U.S. Health Care: A Sickening Feast, a Costly Famine

The case of Al Barnes, an 85-year-old Minnesota man whose wife won't let him die, has been on my mind lately. Lana Barnes insists her husband, whose kidneys are failing and who is in an advanced stage of dementia, would want aggressive treatment. She thinks he has Lyme disease that could be cured with heavy antibiotics. She has his power of attorney and has gone to court to get her way, even though almost every hospital in the Twin Cities has told her there is no hope.

Today's paper broke the news that Mrs. Barnes removed two pages from Mr. Barnes' 1993 health care directive, which had clearly stated he didn't want to be kept alive by machines. So now it sounds like the case will be resolved, and Mrs. Barnes may face criminal charges.

At the same time this tragedy has been happening, two amazing health-related articles came across my computer screen.

Atul Gawande, writing in The New Yorker, tells of "The Hot Spotters" -- the small number of people who cause a vastly disproportionate amount of health care spending. These are folks who have chronic conditions that are never treated correctly. In many cases, they're poor, homeless or immigrants with little English or cultural familiarity with the ways of Western medicine. In Camden, N.J, for instance, one percent of patients account for 30 percent of the cost.

The story focuses on medical heroes like Jeffrey Brenner, who used emergency room statistics in Camden to find the most costly patients and treat them effectively, and Rushika Fernandopulle, who runs a clinic in Atlantic City based on the treatment principles worked out by Brenner. And it tells of another doctor, Nathan Gunn, who does research for an insurance industry analyst, finding the most expensive patients and working through the for-profit system we're stuck with to get them help that will reduce their costs in the long run.

The critical flaw in our health-care system that people like Gunn and Brenner are finding is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control.) For a thirty-year-old with a fever, a twenty-minute visit to the doctor’s office may be just the thing. For a pedestrian hit by a minivan, there’s nowhere better than an emergency room. But these institutions are vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It’s like arriving at a major construction project with nothing but a screwdriver and a crane (emphasis added).

This is where the buzzword medical home comes from. I've been ignoring that phrase, thinking it was just the latest fad, but Gawande's article explains with startling clarity what it means -- both in making sick people's lives better and in saving money. Connect patients with a doctor and support staff who keep in close contact, visit their homes, have an authentic connection with their cultural backgrounds -- and watch health quality go up and cost go down.

And then there's the other side of the health-care coin: people who get too much treatment or treatments they don't need. Harriet Hall, over at Science-Based Medicine, makes the case by providing a thorough review of a book called Overdiagnosed: Making People Sick in the Pursuit of Health by Gilbert Welch.

As Hall writes, "We are healthier, but we are increasingly being told we are sick. We are labeled with diagnoses that may not mean anything to our health. People used to go to the doctor when they were sick, and diagnoses were based on symptoms. Today diagnoses are increasingly made on the basis of detected abnormalities in people who have no symptoms and might never have developed them."

Whether it's tests ordered to cover a doctor's butt, a company selling MRIs to symptomless people who think more information is always better, or all the mammograms and PSA tests catching cancers that would never kill anyone, we're a wealthy nation awash in medical gewgaws we don't need and that can actually harm us. The standout stat from Hall's review: "Whole body CT scanning finds abnormalities in 86% of asymptomatic people." So everyone needs surgery immediately to fix those abnormalities, right?

Hall includes info on osteoporosis, breast and prostate cancer, thyroid cancer, colonoscopy and much more, making it clear Overdiagnosed is an important book.

All this combined in my head with the Barnes case. Here's a guy who's been taken by ambulance to the hospital 78 times in the last nine years. He's covered through Medicare and the VA, so all of this care that he would never have wanted has cost everyone a bunch of money.

Poor Mr. Barnes is a prime example of the problems described so well in both Gawande's article and Welch's book: too much treatment, but not enough.