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 in the entire world. In fact, in the 2016 Global Burden of Disease study, the US healthcare system was ranked only 29th in the world. 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 actual health care: the US fans the flames of the fire instead of turning off the stove. Doctors’ concerns about upsetting patients and the legal repercussions that might follow result in expensive and entirely unnecessary care with overtesting, overdiagnosing, and overtreating. To simply put it, America’s healthcare system is broken.

Overview of the American Healthcare System

Imagine that everyone in the US crosses a bridge that hangs over a river every single day. The walls of this bridge are relatively low, so people occasionally fall into the river. Once in the river, a professional fishes them out, or at least tries to. Then, the cycle repeats, over and over. Often the same person falls off the bridge again and again and needs to be rescued from the river 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. It is said that 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.

Primary care physicians (PCPs) are perhaps the most significant specialty in the entirety of medicine. After all, they are the base of the pyramid of healthcare. Furthermore, in theory, they are the vanguard of preventative medicine, but our current healthcare system does not permit them to properly do their job. The US government does not sufficiently emphasize preventative 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 take a proper 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, which has contributed 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 maybe 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. This problem is only accentuated by the acute PCP shortage the US is currently 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 early on. Furthermore, the goal in the emergency department is almost always reduced to just 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 low-cost but extremely effective lifestyle changes. 

Primary Care Physician Shortage

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 for example, may overtest, using the latest, but expensive, technology without regards 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 the 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, esteemed author 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 thus do not improve outcomes; they just increase healthcare costs.

The economics of healthcare also wrongly encourages physicians to just do more. Surgeons, for instance, are paid for each surgery they perform. The economics do not care about whether the patient actually needs the surgery, whether the benefits outweigh the costs, whether the patient is better off after the surgery than before. The surgeon does not get paid the same for dissuading the 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.

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”

In its current state, the US healthcare system is, unfortunately, a disease care system. Interventionist medicine supersedes preventative 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 significant part must paid by the American taxpayer. We are stuck in a ditch, but the bright side is that we can see our way out. When society as a whole begins to start rewarding preventative medicine and improving outcomes over doing more just for the sake of doing more, then we can improve healthcare from all angles. This will require a revolutionizing of US government priorities when it comes to healthcare. This will require a revolutionizing of medical schools to emphasize prevention over intervention. This will require a revolutionizing of patient expectations when going to the doctor’s as patients will need to be empowered to take their health back into their own hands. These seemingly insurmountable barriers should not discourage us because I know that together we can rise above them to repair the US healthcare system.

 

References

“American Health Care: Health Spending and the Federal Budget.” Committee for a Responsible Federal Budget, 16 May 2018, www.crfb.org/papers/american-health-care-health-spending-and-federal-budget. Accessed 27 June 2019.

“Escape Fire: The Fight to Rescue American Healthcare.” Tubi, 2012, tubitv.com/movies/300834/escape_fire_the_fight_to_rescue_american_healthcare?autoplay=true&utm_source=google-feed&tracking=google-feed. Accessed 27 June 2019.

Fullman, Nancy, et al. “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, vol. 391, no. 10136, 2 June 2018, pp. 2236-71, www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30994-2/fulltext. Accessed 27 June 2019.

Gawande, Atul. “Overkill.” The New Yorker, 4 May 2015, www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande. Accessed 27 June 2019.

New Yorker: “Overkill.” Occtegrity, occtegrity.com/the-collateral-damage-of-unnecessary-medical-care/. Accessed 27 June 2019.

Overview of the American Healthcare System. Boston University Medical Center, sphweb.bumc.bu.edu/otlt/MPH-Modules/HPM/AmericanHealthCare_Overview/AmericanHealthCare_Overview_print.html. Accessed 27 June 2019.

Pendick, Daniel. “Most Headache-Related Brain Scans Aren’t Needed.” Harvard Health Publishing, www.health.harvard.edu/blog/headache-related-brain-scans-arent-needed-201403197080. Accessed 27 June 2019.

Ryder, M. Broken Healthcare System in the U.S. 12 Nov. 2018. Newstimes, www.newstimes.com/opinion/article/Charles-Atkins-MD-American-s-Health-Care-13381910.php. Accessed 27 June 2019.

Shortage of Primary Care Physicians. The Leading Physicians of the World, theleadingphysiciansoftheworldblog.wordpress.com/2017/03/22/infographic-shortage-of-primary-care-physicians/. Accessed 27 June 2019.