Bitter pills

A week ago, Andrew Sullivan wrote a thoughtful post about what healthcare reform is apt to mean in the long run.

Remember all those old black and white movies where you saw scenes in which the father of a sick child simply says “we don’t have the money for the operation.” And little Johnny dies. How far away that passive stoicism now seems. Within a few decades, what was once taken as fate is now rejected as a moral obscenity. Because, given what we have achieved in those decades,  it is a moral obscenity. We are all physical beings and we are never as equal as when we face sickness and mortality. Because we have so feasted on the tree of knowledge, it becomes morally intolerable to prevent its fruit from being given to all.

At the same time, as a matter of economics and mathematics, we also know at the back of our minds that we simply cannot give it to all – because these breakthroughs involve huge investment, highly trained experts, and inherently expensive technology. And as the options for health grow, we are forced to make choices that were previously out of our grasp, and those choices make us, in some way, gods. We collectively decide who can live for how long and who can die – because for the first time in human history we really have that choice. In fact, we have no escape from that choice. Healthcare is no longer triage, where sickness and death is the norm; it is an open-ended, blurry range of positive choices, where wellness is the expectation.

He goes on to discuss the difficult topic of rationing, with a focus more on the big-ticket items like end-of-life care, chronic illness, etc. This kind of serious question has already become a pressing problem for cash-strapped states, and it demands a serious conversation free of inflammatory, ridiculous distractions.

However, our national conversation cannot focus solely on ICU stays for the terminally ill or expensive investigational drugs.  We also have to confront the nickel-and-dime costs that accrue when caring for the well.

The truth is that we consume too much healthcare, and by “we” I mean everyone.  Even after squeezing out every possible inefficiency (and believe me, there are inefficiencies galore) paying less for healthcare means getting less healthcare.

As a primary care provider, of course I enjoy the benefits of over-c0nsumption.  Parents who opt to have their obviously healthy children checked due to some vague symptom or another are bread and butter for a practice like mine.  Over time, one gets to know the families that are intolerant of any symptoms, and who come in multiple times for the same uncomplicated upper respiratory infection because things aren’t better yet! Reassuring anxious parents is as much a part of my job as vaccines or more serious illnesses, and parents who aren’t satisfied with my answer will just go somewhere else to get another opinion anyway.

“Just make sure his ears look OK” visits add up over time.  Deciding to go to the local ED for a non-emergent complaint instead of waiting twelve hours for our office to reopen adds up a lot over time.  These kinds of patient/parent decisions are hardly unique to my practice, as I imagine anyone staffing an ED could tell you.  Insurance (public or private) insulates patients from the cost of this kind of over-utilization, piling ever-higher as an abstract concept instead of being perceived in the same way as fees for other services.  (Of course how insulated one is depends a great deal on what kind of insurance coverage one enjoys.)

From what I can tell, this aspect of cost-containment has yet to become part of our conversation.  Frankly, I have no idea who has the political courage to say to the American people that they may need to accept being more discerning consumers of health care and getting by with more judicious use.  I can’t really imagine President Obama saying “you’ll have to go to the doctor’s office less” and surviving; one may as well slap a cardigan on him now and be done with it.  But we cannot truly address how much we spend for medical care without acknowledging how we all contribute to the tally, in ways big and small.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Very good points. Over-consumption of healthcare is a huge driver in the costs for medical insurers. I would personally rather see health insurance as more like car insurance and reserved for emergencies. We simply need to redefine what ‘elective’ procedures are.

  2. Dr. Saunders, welcome to the League of Ordinary Gentlemen. I look forward to reading about health care. Some questions:

    “Frankly, I have no idea who has the political courage to say to the American people that they may need to accept being more discerning consumers of health care and getting by with more judicious use. I can’t really imagine President Obama saying “you’ll have to go to the doctor’s office less” and surviving.”

