The Machine That's Bankrupting America
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The Machine That's Bankrupting America
The $2 million MRI scanner and what's wrong with U.S. health care.
By Mark Gimein
Posted Monday, September 21, 2009 - 6:10am
The main question of the national debate on health care has been who should pay for it, but lurking behind it is another one: Why does American health care cost so much in the first place? If you want an answer to that question, there's no better place to start than the proliferation of the gleaming new magnetic resonance imaging machines filling U.S. hospitals.
According to the latest data, the United States has just over one MRI scanner for every 40,000 people. That number that may not sound high, but it means that we have more than three times as many devices per person as you will find in the United Kingdom or France, and almost four times as many as in Canada. Only Japan, an MRI-happy outlier, has more.
Obviously, the MRI is an extremely useful tool, giving doctors an ability to see inside the body and diagnose conditions that would otherwise have required them to probe and cut their patients' bodies. It is also expensive to buy—about $2 million—and expensive to operate. Worse, the machine is used aggressively for tests such as breast cancer screening and yields a high rate of false positives that lead, in turn, to unnecessary surgeries.
Though MRI scanning has obvious advantages over invasive procedures, its use on the very sick is also not cost-free. When my own father was dying of cancer last year in one of New York's best hospitals, he was subjected over a period of weeks to a battery of scans. While the healthy may think of MRIs as an almost entirely benign procedure, it is not at all the same for a patient whose spine is fractured in several places from bone marrow cancer, who cannot easily lie flat, and who is hallucinating from morphine. My father came down with pneumonia from complications involving sedation for what should have been a harmless scan. In these situations, even non-invasive, seemingly harmless procedures come with risks and difficulties.
The physician and writer Atul Gawande, in an extraordinary article in The New Yorker, detailed how doctors with a financial interest in expensive cardiac procedures have driven skyrocketing medical costs in McAllen, Texas. Gawande demonstrates strikingly in his story how the financial interests of doctors push patients into expensive operations of questionable usefulness. As Gawande shows, even for doctors who do not consciously seek to profit from pricy procedures, the emphasis on expensive treatments changes the norms of medical practice. And we can almost certainly add to this that it changes the expectations of patients, who come to believe that more treatment equates to better treatment.
The MRI data is a good proxy for the much more general tendency of American physicians and patients to count on expensive technologies and operations. In case after case, however, the confidence in this approach to medicine turns out to be misplaced. Whether it is the latest artificial hips, which then need replacement themselves, or elective full body CT scans that expose patients to radiation and lead to treatments of uncertain benefit, the reliance on technology leads to medicine that is more expensive without being better.
Photo of an MRI machine by Medioimages/Photodisc/Digital Vision/Getty Images.
Comments
When it comes to US
When it comes to US healthcare you can never be to sure especially if you are an independent contractor be sure to do your research and get what you deserve.
MRI
Liabiilty & Unions is the reason of higher cost on everything in America. No other country has the liability problem we face. Democrats continue to pander to trial lawyers
Where Big Money is Wrong on MRI
In his article, Mr. Mark Gimein ignores the fact the medical imaging is a front-line tool in diagnosing life-threatening diseases early when they are most treatable. The bottom line is that diagnostic imaging, such as MRI and CT, saves lives and money. In his accusation that MRI machines are the villain that is “ruining health care,” Mr. Gimein fails to recognize that a non-invasive diagnostic scan is often less expensive than an invasive test and that by using diagnostic imaging to detect and treat diseases earlier, health care systems reduce costs by, for example, avoiding lengthy and repeated hospital stays.
But what’s most disturbing about the essay is not his misunderstanding that diagnostic imaging actually reduces health care costs, rather it’s the implication that patients, such as those with breast cancer, should be denied access to advanced imaging. I’ve met countless patients who insist that a diagnostic imaging test saved their life and without access, they wouldn’t be here today. I’ve met families who’ve lost loved ones to Inflammatory Breast Cancer – a disease that MRI detects but typically mammography doesn’t. These families have told me that if their loved one would have had access to a breast MRI scan, they might be alive today. Does Mr. Gimein believe these types of patients shouldn’t have access to MRI?
