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Why American Health Care Costs So Much

Posted By Lewis Mehl-Madrona, Thursday, April 07, 2011
Updated: Friday, June 10, 2011

We spend so much more time talking about how to pay for health care in the United States than we do wondering if what we get is worth what we pay or how to make health care more cost-effective. My fields are family medicine and psychiatry, and, to my chagrin, rarely do the two specialties communicate. Here’s an example that cost the health care system enormously. These kinds of situations arise commonly.

Recently a mother became concerned about her son who was feeling sad. She talked to him enough to learn that he was being bullied at school and that sometimes he wondered if it wouldn’t be better not to be here. She took him to their family doctor who said he didn’t do mental health and she would have to take her son to the emergency department at the hospital so he could get services.

At first this sounds crazy, but in our health care systems, the fastest way to get an appointment at the community mental health center is to go to the emergency department. Otherwise, one waits months for an appointment (at least where I work). It’s more questionable for the family doctor to say, "I don’t do mental health.” We have extensively training in handling mental health issues during our three year residency. In Canada, where residency training is only 2 years, family doctors are expected to manage all mental health issues with psychiatrists available only as consultants, and actually do so.

So, the mother took her son to the emergency department. They waited five hours to finally see a physician. He asked the son a few questions. The coup de grace came when he asked the boy if he ever felt as if it would be better if he were there. The boy agreed. Sometimes he thought that way. The physician left the room for an hour and returned to announce to the mother that he was transferring the boy to the regional psychiatric center by ambulance, because of his suicidal ideations. The mother objected. "I can take my son in our car to somewhere else to be evaluated, just like I brought him here.” The physician left the room and returned with a social worker and two security guards who told the mother that she would be arrested and detained if they interfered with the transfer of her son by ambulance and that Child Protective Services would be involved because of her failure to recognize the gravity of the situation and that her son needed immediate treatment. She acquiesced and followed the ambulance in her car. By now, her son was terrified.

At the Regional Psychiatric Center, they waited another 5 hours before they saw a social worker who took the history. Then a physician in training (called resident physician) came to talk to the boy and her. After a total of eight hours at the Regional Psychiatric Center, they were allowed to leave with a prescription for 5 mg of escitalopram, a selective serotonin reuptake inhibitor (Brand name, Lexapro) and some names of some private therapists to call in their home community. Imagine the charges stacking up. The family doctor billed for an office visit. The emergency department charged almost $2000 for their evaluation. The Regional Psychiatric Center charged $2500 for their evaluation. The ambulance transfer had cost $500. The prescription cost eighty dollars.

At the Regional Psychiatric Center, the social worker and the resident physician had managed to figure out that the child had no plan to kill himself, but only sometimes wondered if it would be better to cease to exist. In fact, until his encounter with the psychiatric system, the child had not actually considered that people really killed themselves. His concept had been more wistful and fanciful as he wondered if it would be better not to exist. Presumably others have wondered the same thing without benefit of Regional Psychiatric Care. The mother’s observation was that each time she was transferred her caregivers seemed younger and less experienced. At the same time, with each transfer her son was becoming more and more frightened.

In the end, after an extra $6000 in billing and probably the worst day of this mother’s and this child’s life, the end result could have happened in the family doctor’s office. He could have listened to the mother and the child and could have made a determination that these thoughts were not connected to a plan or to an intent to die, but rather an expression of how miserable the child felt. He could have written the same prescription since this drug is widely detailed to family doctors with instructions on its use. He could have given the mother names of psychotherapists in the community to call. In an enlightened office, he could have had a therapist on call for his office or visiting on a regular basis each week to handle these kinds of situations.

Why didn’t he? One explanation is fear of malpractice. That drives much of the insanity in American health care and is not so nearly a problem in other countries. These other countries have social networks to care for people who are injured in medical mishaps. We don’t. The only choice available to our injured patients is to sue. Another explanation is the silo model of American medicine. Each specialty keeps to its own domain somewhat exclusively. Internists don’t talk to psychiatrists and don’t treat psychiatric disorders. Similarly, psychiatrists don’t talk to internists and don’t treat medical disorders. However, the body is one. The arbitrary separations we create do not actually exist in nature.

If we are going to actually afford an accessible health care system, we will need to address these questions of how care is delivered. Failure to do this will bankrupt our healthcare budget.

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