    I was under the impression that Americans visited the doctor’s office far more infrequently than citizens of other developed nations (see this post and accompanying charts:; yet we still spend nearly double per person the levels of other developed nations, many or most of which have single-payer systems or variations of such (Japan subsidizes everything 70% for instance). If we further extrapolate those statistics specifically in the cases of America and Japan, we find that America is around $2,000 per visit while Japan hovers somewhere at a tenth of that and still manages to trounce us in life expectancy.

    What would be the potential explanations for this staggering difference? Do middlemen here really take that big a piece of the pie? Is there rampant fraud and theft? Are we considerably less healthy than citizens of other developed nations? Do we demand more services per visit? Do we demand the riskiest and most expensive procedures at disporportionate levels? Do our doctors get paid too much? Is this just a misleading statistic? (I can’t find any statistics based on median cost per person, which would probably be a better metric given the scope and scale of advanced experimental medical procedures here.) Are potential legal liabilities driving up the risks and hence the costs of nearly everything? (In my experience working with a malpractice attorney, I would say yes, absolutely.)

    Either way, I find it an unrealistic goal for Americans to make fewer consultations with primary care physicians. It makes far more pragmatic sense to bring the doctor to Americans via information technologies (as Tim Garson discusses in this lecture: so we can get a real consumer-driven medicine more suitable for the information age.

    • I resorted to shorthand a bit. Rather than doctor’s visits per se, it would probably be more accurate to describe healthcare consumption as a whole, though I don’t know if there’s a term that does so tidily.

      The most recent data about doctor visits per capita by country I could find quickly are over ten years old, but seem to indicate that we see providers in the US more than any country but Japan:

      Finding out how many tests are run, medications are prescribed, etc. at those visits would take more digging. I also wonder about things like ED visits, and can’t find any comparative data comparing the US to other developed nations.

      Anyhow, you ask a bunch of good questions about a variety of topics. I don’t pretend to be an expert on healthcare policy, but giving my perspective on them is the whole point of this blog.

      Finally, I agree that tailoring medicine to an information-based society is an important goal, but there’s only so much one can do for individual healthcare using broad-based information tech.

      • That’s interesting. The article that I linked to suggests that visits to a doctor’s office are between 0 and 4 per person for America and more than twelve per person for Japan, but I guess if the metric were “consultations” it would include things like phone calls and email exchanges.

        There needs to be a real streamlining of the statistical description it seems, or a good database where such statistics can be found. There are so many political and economic interests in the health care debate that it may be near impossible to find comprehensive and useful neutral statistics.

  3. I see two factors in over-medication and over-treatment, the first is liability.

    The day my mother retired as an anesthesiologist, literally walking out the door after her retirement party, the crash cart came sailing down the hall. She followed it instinctively: a breach birth was in progress. An emergency C section later, the surgeon told my mother: “I hope your insurance has a good tail on it: if that kid doesn’t turn out to be a Rhodes Scholar you’ll be hearing from those people.”

    Sitting on the porch of my uncle the orthopedic surgeon’s home, sipping some very good scotch with my cousin and her husband the malpractice attorney who’d recently won a huge judgment, my uncle asked the following hypothetical to his son-in-law. “If I detect an osteosarcoma in the tibia of a teenage boy, amputate his leg and save his life, wouldn’t it be appropriate to follow the example of malpractice law and award him a percentage of his earnings for the rest of his life?” The son-in-law, a little drunk, got quite offended and said “It doesn’t work that way.”

    But that’s exactly how it works: I know the insurance industry: there are two main providers of malpractice insurance: if you’re blackballed by one, you’re blackballed by them all. An anesthesiologist friend was on call when a morbidly obese drunk woman came into the ICU off an ambulance, having just caused a two-fatality car crash. He intubated her, she aspirated some vomit and successfully sued him. He had three kids in med school at the time. He’s no longer practicing. These days, in light of the blackballing, there’s a trend afoot to do self-insurance, further driving up the price of medicine. Local trends in malpractice judgments have driven every OB/GYN practitioner out of southern Illinois.

