At Forbes Ellie Kincaid restates the now 15 year old claim about U. S. health care (it’s the prices, stupid):
Spending on pharmaceuticals was $1,443 per capita in the U.S., double the average of $749 for the 11 countries studied. American generalist physicians also made nearly twice the average for all the countries, at $218,173, with similar trends for specialists and nurses. But a bigger proportion of U.S. spending went into administrative healthcare costs: 8% compared to an average of 3%. Most of the data for the study published in JAMA came from the OECD and World Bank.
“Some of the more common explanations about higher healthcare spending in the United States, such as underinvestment in social programs, the low primary care/specialist mix, the fee-for-service system encouraging high volumes of care, or defensive medicine leading to overutilization, did not appear to be major drivers of the substantially higher U.S. healthcare spending compared with other high-income countries,†the authors wrote.
She continues with a hat tip towards the excess utilization theory. Why can’t it be both? Half of Medicare recipients take five or more drugs. That’s overutilization but it’s physician-created overutilization and I would argue that it’s unethical. I’d be willing to bet a shiny new dime that no one really knows what the interactions of all of these drugs are and that relatively few combinations have ever been studied.
IMO we’ll never bring sanity to our health care system without substantial structural changes in how health care is delivered and how it is paid for. Since that will inevitably mean that someone’s earning will be reduced and someone won’t get as much care as he or she wants, those changes will be fought tooth and nail.
Polypharmacy is a worldwide problem in countries that have first world medicine. Much written about. Not just a US problem so doubt that structural changes in our system necessarily address the issue. Needs to be addressed as a separate issue. I could cite some papers if you want, but there are so many that if this is an issue of concern for you then I suspect you must have read dozens of the hundreds or thousands that exist on the topic.
Steve
It’s not a problem for me personally since I do not presently take any medications other than an occasional NSAID. But I’ve known several people who had significant health problems that were significantly ameliorated when they stopped taking (under doctor’s direction) the medications that had been prescribed for them.
I don’t know what the solution to our full array of health care system problems might be. I suspect that the solution will involve changes in compensation levels, how care is paid for, taking care of ourselves throughout life through more or less traditional wisdom, and changes in attitude about end of life care. I doubt we can do much about any of those other than chipping away at the edges without substantial structural changes.
I’m not sure how reasonable it is to aggregate overmedication in the U. S. with that in, say, Thailand where practically everything is available over the counter. In the U. S. those medications are mostly prescribed by physicians. Changes in how physicians are compensated would reduce the incentives for overmedication.
Why isn’t it the basic architecture. Medicine means treating disease, not preventing disease. And we don’t believe in watch wait and see. We treat.
People still eat their way to diabetes, heart disease and perhaps cancers. No outside disincentives. Then we treat these expensive diseases. Bump your head? Off to get an imaging study. And what if the last 6-9 months of your life wasn’t covered by the tax base, but rather by a self financed insurance policy paid for throughout your life. But we have no political will to force people to take personal responsibility.
So what do you expect doctors to do? Turn patients away? And when demand is high, and on someone else’s nickel, what do you think will happen to prices?
I expect them to live up to their ethical obligations without dragooning me into them any more than I dragoon them into my performance of my own ethical obligations.
You do realize that the very large majority of time docs don’t make more money by writing for more meds don’t you? As I noted, this is a worldwide issue. Only in some very broad sense does this strike me as an ethical issue. It is mostly a practice issue, trying to figure what is best, when it is not alway clear. There is not and never will be a study looking at every combination of drugs one might want to see. You took some math courses. Figure $20 million apiece for each study for all of the combinations of the 10-20 most common drugs. Best you can do is be aware of the pharmacology and actions of each drug and be aware of cited problems. This is actually one area where EMRs can actually be a positive.
Also, just to put this in perspective, my typical 68 y/o 5’9″ 250 lb coming in frequently had HTN, diabetes and GERD. That easily nets you one stating, two BP meds, one diabetic and med and one PPI or other GERD med. You have 5 right there w/o even accounting for OTC NSAIDs, vitamins and supplements. Nothing unethical here, and a pretty common scenario. Now, add in the fact that lots of people see more than one doc.
Steve
Physicians don’t charge for follow-up visits in Pennsylvania? Medicine must be practiced differently there than in Illinois.
Maybe I’m wrong but I think that in the majority of cases polypharmacy creeps up rather than coming all at once. I would also speculate that multiple physicians prescribing multiple different medications is commonplace. I also have less sympathy for the urge to do something than you do.
Uhhh… I resemble your remarks. I’m on medicare and I have prescriptions for five drugs, plus I take aspirin and a vitamin pill every day as my doctor suggests. (One’s for cholesterol and the other four for COPD, to answer your curiosity.) And yes you’re right that this is costing my fellow citizens (and me too) a bunch.
Still I think you’re missing a point. My impression is a lot of medications are sort of scatter-shot in their effectiveness.
Take those aspirins, for instance — kiddie doses at 83mg, coated to be non-irritating, and available for maybe 5 bucks for a bottle of 200 at the nearest pharmacy. The notion is, if a 1000 middle aged men take one aspirin a day, at the end of a year they will have had one less heart attack. This isn’t perfection. Maybe they’ll still have 19 heart attacks instead of 20. Maybe they’ll still have twenty but only two will be fatal instead of three. (For middle aged women, same thing but substitute “stroke” for “heart attack.”)
So these thousand guys are collectively spending ten thousand bucks on aspirin to hold off one heart attack. Is it worth it? Yeah — that’s about one day of intensive care in a hospital, which would probably be cheap for a major attack. But we can’t predict in advance one the one guy is who’s going to get that benefit, and we have to admit the little pills maybe aren’t doing much good for 999 guys in that 1000 who are each pissing away ten bucks a year.
Still, if we argue saving a life is maybe worth a million bucks — which is the kind of argument we make when we widen highways or put up traffic signs or cut down lead emissions in gasoline — telling older guys and gals to take some aspirin makes sense.
But I suspect there’s a LOT of this. It’s not the case that each of my COPD meds inevitably makes me healthier or extends my life; it’s that one of them stretches the odds in my favor by 5% or so, and three of them give me 15% better odds of surviving a year, and so on. So would moving to a rural area with cleaner air, and taking a hike every day, and getting some exercise, let’s admit, but taking pills involves a whole lot less effort. (I’m totally making these odds up, by the way, and maybe Steve can set me right. But hand waving is one of the things I do for exercise.) Same thing with that anti-cholesterol drug (middlin expensive) and the aspirin (cheap),
Anyhow, from my own example, I suspect what you see as “over prescription” is the result of doctors thinking three weakly-effective medications will probably help their patients more than three times the dosage of one weakly-effective medication. Which quite likely might be true.