Just as with our current economic meltdown, we should have seen our healthcare crisis coming. America has the most expensive and yet not the best healthcare in the world. Certain forces have been at work to create this perfect storm. While plans have been proposed to increase access to health insurance and streamline information sharing by digitizing medical records, government has failed to identify some elephants in the room that need to be addressed.

Litigation

What distinguishes American healthcare from that of all other first-world nations is the prevalence of litigation. Medical tourism is burgeoning because patients recognize its enormous cost savings. The same surgery done abroad can be one-tenth of the U.S. price. Absence of potential litigation accounts for the difference. The cost of drugs in general, and vaccines in particular, are astronomical because litigation has been factored into the price. Physicians in America order far more tests than those in other countries because of the fear of litigation. Any effort by congress to control healthcare costs must begin with tort reform. There has to be a cap on malpractice and adverse drug effect settlements. Any new government sponsored insurance needs to require arbitration in lieu of litigation.

The Pharmaceutical Industry

Years ago, President Dwight Eisenhower warned the nation to beware of the military-industrial complex: the industry of war fuels the need to have more wars. A parallel can be seen in the pharmaceutical industry. Continual drug development with escalating cost is a self-perpetuating phenomenon. Antibiotic resistance is the pharmaceutical industry's best friend. New antibiotics with increasing potency are constantly being developed to overcome drug resistant bacteria. As soon as a new antibiotic becomes marketable, drug sales representatives generously supply doctors with the new drug. This drug should actually be used sparingly and for specific drug resistant infections, but because of the convenience, doctors frequently give away and prescribe the new antibiotic, it becomes widely used, and the result is more drug resistance requiring even newer drug development. Somehow, this kind of drug overuse has to be controlled.

The U.S. is the only country in the world that allows drug advertising. Choice of drugs should be left to the treating physician without the pressure of patient demand for the newest and most expensive version. Many new drugs are "me too" drugs, just slight modifications of older tried and true drugs. The difference is in cost, not efficacy. Advertising for non-prescription drugs constantly reinforces the notion that the only answer to any discomfort is a drug, a notion that has become as American as apple pie. Because of widespread advertisement, Americans unthinkingly take nonsteroidal antiinflammatories, which have potential serious side effects such as gastrointestinal bleeding and kidney failure, for such non-life-threatening conditions as the common cold. Risk outweighs benefit in these cases. We need to revert to banning drug advertising.

Physician Behavior and Training

American physicians habitually order more tests than are necessary. Clinical guidelines based on research have helped assuage this wasteful behavior. For instance, years ago, research found that routine chest X-Rays were of no benefit for annual physical exams. Similar guidelines have been established for taking X-Rays for ankle sprains. Finding what are the most unproductive tests and establishing national guidelines for when to use them could help bring down cost.

The price of our technological progress is the loss of clinical skills among the current generation of physicians. In an article entitled The Demise of the Physical Exam (Jauhar 2006), the author, a professor of medicine, expresses the prevailing view among today's physicians: that the physical examination is "an arcane curiosity," performed as a ritual that preceded their real tool for problem-solving-- technology. For centuries, doctors have been taught to begin with a thorough history and physical examination followed by tests to finally arrive at the final diagnosis based on the total information gathered. The current method virtually eliminates the initial steps. Doctors perform a cursory history taking and physical exam, and then order the tests related to the patients' symptoms to obtain a diagnosis. With this method, I have witnessed not only excessive waste from unnecessary tests but also the misdiagnoses of common conditions such as small bowel obstruction, congestive heart failure, and appendicitis. This sea change in medical practice constitutes one major reason why American healthcare has become so expensive and yet less than satisfactory. There is a dire need to retrain physicians to return to basics. And the need is urgent because the medical trainers are losing the very skills they should be teaching.

Over half of the American public recognizes that the Western medical approach has limitations and seeks complementary and alternative care. Skeptics among the medical establishment scoff and explain away the trend by saying that these patients "weren't very sick to begin with." What they fail to recognize is that Western medicine, while having advanced treatments for advanced diseases, have far fewer remedies for early-stage disease, or, the "not very sick." Traditional Chinese medicine teaches that illness begins with some dysfunction in the host that causes him or her to succumb to disease. Unlike the Western approach, which focuses only on disease, Eastern medicine also strives to restore the patients' weakened function to regain health. Familiarity with this approach among primary care physicians could not only bring down healthcare cost but also enhance physician satisfaction with work. If the physician prescribed herbs for the common cold, there would be fewer cases of bronchitis, the leading condition for which antibiotics are overprescribed. If acupuncture or acupressure were first-line treatment for back pains and soft tissue inflammation, patients would improve. This would lead to fewer MRI's ordered and fewer surgeries performed. If acupuncture and herbal therapy were first-line treatment for infertility, it would eliminate the enormous cost of in-vitro fertilization in many cases. In the past decade, the insurance industry has begun to recognize that some forms of complementary care obviates far more expensive treatments such as surgery and are adding them to its covered benefits. It is time for government-sponsored insurances to awaken to this fact.

In the past decade, the number of medical school graduates entering family medicine and internal medicine training has dropped by half. The shortage of primary care doctors has led patients to overuse costlier secondary and tertiary care facilities such as emergency rooms and hospitals. Several factors account for physicians' disenchantment with primary care. Compensation is low when compared with specialty careers. Bureaucratic paper work is daunting. Often primary care physicians are frustrated because they have no means within the Western paradigm to treat common conditions. The very reason for entering the medical profession, to help heal and relieve pain and suffering appears unachievable, and they see themselves as mere triage agents. If these physicians were able to use complementary and alternative medicine, the gratification of seeing their patients actually improve would certainly boost their level of job satisfaction.

Other players are insurance and patients. The private insurance industry has recognized that prevention is more cost-effective than cure. Many offer prepaid health plans and cover routine physical examinations. Medicare, to date, retains its antiquated policy: coverage for disease and not prevention. It is time for Medicare to enter the 21st century. Patients used to pay the doctor directly for services. Now, usually a third party, the insurance pays. Now, no longer aware of costs, patients feel entitled. If they have insurance, every test and treatment should be covered. The media sensationalize such cases, portraying the patient as victims and insurance companies as demons for not covering exotic treatments that have a low prospect of cure. Such cases often result in litigation, of course, further driving up cost. It is time to educate doctors and patients alike about cost and to behave responsibly. Correct treatment requires correct diagnosis. This fundamental principle applies to finding solutions to our healthcare crisis.


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