    The second is truly perverse: since the advent of sulfa drugs and anesthesia, the patient has become his disease. A growing number of MDs have completely abandoned GP work in favor of specialist practices: fewer hours, better money and the remaining GPs are referring everything to them anyway. There’s a growing number of medical practices that simply refuse to deal with Medicare / Medicaid: I know of open Medicare claims open since Katrina. The RN community has tried to step into the gap but the MD community has resisted the trend. Highly qualified RNs are replaced with Filipinos.

    The worst part of this mess is the failure of the medical community to back meaningful information standards. HIPAA has been the law for several years and some shops still haven’t come up to snuff. Everything’s a one-off custom implementation, the insurance industry is two decades behind implementing the most obvious reforms. Information security is nil in the medical industry. The states have made a dog’s dinner of accreditation and revocation. The list goes on and on. The unseemly reticence of the medical community to come clean about its own internal inefficiencies and MD hubris will require some serious dragon slaying and I don’t think the government is up to the challenge.

    • Malpractice ins. is an issue. My GF’s dad is a doc. He was sued and the lawyer admitted he threw some claims into the suit because he hadn’t read all the paperwork and didn’t want to miss any potential claims even though it turned out the claims were bogus. However many states have had some MalPracIns reform and seen little if any effect on medical costs. Yes electronic records would likely improve care all around and the leading cause of malpractice ins. claims is actual malpractice.

      • Malpractice reforms are mostly so much eyewash. Some little kid presents with the sniffles and there’s the spectre of some shitworm malpractice attorney standing there in the exam room like the Ghost of Christmas to Come with his little checklist: “Why didn’t you give the dear little departed Cratchit boy an MRI and refer him to a specialist?”

    • A few comments —

      First off, one of the neonatal ICUs I worked in as a resident was staffed almost entirely by nurses from the Philippines. There was no discernible difference between the care they provided and that of the nurses at the private hospital one block over. Also, they taught me how to say “What?!? I’m busy!” in Tagalog.

      I will certainly agree that there are too many physicians who refuse to adopt appropriate information technologies. (If your provider doesn’t use an electronic medical record, you should probably ask why.) With regard to the various states, I’m inferring that you’re referring to licensing. The states where I’ve been licensed have seemed appropriately diligent, and take complaints very seriously.

      I concur that the medical community has been too apt to circle the wagons. Having recently attended a conference on liability prevention, I can say that this culture is changing, with more emphasis on dealing forthrightly with error. I also don’t think the medical community is uniquely self-protective. Can anyone think of an industry that rushes to disclose its deficiencies?

      • Can anyone think of an industry that rushes to disclose its deficiencies?

        The software industry. The operating system industry. The robotics industry. The airline industry. The automobile industry. In short, every single one I’ve worked with, except for two: the health care industry and the government.

        Now you know.

        • I’ll take your word for it that all of those industries are forthcoming of their own volition. My recollections are that Toyota, at least, has had some trouble being quite so straightforward. If you aver that the tech industries are inclined to disclose their shortcomings, then I consider myself better informed.

          • …you are aware that Toyota’s “sudden acceleration incidents” were as much a fantasy as any others, right?

      • There’s another huge beef I have with Medco Inc. : the incestuous relationship between Big Pharma and Medco Inc. All these “conferences” put on in the Bahamas, featuring cheap booze and expensive hookers and an Arnold Palmer golf course, with juuuuust enough time in the conference hall to call it a conference.

        All those pretty little drug reps in their expensive lightweight wool suits, dropping off samples so they’ll end up scribbled on someone’s prescription pad, oh yeah, every time these drug companies whine about the costs of research, just remember they spend about twice as much on marketing. Some drug coming off patent? Hell, let’s just patent some trivially derived isomer and put that back under patent. Just how many drugs do we need to treat trivial conditions easily managed by telling the patients to lose 30 pounds? You wouldn’t believe what I’ve seen from inside the firewall at Pfizer, who I do not hesitate to name as one of the most corrupt corporations I’ve ever seen. And the medical community lines up like so many soldiers at the doors of the pharmaceutical brothels: complicit in the systematic screwing of the American public, armed with the levers of authority and fear and the finest lobbyists money can buy.

