Health costs are high, and here’s why

Health costs are high because the body is complicated and doctors and patients hate ambiguity. The cost is high because a missed diagnosis can lead to death and a large lawsuit. The cost is high because we have many specialists that view the body in tiny pieces and want to feel 100% correct about their piece.

Let me give you a real life example.

My patient, Rick, is a brilliant attorney. He has insulin dependent diabetes and heart disease and he takes good care of his health. He pointed out that his lower leg (around his shin) was red and swelling and then forming a painless hard lump. The exam showed a little redness, a tiny puffiness and a small firm lump in his leg tissue.

I ordered some blood tests to make sure his diabetes was under control and to look for infection. Because I couldn’t put a name on it and I was unwilling to say, “Let’s watch it, I don’t think it is anything serious.” I told him to ask his dermatologist , who he was seeing anyway. The dermatologist said it wasn’t in the skin, it was deeper so he was referred to an orthopedic specialist. The orthopedic doctor said he wasn’t sure and did an X-ray. Since the bone was fine he ordered an MRI. The MRI showed no tumor, no vascular problem.

After several months of doctor’s visits and spending $2,626.40, we have no diagnosis and I realize I should have said, “Let’s watch it, I don’t think it is anything serious.”

Rick has high deductible health insurance. He pays $4,800 annually out of pocket before insurance kicks in. He usually hits his deductible because of the diabetes medication and tests.

None of his doctors own imaging centers or labs. We don’t make any money on ordering tests. We all wanted to help the patient in the only way we were trained to do.

I asked him if he would have been satisfied with me saying, “Let’s watch it, I don’t think it is anything serious,” after that first visit. He said, “Yes, I trust you”. But he still has a leg that is swelling and a lump that forms daily. The symptoms are mild but strange.

Now we will watch it and it will probably go away but we’ll never know what it was. That happens more often than not. We can all rest better knowing it is not serious but achieving our collective “peace of mind” is one reason why health costs are so high.

Toni Brayer is an internal medicine physician who blogs at EverythingHealth.

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  • Paul MD

    Very true. We test sometimes to prove that there is no needle in that haystack. Sometimes watching is the right thing to do but only through the retrospectoscope with a good outcome. When observation leads to delay in diagnosing the legal profession doesn’t give you a pass as being reasonable is not a defensible position when being sued.

  • Andrew

    But would it be more cost effective and medically beneficial in this example, or others you might be able to think of, if there was a (secure) centralized medical database where all of doctors involved with a patient’s care could access and update their complete medical history?

    • Allen

      Andrew: Yes, very much so. The devil however is in the details. Politicians talk about things like that, but pass the HIPAA laws which make it a crime with me as the perpetrator if your medical information gets leaked.
      Given the current political climate would you trust the government to secure all of your most intimate details.

  • Toni Brayer, MD

    Jadedm: I was the primary and yes, I would have appreciated that. I always hate it when my referral makes yet another referral (which then goes on and on) without my involvement.

  • Jadedmd

    What, no biopsy? (I realize I’m part of the problem). Derm maybe shouldn’t have referred to another specialist but rather send it back to the primary to make decision on further eval

  • joefouche

    How does this explain why the cost was $2600? Presumably these tests would have been 50-80% cheaper in many other countries.

  • Yious

    As a regular patient who visits this site because I like reading the doctors views of events….I find what you did to be what you SHOULD do because what happens if you don’t and it is something bad?

    Would you be happy if you HAD said this due to his insurance and then he died a few days later?

    I have insurance that makes me pay a LOT but dammit, if a doctor isn’t sure about something, I will PAY to find out what it is

  • Steffan Lozinak

    This is all very true. Lawsuits and our inability to forgive medical mistakes really make it hard on all of us. It slows progress and prevents some “riskier” methods from even being an option… which is silly. People should be able to choose what they are willing to try or not try. (That goes for a lot of things).

    I mean, I can understand a lawsuit over a doctors mistake (like removing a kidney when a person goes in for appendicitis)… But a lot of the lawsuits I think just slow down progress.

