-conscious.

Over-utilization of health care services in the US has many causes. Defensive medicine is one of them, but another is the profit motive. The income of medical facilities and physicians increases when more tests are performed. As Allen (2003)¹⁷ pointed out, the US third-party payment system rewards technologically intense services. Surgical and other procedures are reimbursed at a higher level per unit of time expended by the practitioner than are cognitive services. This leads to the tendency for medical students who wish to make money to select higher paying procedural-based disciplines. ¹⁸ 

Physicians’ mode of practice and patient expectations are inextricably intertwined. Patients generally believe that more tests are better than less. For instance, patients with migraine headaches often request an MRI scan of the brain because they believe that a doctor cannot exclude a brain tumor without a thousand dollar test. Patients given a diagnosis like multiple sclerosis or amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease) usually go to several other doctors looking for a “better answer”, each of whom will do yet more tests.

Neither physicians nor patients with third-party payment-type health insurance have any incentive to practice cost-effective medicine. Medical students do not receive courses in this. The original concept of the Health Maintenance Organization (HMO) was to make the physician a stakeholder in cost-containment, but the rigorous application of this was generally unpopular. More recently, health insurance companies offer patients a series of plans with graded premiums and deductibles, the more costly of which allow the patient more flexibility. However, it has yet to be demonstrated that these reduce the number of services received by patients.

Patient expectations and national characteristics of medical practice may be important factors in the high cost of health care in the US. Five vignettes from my academic neurology practice illustrate over-utilization in the US health care system.

 

Vignettes of over-utilization

 

Vignette 1: “Do I need a back operation?”

The story. A friend told me that he was scheduled for back surgery the following week. His general practitioner had referred him to an orthopedic surgeon, who had arranged X-rays of his back and hips, a CT of the abdomen and an MRI of the lumbosacral spine. He was told these showed discs pressing on the nerve roots going to the sciatic nerve. I asked him about his symptoms. He had intermittent right leg pain for a year, but when he said there was no accompanying back pain I suggested he made an appointment to see me.

In my office he told me he was 67 and previously in good health apart from a mild heart attack five years ago. The pain in the right leg started a year ago in the calf and lately was also in the thigh, and came with walking. Originally the pain would come when he walked for half an hour, but gradually the distance had decreased and now the pain would come after walking a block. It would disappear if he rested for thirty seconds and again he could walk a block before the pain stopped him again. He was surprised I asked him all these questions, since his general practitioner and orthopedic surgeon had not interrogated him like this.

Examination showed that there were slight signs of damage of the right S1 nerve root and absent arterial pulses in the whole of the right leg. It was clear that the cause of the exercise-induced pain was blockage of the arteries of the right leg above the groin and that he needed an operation to open these arteries, not surgery on his lumbar spine to remove herniated discs.

     The cost. The medical and surgical consultations up to that time cost about $1000 and the X-rays, CT and MRI scans probably cost about $4000. The total cost of the unnecessary back surgery would have been at least $10,000 and more if there had been complications. All this could have been avoided if his doctors had taken the history of his complaints, rather than saying: “Pain in one leg? Must be a back problem. Get these tests and we will see what needs to be done.”

 

Vignette 2: “We cannot let the patient starve to death.”

     The story. The aunt of a friend developed Alzheimer’s disease in her 70s. She went into a nursing home, progressively deteriorated, became incontinent and bed-bound, and was eventually totally unresponsive. When the nurses began to find it difficult to feed her by mouth, the doctor said that a gastrostomy tube needed to be inserted into her stomach to allow them to continue her nutrition. The patient had a living will but her niece wanted everything done to prevent her aunt suffering and gave permission for the procedure.

     The cost. The total cost of placing the gastrostomy tube was about $1500. The patient lived for another two years in the nursing home costing Medicaid and Medicare over $120,000. The right course of action would have been to declare further medical care futile and simply provide comfort care for the patient, allowing her to die peacefully.

 

Vignette 3: “I cannot let my mother die.”

     The story. A 70 year old lady was standing by the side of the road when she was hit by a car, thrown thirty feet, and sustained a severe head injury. She did not have a living will but had told her family that she never wanted to live “as a vegetable”. She underwent emergency surgery to remove clots inside the skull and brain, but remained in a coma on a ventilator. A week later the director of the intensive care unit met with her son and daughter to tell them that there was no hope of their mother recovering. The son asked: “Is my mother brain-dead?” The doctor said that technically she was not. The son then asked: “Are you telling me that she will not make any recovery?” The doctor said that she would make a little recovery but would probably never be able to survive outside a nursing home. The doctor offered to withdraw the ventilator and keep his mother comfortable, but the son said he wanted everything done for his mother.