        • Jesus. Calm down there, Matt Taibbi.

          See, I know that you think you’re being all eloquent and interesting, but I’ve heard exactly the same rant about the oil industry, the software industry, the defense industry, automobile industry, mining, logging, paper, anything. It’s all the same “HURR BIG BUSINESS DURR”.

        • That’s a pretty damn big brush you’re tarring us all with, Blaise. I’ve been to plenty of conferences, and I don’t recall seeing a single hooker. Or traveling to the Bahamas. Or playing any golf. You seem to be reverting a bit to shopworn stereotypes.

          In addition, there are plenty of providers who don’t hobnob with drug reps, who use generics as much as possible, and who don’t stock samples. Are there doctors who do exploit what amounts to graft from Big Pharma? Sure. Do I have trouble with, among others, the AMA because of its peddling data to Big Pharma? You bet. Are doctors as generally corrupt as you seem to think? Nope.

          • People cry about how drug companies buy lunch for doctors.

            How else are you going to get them to sit still long enough to read about your new beta blocker, or whatever?

            It’s not like they have nothing to do but sit around and read product literature all day.

            And, before you start in with the “well that’s just ADVERTISING”…advertising is how people learn about new things. Things like, say, drugs that perform better than old ones and have fewer side effects. Of which there are many–but, since they don’t fit into the standard rant about “dick pills and fat fixers”, you don’t hear about them. It’s boring to read about the differences between, say, misoprostol and pitocin. Much more fun to stand around and invent things to get mad about.

            It’s funny, really. The same people who tell you that terrorism is a myth and the Republicans trade on scaring people will turn around and invent this terrible hobgoblin of a medical industry.

          • Just stop there, while you’re still ahead. I built the data pipes for Pfizer’s acquisition of Warner-Lambert and I currently consult for five franchises of Blue Cross Blue Shield. You might want to check this out. Pfizer settles these out of court: it’s a cost of doing business.

          • Right, and I have family members who are currently involved in drug development, and not for “trivially derived isomers”.

            The fact that you emptied some trash cans and implemented a turnkey solution for Pfizer does not make you an expert on the medical industry.

          • In point of fact, I am but one of the thousands of outsiders who’s seen the totality of the layout of Pfizer’s data model and its SOA layout. They pay us to do what their own people cannot or will not and they pay us molto bene. I am a tapeworm in the gut of the health care industry. It is hardly an argument from authority to observe and comment upon the crap which passes through the 1-topology between mouth and asshole in the industries for which I consult.

            You talk a whole lot of trash, but it’s your family members, not you, with the chemistry degrees and the jobs. Easter dinner is coming up, I’m sure you’ll have the opportunity to ask them about Homologs, Analogs and Isomers and their respective patent rights, terms you may decide to look up now that I’ve mentioned them, over the turkey.

            Your pitiful attempts at dissing me really aren’t going anywhere. Give it up for a bad habit. I’m beyond getting mad at the likes of you.

          • “I’m sure you’ll have the opportunity to ask them about Homologs, Analogs and Isomers and their respective patent rights, terms you may decide to look up now that I’ve mentioned them, over the turkey.”

            Ah-heh. You don’t know what I do, or what they do, or what we chat about every day.

            You’re not the only smart person in the world. It’s unfortunate that you can’t admit it.

    • “Highly qualified RNs are replaced with Filipinos.”

      What’s wrong with Filipinos, you fucking racist?

      • Fuck you so much, Duck. Importing labor to cut costs and you’ve got no problem at all.

        • I’ll actually go on the record as saying that I have absolutely no problem importing labor to cut costs. But I’ll also add that it’s out of line to accuse of racism someone who does not share that conviction.

          • I’m not the one who brought up Filipinos in a context that implied “inferior”.

