US-healthcare
The price of it all

Rinckside 2013; 24,8: 15-16.

t's always a painful sensation when one realizes that a service or a product one pays for is overpriced and of inferior quality. At times I am asked to give a second opinion about imaging examinations, mostly magnetic resonance studies made in private offices in the U.S.A.. It's usually patients from Latin America who traveled to the US because they believe that the health system in Miami, New York or Chicago is better than in their home country. Many among them would be aptly and correctly served at home by well trained radiologists, even better than in the U.S.A..

Usually the quality of the studies I see is sufficient to make a diagnosis, but in a number of cases there is no reason to be proud of the radiological work. Equipment main­ten­ance is not written with a capital M and image artifacts are common — it seems that the more expensive the apparatus is the more artifacts you get. Sometimes one also wonders whether there is enough competence, experience and professional integrity to choose certain kinds of studies, and to perform and evaluate them. However, it's not my business to discuss this with a patient or colleague who just wants my opinion concerning a certain study and diagnosis.

Often I am told what the patients were charged for their studies. Again, I don't com­ment on the prices although sometimes I have to swallow hard. I got a health insurance that covers treatment all over Europe and the rest of the world. It is not cheap. The US is the only country that is explicitly excluded: for the US one needs an additional in­sur­ance — some in­sur­ance brokers even suggest air-evacuation back to Europe in non-life threatening situations: because of the cost. There is a chasm between the US and the rest of the 'developed world' that cannot be explained by the standard of medicine. There are more than enough studies underlining that US-Americans do not get better health care than patients elsewhere.

   Nearly twenty years ago I wrote in one of my columns:

"Two terms are important: 'patient-driven', which means that the patient must be the center of medical thinking; and 'outcomes' because that is what is important for the patient. To many administrators, politicians, radiologists and industries, patient outcomes are secondary. We hardly know anything about the outcomes of what we are doing in diagnostics and therapy [1]."

This has not changed. Even worse, today the US spends 20 percent of its gross domestic product (GDP) — an estimated US$ 2.7 trillion for 2013 — on health care. In the column I mentioned above I referred to the status in 1990: at that time the expenditure was 10.7% of the GDP. In the meantime it nearly doubled.

"Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices."

   Earlier this year, there were several long and alarming articles about this problem in Time Magazine and in the New York Times [2-5]. As Elisabeth Rosenthal in one of her three articles in the New York Times stated:

"[US] Americans pay, on average, about four times as much for a hip replacement as patients in Switzerland or France and more than three times as much for a Cesarean section as those in New Zealand or Britain. The average price for Nasonex, a common nasal spray for allergies, is $108 in the United States compared with $21 in Spain. The costs of hospital stays here are about triple those in other developed countries."]

and:

"Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. And almost every interaction can be an opportunity to send multiple, often opaque bills with long lists of charges: $100 for the ice pack applied for 10 minutes after a physical therapy session, or $30,000 for the artificial joint implanted in surgery."

The trend in Europe is similar, medicine turns into a for-profit market segment — radiology being at the forefront, but not the leader.

   As a potential patient, I have nothing against paying a fee to fellow physicians, also covering the salaries of their assistants and secretaries. However, I object to feeding un- or even counterproductive bureaucratic parasites in hospital administration, state health administration, in a grotesque 'health' industry and — above all — insurance companies and banks. Increasingly and without pity, they bleed sick and helpless people dry — bye, bye Hippocratic oath; what's left is business and self-interest. And — why do US health outcomes lag other countries?

As a physician I add: Why should I fatten an overblown administration with my work — why should a single medical doctor work to support a pernicious pack of pencil pushers and con men?

   The health system in many European countries is better, but for how long? For the U.S., neither Steven Brill in Time Magazine nor Elisabeth Rosenthal in the New York Times offered a solution to this problem. I guess they know why. Personally, I have never been in favor of a state health system, but what the U.S. needs is a state-regulated system with state-set (low) reimbursement ceilings for medical services, a separation of physicians from the health management and insurance business, and a nationwide obligatory health insurance for all. In other words, a revolution that would change the entire social structure of the United States of America.

References

1. Rinck PA. Playing with numbers in the health care game. Rinckside 1994; 5,1: 1-2.
2. Brill S. Why medical bills are killing us. Time Magazine. 4 March 2013.
3. Rosenthal E. The $2.7 trillion medical bill. The New York Times. 2 June 2013. A1.
4. Rosenthal E. American way of birth, costliest in the world. The New York Times. 30 June 2013. A1.
5. Rosenthal E. In need of a new hip, but priced out of the U.S. The New York Times. 3 August 2013. A1.

Citation: Rinck PA. US-healthcare – the price of it all. Rinckside 2013; 24,8: 15-16.

A digest version of this column was published as:
Rinck PA. US-healthcare – the price of it all.
Aunt Minnie Europe. Maverinck. 2 October 2013.