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 require them to probe and cut into their patients' bodies. It is also expensive to buy -- at 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.
Although 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 noninvasive, seemingly harmless procedures come with risks and difficulties.
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Gawande demonstrates 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 with better treatment.
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The MRI data are a good proxy for the much more general tendency of U.S. 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 hip, which then needs replacement itself, or an elective full body CT scan that exposes patients to radiation and leads to treatments of uncertain benefit, the reliance on technology leads to medicine that is more expensive without being better.
Continued: Worried about rationing
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