  4. Due to, I’m sure, the fits and starts inevitable when integrating a new blog into a site, I can’t see the 16 comments already added to this post, so forgive me if this has already been discussed:

    Reading your piece here, Mr. Saunders, I’m struck not only by how little I know about medical costs (beyond the talking points and generalities) but also by how ill-equipped our society is to deal with reality, as you more or less said.

    Considering that I think people for whatever reason might get even *more* outraged by being asked to refrain from doctor’s visits unless it’s truly necessary, it has me thinking more and more we simply live in a world where, if we want universal or near-universal healthcare (and I think most of us do — I certainly do), then there’s just no other way around the unpleasant fact that costs controls which could be called “rationing” are inevitable.

    So maybe it’s time that the intelligentsia/commentariat moved away from a rhetorical paradigm in which we all fight over the best ways to stave off rationing, and towards a model where we debate who can design and implement the most humane, efficient, and just system of rationing possible.

    • Rationing assumes that health care is a fixed and finite good, but it’s quite obviously not, especially since our collective future is biotech and scalar, technological improvements are inevitable. What we really need is a healthcare system that responds to consumer-driven market forces plus an adequate safety net befitting any public good.

      • Wouldn’t rationing have to do with costs, not whether or not HC itself is finite? We are making medical advances, but my understanding is that these haven’t (at least not yet) been *cheap* (or cheapening) advances.

  5. I understand your point but I’m not sure it answers my question. Apologies if I was unclear.

    I was more thinking along the lines of cost-control as it’s discussed in the political conversation today — aging baby boomers, high rx costs, often lots of latitude provided to doctor and patient to perform as many tests as deemed worthwhile, etc.

    • But all those discussions of cost control assume that costs and services are fixed, and they aren’t. We do already ration things like kidneys by, for instance, not giving kidney transplants to 90-year old patients, but we don’t really ration “health care” as an abstract good, nor can we. If you’re talking about standards, like maximum number of x-rays patients can be allowed to receive in a year, then that’s something different since it’s based on safety and not on cost.

      But, to go back to all the rationing memes that crept into the public discourse during the whole health care debate last year, if there is a shortage such that we need to ration, then before we start making people wait in lines or round up magistrates to serve on death panels, we should consider structural reforms like incorporating more IT into early diagnosis or replacing primary care physicians with RNs first. That’s where I stand at least. I think there’s enough room for improvement that we shouldn’t worry about rationing just yet.

      • That makes a lot of sense to me. Your comment up-thread about using the internet etc to communicate more info to Americans so they don’t just go to the Dr. is a great idea. We’ll need to combat years of destructive and traumatic Web M.D. searches, however. People will be shocked to find how non-lethal a stuffed nose truly is.

        • Yeah, another thing that would possibly usher in a sea change is getting people to realize that the medical profession can’t really do anything for them unless they are exhibiting symptoms.

          I know it sounds quite obvious, but a headache is usually not a symptom of a brain tumor. If someone with a headache went to the emergency room instead of taking some aspirin, he’d probably be told to take some aspirin and then told to go home and come back if it gets worse (at least I hope so). His headache gets better and he doesn’t come back = no brain tumor. There should be protocols which people have access to which strongly encourage them not going to see a doctor for headaches and stuffy noses. In this sense, we already ration care by not giving every patient with a headache an MRI, so we can ration it further by allowing most of those patients to self-select themselves out of the class of patients waiting for medical attention at the emergency room.

          • Just a quick reply, then it’s off to dinner for me. I agree that increased access to information may help some people realize that their headache is probably not a glioblastoma. Our practice has an extensive website, with information on the safe home management of many common ailments, and extensive links to other reliable sites. There’s no way of knowing how many visits we forestall (though, come to think of it, that might be an interesting study) by providing this information. However, access to this information doesn’t prevent a great many people from coming in for those “just check his ears” visits I mentioned already.

            And that doesn’t even begin to take into account how much awful, shoddy, downright harmful misinformation there is available on the Internet. (Thank you, Arianna.) Getting patients to reliable sources of information is a task unto itself.

Comments are closed.