At the Medical Imaging & Technology Alliance (MITA), we strongly support efforts to ensure imaging is used appropriately. To that end, we support mandatory accreditation of imaging centers and clinicians as well as a robust roll-out of physician-developed appropriateness guidelines so patients get the right scan at the right time. The use of appropriateness guidelines is how the medical community can reduce unnecessary scans without compromising patients’ access to them.
Ilyse Schuman
Managing Director, MITA
Health Care
Yes, American health care is good but is it the best in the world for what many Americans pay I don't think so. Many people have commented that as Americans we have a choice. Yes, some Americans do have a choice if you have health insurance but many Americans who do work don't have health insurance so their choices are limited unless they happen to be poor enough to qualify for various government programs or have the money to pay out of pocket which can be extremely expensive. Also, even with insurance medical expenses can be expensive in the U.S. between fees for doctor visits, medication and other things.
I had a medical procedure done in the U.S. last year shortly before coming to China to work here. This procedure cost my health insurance company over $5000. It took over three months to have this done between waiting to see a doctor, getting scheduled to have a sonogram with a specialist, and getting the results back, etc. It cost me just over $160.00 in out of pocket expenses. Plus, another $50 for medication to bring the problem under control.
I couldn't find another job in the U.S. after being laid off and had the choice of "retiring" to get health insurance or collecting unemployment. I decided health insurance was more important. At that point, this was a large sum of money to pay when I had no income coming in. Luckily, I had saved part of my paycheck on a regular basis. If I hadn't had savings I don't know what I would have done. Of course, this is over and above the $800 that my former employee and I pay each month for my health insurance.
Six months after coming to China the same medical problem occurred. I went to the local hospital. I arrived at the hospital at 9:30 a.m. in the morning by 3:30 p.m. that afternoon I had been seen by a specialist, had a sonogram, got the results back, and had surgery. I had to wait a week to get the results back from the surgery but it cost me less than $70 for this including medication. Many Americans would have complained about being seen by number instead of name and about the fact that the hospital was older but the equipment including an MRI was as modern and uptodate and the radiologists as well-trained as any I've seen in the U.S. I know Chinese doctors and radiologists aren't paid huge salaries but why the huge price difference for the same procedure. When I returned to the States I took the sonogram pictures and translated test results and other information to the American specialist I had previously seen. She told me they had done exactly what she would have recommended.
Last weekend I visited a friend in the brand new hospital that has opened in the past year in this Chinese city. The hospital and its equipment, including an MRI, numerous sonogram machines, and CT matches up to anything that I've seen in the U.S. and various countries in Europe.
Some politicians, commentators and others have to stop fear mongering about American healthcare and rationing as it already exists. Certain countries already have better healthcare than the U.S. for much less money. Do we really want to end up with a few people in American receiving very good health care including all the MRI and other tests that may not be medically necessary at the expense of the rest of us?
MRI's
Having been in practice for almost 25 years, I have seen MR replace CT (a much less expensive technology but with a considerable radiation dose) for many routine studies. Despite the large increase in the number of MR scanners though, the price per scan has not decreased but has in fact increased across the board. Physician owned scanners and other diagnostic facilities are, I believe, a major driver in healthcare costs.
MRI scanners
While reasonable people can conclude that unnecessary tests will raise the costs of healthcare. It is unreasonable to conclude that the United States has to many MRI machines.
Many years ago I had injured my knee at work. The pain was severe and the injury hard to diagnose. Not being a medical professional myself I had to rely on the doctors and other medical professionals for their advice and diagnosis but no one seemed to be able to figure it out. One doctor, recommended by my employer, suggested I was simply pretending... The injury was not so severe that it prevented my employment, at least most of the time, but it did create periods of intense pain that left me unable to walk or use my leg for minutes and sometimes hours at a time.
After several x-rays, after months of physical therapy and then two different chiropractors I was at my wits end. My knee was not getting better and no one had pinpointed the problem. Neither my insurance nor the Workman's compensation insurance was willing to pay for surgery unless they knew what the surgery was going to correct beforehand. Finally, an elderly orthopedic surgeon recommended by my retired family practitioner suggested that I have an MRI done on my leg.