  • Martin Young

    Never underestimate the therapeutic value of negative tests. EG Patients with chronic headaches may only improve or take other diagnoses like stress seriously when there is conclusive evidence that there is no underlying tumour. Doctors offer opinions that sometimes need to be backed up. Expensive I know but it is what patients expect of us.

  • Doc D

    Good anecdote, and probably very common. It’s interesting that the issues of trust and certainty motivate this patient’s experience. A lack of either or both can result in therapeutic failure, but it’s hard to quantify that impact. It would be nice if we could draw a serum trust level, but I think a lot of us are hesitant to take a chance on our subjective impression of how solid our relationship is with any given patient.

  • rransom

    This analysis is superficial. You give only end reasons why HC in the US is so expensive, namely that uncertainty leads to diagnostic testing leads to costs. A more sophisticated analysis would have investigated why he paid 2.6k in the United States whereas he would have paid much less in Japan or Western Europe. Such an analysis would have discussed such things as technological advance, high physician and other HC worker salaries in the US, wasteful spending in HC, supply demand mismatch in HC, malpractice risk, etc, etc. Perhaps most importantly, it would have discussed monopoly and monopsony and informational asymmetry in HC markets, including a lack of price transparency. These are the causes of the high cost of HC, not a couple of consults.
    Kenneth Arrow’s 1963 paper in the American Economic Review (Google it) should be part of your knowledge base if you are to comment on HC costs.

  • Toni Brayer, MD

    rransom: Get off it. This was not a scientific analysis, it was a blog. The next time I write a scientific white paper for publication I will consult you.

    P.S. I don’t need to read a 1963 paper to comment on HC costs. I live it every day from the provider and the patient side.

    • DrJohnM

      Bravo, Dr Brayer.

      Monopsony? Informational asymmetry?

      Give me a break?

      Us masters of the obvious–bloggers–need to stick together.


    • rransom

      You don’t need to bother to read the seminal paper on your discussion topic? Think about what you’re writing.

  • Molly Cooke

    I am familiar with monopoly and monopsony, price transparency and informational asymmetry but none of these concepts weaken Dr. Brayer’s point that sometimes a) the best course of action is a bit of judicious watchful waiting (the patient is often one of the prime watchers) and b) there are many reasons why this can be difficult, even impossible, to do. I also agree with her point, and this is hardly a novel observation, that we have a spectacular amount of wasteful dyscoordination, often related to subspecialist-to-subspecialist referrals. I refer to an endocrinologist for a technical question about carb counting; the endocrinologist notices that the patient has an LDL of 104 despite my statin and sends the patient to a lipidologist; the lipidologist wonders if the anti-hypertensive regimen is optimized and sends the patient to a cardiologist; the cardiologist observes that the patient isn’t on an ACE-I and adds it; the patient is entirely overwhelmed and confused and doesn’t know to say that I stopped the ACE-I two years earlier because of an intractable cough which resolved with withdrawal of the ACE. And, yes, it’s in the chart, but it somehow escapes attention.


    I am a pcp family practice and a general surgeon by specialty retired practiced for 25 years. stress caused me to have MI4vessel cabg followed with mulitple tia and full blown cva. Here is my example of why HC cost hit the ceiling…its not coming from MD specialists like us. Our fee schedule and re imbursement are in line and close to inflation scale but the law makers blame us as well as media sensationalized doctors to blame for this out of control HC cost. i just had a recent cardiac cath follow up two months ago. my medicare HMO paid the hospital $31,000.00 my co pay for this was 175 dollars. I dont know how much my cardiologist bill is for this 15 minute procedure. Two of my regular vein graft were both occluded but the two mammary intercostal arteries bypasses were open. i am asymptomatic and doing fine health wise. My point is half of this hospital fee could have been channeled to other medicare patients. equipements and devices have been written of or paid off perhaps few years back. i really dont know the breakdown or transparency on this…my cardiologist as a specialist probably get a fraction of this bill…like 2000 dollars for doing a 15 minute job.

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