     The cost. She remained in the intensive care unit for another month, which cost of about $100,000, and then went to a nursing home. She could live another five years at a cost of more than $300,000 a year. The best course for the patient would have been for her to have completed a living will years before and to have made sure that her children understood that the ventilator should be turned off if she had such an accident.

 

Vignette 4: “You need a colonoscopy.”

     The story. An 87 year old lady was brought by her daughter because of memory problems. Examination showed that she had early Alzheimer’s disease. Her daughter said that her doctor was looking after her hypertension and diabetes, and had arranged a colonoscopy next week because “everyone needs the test every ten years to prevent colon cancer”.

     The cost. The total cost of the colonoscopy might have been $1100. However, she was a frail old lady and might well have suffered complications from sedation and the procedure, and might even have died. The colonoscopy was unnecessary in a lady who was already dementing and who probably had less than two years to live.

 

Vignette 5: “You have Lou Gehrig’s disease.”

     The story. This is the story of a typical US patient with ALS. He became aware of some neurological symptom, such as dragging the feet, wasting of a hand, flickering of muscles, or slurred speech, and consulted a neurologist. The neurologist found signs that strongly suggested the diagnosis of ALS but did not tell this to the patient. Recognizing that at this moment ALS is incurable, the neurologist, according to US practice, wanted to make absolutely sure that no other condition was responsible for the symptoms. The patient had a large number of expensive blood tests, MRI scans of the brain and spinal cord, electrodiagnostic studies and a spinal tap. The patient kept coming back to the neurologist for further examinations and tests, while he gradually develops more disability. About a year later, the neurologist finally told him he had ALS.

     The cost. Leaving aside the emotional cost to the patient of being left uncertain for a year about what is causing the progressive paralysis, the financial cost to the health system of these tests may be about $10,000. Additionally, a number of patients undergo unnecessary spine or nerve surgery as a result of mistaken advice that this may arrest their condition.

 

 

Discussion

 

Reference was made in the Introduction to the part that administration, malpractice insurance, defensive medicine and the price of goods and services play in the high cost of health care in the US. The five vignettes above provide examples of over-utilization of medical services that add to the cost of health care in the USA.

Matters Raised by the Vignettes

The primary care physician of patient in Vignette 1 failed to make the right diagnosis and referred the patient to the wrong specialist. This led to incorrect investigations and could have led to unnecessary surgery. The answer to this problem might seem simple; we need to train primary care doctors better. An improvement in the primary care base in the USA, with everyone having a well-trained family physician, would go a long way to help.

It has long been recognized that the US does not have a comprehensive primary care network and needs to train more primary care physicians.¹⁹ The United Kingdom has about 550 family practitioners per million of the population, ²⁰ while Canada has about 740 primary care physicians per million. ²¹ In comparison, the American Academy of Family Practitioners has about 58,500 active members, ²² or 200 per million of the US population. In the US internal medicine specialists also provide primary care for many patients, perhaps without the breadth of training of family practitioners. The American College of Physicians has about 104,000 full members of whom perhaps a half (approximately 180 per million of the US population) provide some primary care. ²³ Physician assistants and nurse practitioners, who number about 500 per million of the US population,²⁴ provide primary care but are not as fully trained in diagnosis as are family practitioners.

Vignettes 2 and 3 illustrate different aspects of how society bears the financial burden of decisions made by physicians and families, since both patients were covered by Medicaid and Medicare.

The doctor in Vignette 2 might well have told his wife that he would not want to be kept alive if he developed advanced Alzheimer’s disease, but nevertheless he felt unable to tell the niece that continuing care was futile and that her aunt should be allowed to die peacefully without a feeding tube. The family of the patient in Vignette 3 could not give up hope of recovery of their mother despite the strong advice of the doctor that no useful recovery would occur.

Neither the doctor in Vignette 2 nor the family in Vignette 3 was a stakeholder in the financial burden, otherwise they might have made their decisions taking into account the issue of cost.

The doctor in Vignette 4 may have been practicing defensive medicine, making the recommendation for a colonoscopy to prevent himself being sued if the patient were later to develop colon cancer, or he may have been “doing things by the book”. However, he was not thinking of the patient as a whole, nor was he trying to limit health expenditure.