The rural hospital near my home did not have an MRI machine and there was another weeks wait until a portable unit was brought in on the back of a semi trailer. By this time I was not working at all because of the pain. The MRI was done and the elusive problem was found. Within two months of surgery I was able to work and walk without pain again.
The MRI is quite possibly the best diagnostic tool ever invented. Each hospital in America should be required to have one just as they are required to have running water and tongue depressors. As with any technology, MRI machines are expensive, however the costs associated with these machines should have gone down as more and more were built for demand. If these machines are still costing the same now as they were back when I needed one, then perhaps someone needs to look at why our medical system is overpaying for machines.
1. If he's just using MRI
1. If he's just using MRI machines as an example, then I think this article's title is misleading, even if he did mean it as some abstract metaphor.
2. The US has more machines per capita when compared to other countries, but a lot of that is probably a function of distance to travel to the nearest machine. The US has a much more dispersed population than countries in the EU, or even Canada.
3. A lot of the claims that were made about MRIs leading to unnecessary surgery or creating an uncomfortable environment for lots of people are not even relevant because the number of surgeries saved by the MRIs far outweighs those issues. So what if we don't have a perfect tool? At least it's better than the alternative.
4. Other than these points, I agree with the author's main points. There are definitely abuses in the system, and we need to find a way to change the system of incentives. We definitely need to change our perspective and even culture of health care in order to really make a change in this unsustainable system.
Beware people with simple answers II
Ref infant mortality, I'm well aware of the data from the Common Wealth fund. The trick is that in the US, babies are given a chance that would not be born elsewhere. If you don't believe that, answer this: where would you rather have a baby? Chicago or Mexico City?
I think that all of the
I think that all of the posters on this subject are ignoring or unaware of the fact that unnecessary/useless procedures and tests are part of the healthcare cost problem. The author is just using MRIs as an example of a high tech machine that is very important and useful, but not the answer for everything and the same goes for other high risk/high tech medicine that is costly and has questionable outcomes. He isn't saying that MRI machines are bad in general, but that the way that we go about treating people is flawed with respect to cost and benefit. It isn't a good thing that because of our procedure-happy and cost inefficient medical system a great many people don't have insurance or access to healthcare and others get a battery of tests that are useless or harmful in some cases.
And by the way Rosswellric, the author is implying that it would seem unnecessary to have three times as many machines than other countries because they have better healthcare systems with respect to access to care and spend 40% less than we do on healthcare costs.
Food for thought:
50% of healthcare costs are spent on the last YEAR of life in the US.
The United States has the highest rate of preventable deaths when compared to EU countries and Canada.
The United States' infant mortality rate is the fourth worst in the industrialize world.
In my honest opinion, I think our health care system stinks and we should be able to do better than this.
Beware people with simple answers.
Wow. Thanks for misrepresenting the state of American healthcare. This is easy to do given healthcare's immense complexity. But, let's clarify a few things:
1. As recently as 1985, exploratory surgery was the standard of care. The near elimination of those procedures was described as one of the 11 greatest acheivements of the millenium on par with the polio vaccine.
2. American life expectatancy is a function of more than healthcare. Here's a question for simple thinkers: the average 50-year old American is 20 pounders heavier than a 50-year old European. That costs us ~$220B per year in obesity related costs. I wonder if that impacts life expectancy? (It does). The trick, of course, is that obesity is a function of our culture and our nutrition. Healthcare is simply the catcher of our bad habits.
3. Our healthcare system must improve. But, let's not sell it short. All of those healthcare systems that you admire benefit from our innovations. Consider: the top 5 US hospitals generate more clinical trials than any other country. The polo vaccine was developed in Pittsburg, the MRI in Chicago, the CT in Milwaukee, stents, pacemakers, etc. Those innovations then spread throughout the world. Essential to note is that our healthcare system is the only system with the incentizes in place to generate those innovations. If were model France and Germany, everyone loses those innovations.
Lastly, I do agree that there are too many cozy relationships between radiologists and machines. Thankfully, recent legislation has changed the incentives that led to that happening. Now we need to identify and prosecute those who knowlingly abused the system.