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Patient, heal thyself

Consumers' lofty expectations are a big factor in the rising cost of health care.

By Andrew G. Kadar

Most of us are happy with the medical care we receive; we just think it costs too much. We want to maintain all the conveniences and quality we enjoy, provide the same care to all the uninsured, and pay less for the whole package.

Politicians hold out the promise that we can do all of this - if only doctors, hospitals, and insurance companies could behave a bit better, get a little less greedy, become more efficient, and computerize record-keeping. Patients don't have to change one bit in this fantasy.

But if we want to get serious about reforming health care, and if we want to cut costs, then patients have to look in the mirror as well as point fingers. One cannot seriously analyze any set of transactions, including medical care, by looking only at the supply side of the equation and ignoring the demand side.

Americans expect and demand more timely, more convenient, more technologically advanced, and therefore more expensive care than people in other countries do. In other countries, people expect and accept that there may be a long wait for tests, particularly those that involve expensive equipment. But we don't want to wait for weeks or months for diagnostic tests such as MRIs and colonoscopies. Once we believe a procedure will benefit us, we want it when we want it - and at our convenience, not the convenience of the providers.

It's easy to see how this leads to higher costs. Having more MRI machines in a community, for example, shortens the waiting time for testing. But it also means excess capacity. If machines are scarce, they tend to be in constant use as people await their turn to be tested. But if we have enough machines that people can get tested quickly, then the equipment will sometimes sit idle, waiting for patients.

The United States has more than four times as many MRI machines per person as Canada or Great Britain. Canadians perform nearly 40 percent more exams per machine. Since MRI machines don't come free, our greater capacity generates higher per-test expenses.

A related factor compounds the cost difference between the two countries. If pricey machinery is scarce, fewer tests end up being performed. Some people will get well while waiting; some will choose to live with their symptoms; some will die before they get to the front of the line.

To take another example, American orthopedists perform far more knee and hip replacements than their counterparts in any other country. The incidence of knee replacements in Americans over the age of 45 is nearly 50 percent higher than in Britons, and more than double the rate among Swedes.

Standard American private-practice medicine tends to be available only to the elite in other countries. A total joint operation costs a whole lot more than a cane. People with wealth and clout in other countries receive artificial joints at a higher rate than their poorer, less influential countrymen.

Total hip and knee replacements reduce pain, increase walking ability, and improve quality of life. But they don't prolong life, and therefore they don't show up in any of the comparisons that critics of American medicine like to point to - the statistics that show we spend more money on medical care but don't have the longest life expectancy. Such comparisons ignore lifestyle differences between countries, quality-of-life measures, and patient expectations.

Our wasteful, lottery-like malpractice system also adds enormously to health-care costs. Defensive medicine leads doctors to order diagnostic procedures that are likely to yield very little or no useful information.

Health-care providers can surely improve in many ways, but that's only half the story. If we want to get serious about improving our medical-care system, then we have to look at the whole picture, including the demand side of the equation.

If we insist on the latest technology at our convenience, and if we permit legislators to protect the lawyer-enrichment program that is our malpractice system, then we will continue to face higher costs than people in other countries, no matter how efficient and altruistic health-care providers become.