Vignette 5 illustrates the high use of resources in the US for diagnosing condition for which there is no definitive test and the diagnosis is based solely on clinical findings. The World Federation of Neurology published guidelines for the diagnosis of ALS ²⁵ that were intended for use in clinical research trials, but, as can be seen from Vignette 5, their use in clinical practice leads to the high cost of making the diagnosis of ALS in the US.

Comparison of Practice Patterns in the US and other Developed Countries

 

My personal experience of practicing in both the United Kingdom and US indicates that practitioners in the US uses many more investigations and perform many more surgical procedures. One reason for this is that health care in the US is based on a third-party payer business model. Physicians treat patients and bill insurance companies or Medicare. The more procedures the physician performs, the more his income. The consumer (the patient) does not have sufficient knowledge to judge if the doctor is investigating and treating the illness in the most cost-efficient way. As far as the patient is concerned, the doctor doing twice as many tests is the better doctor. Co-payments place some of the cost onto the patient’s shoulders but the patient has no basis for knowing whether he could have been diagnosed and treated for half the price.

With regard to cost-containment and cost-efficacy, medical care does not follow classic market place economics. None of the models that have been developed to contain costs in the US, such as HMOs, gatekeepers, fee reductions and regulations imposed to reduce Medicare expenditure have achieved the goal of bringing US health care expenditure into line with that in other developed countries. It seems likely that this will not happen until the business model is changed, at least for a sizable proportion of the US public.

This is not to say that the business model of medical care is without success. The US leads the world in technological advances in the diagnosis and treatment of disease as a result of entrepreneurship. However, it is becoming clear that the US cannot support the cost of the most advanced care for all its citizens unless it is also cost-effective. The high cost of medical care in the US is responsible for the ever-increasing number of individuals without health insurance, 46.6 million (15.9% if the population) in 2005. ²⁶

There are few studies comparing the care of similar patients in different countries. Rohde et al. (2005) ²⁷ compared the treatment of patients with decompensated congestive cardiac failure in Brazil and the US, but did not reference cost. In 2002 Gandjour et al.²⁸ compared cost and outcomes of treatment of acute myocardial infarction in European countries, and in 2005 they reported a similar study of acute back injury. ²⁹ Neither study presented US data. Asplund et al. (2003) ³⁰ compared health outcomes in a stroke treatment trial in 19 countries including the US and found a wide disparity in the use of medical resources, despite there being no difference in health outcomes in the various countries. They concluded that “(d)ifferences in health care traditions (treatment pathways) and social context seem to be major determinants of resource use.”

There is a need for more studies of the type reported by Vader et al. (1997) ³¹, who developed criteria for appropriate upper gastrointestinal endoscopy by presenting about 500 standardized patient-care scenarios to Delphi panels of physicians from US and Switzerland. Criteria derived from such studies could be compared with observed patterns. ^28-30 Only in this way will it be possible to measure how much of the high cost of health care in the US is due to practice differences in the different countries and whether this influences health outcomes. Buto and Juhn (2006) ³² have argued that a quasi-governmental center would best be able to undertake such comparisons of cost-efficacy.

 

Teaching the Practice of Cost-effective Medicine

We have not trained US doctors in cost-effective medicine.³³ However, now the Accreditation Council for Graduate Medical Education (2006) Outcome Project requires US residency programs to teach and evaluate six core competencies, including systems-based practice, one element of which is to "practice cost-effective health care and resource allocation that do not compromise quality." ³⁴ There is good evidence that teaching and applying cost-effective medicine can reduce patient care costs by about 25%. ^35-42

Licensing and board-qualifying examinations could be used to stimulate the practice of cost-effective medicine. The candidate could be given a patient vignette and asked to come to a diagnosis by choosing one from a series of investigations. The test result would then be revealed and might or might not be relevant to the diagnosis. A further series of investigations would now be made available together with those remaining from the original series. Points would be awarded for choosing appropriate investigations and deducted for choosing the wrong (unnecessary) investigations. The goal would be to make the correct diagnosis using the smallest number of investigations, that is, by practicing cost-effective medicine.

 

 

 

Recommendations

 

1.   Research should be directed to compare medical practice in the US and other developed countries by using standardized patient scenarios.

2.   US physicians should be trained in cost-effective medicine.

3.   A center for evaluating comparative effectiveness of medical care should be developed, similar to that recommended by Gail Wilensky, former administrator of the Health Care Financing Administration.⁴³

4.   An alternative system for the provision of health care in the US that mandates cost-effectiveness and cost-containment should be developed. This might be based on the Massachusetts model of universal coverage. ^44-47

5.   The US health care system should be re-organized to make physicians stakeholders in the total expenditure on health care in the US.

 

 

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