[const_cast]

Which seems kind of okay, except when you consider that we pay significantly more per-capita for healthcare as opposed to Canada. Yes, that includes if you take into account taxes, and it's not even close.

Sure, we're not the absolute worst, but we are the most expensive. And, for that, we get close to the worst results. Clearly, our healthcare system is broken in a variety of complex ways.

[rayiner]

As far as I can tell, we pay more for healthcare for the same reason we pay more for schools and more for subways. We’re a low competence, low trust society, and have to compensate for it by making everything subject to litigation to the point where the country is effectively run by lawyers.

My six year old boy ran into a table and got a black eye. Took him to the doctor (because my wife made me), who physically examined him and saw he was fine. But ordered a CT scan anyway (which we got the same morning because this is America). No sane healthcare system would order a CT scan for this! But in our litigation-driven system, the doctor has to do it, because in the extremely unlikely situation that there was an undetected internal bleed, he’d get sued. And some expert would get on the stand and say the standard of care is to order a CT scan every time a six year old boy does a six year old boy thing.

[const_cast]

I don't think this is the sole reason why, I think private sector inefficiency is a big reason why, too.

We have an extremely fragmented system that breeds inefficiency. Thousands of insurers, so hospitals have hundreds of billing specialists. Thousands of plans, so the complexity of what is and isn't covered explodes beyond belief. There's no streamlining, no centralization, no authority. Just bickering and "erm, ackshually" from every party. Every interaction has extremely high friction that comes with a massive, fragmented system.

It's like a microservice architecture with thousands and thousands of microservices. Except their contracts aren't always published, sometimes you need to call them on the telephone. And sometimes you just have to try requests and see if they get denied.

Also, I think a CT for head injury is fairly standard practice. I think they do that in Europe. Anyway I had some pain somewhere inconspicuous once and it was cancer, so. I don't think the issue is we image too much.

[tptacek]

We very definitely image too much. There are apparently as many MRI machines in Massachusetts as there are in all of Canada. "We image too much" is a pretty common complaint in health policy discussions; Rayiner is not just making that up himself.

[const_cast]

I don't know, maybe, but at the same time our cancer screening recommendations are pretty conservative and we're actively looking to lower the screening ages for some of them because enough are slipping through the cracks.

We do image a lot for injuries. Maybe it's to give radiologists something to do, I don't know.

[tptacek]

First, when we're talking about imaging overuse we're generally talking about injuries and back/joint paint.

But it's also probably not true that we screen less aggressively than Europe. For instance, I think we start breast cancer screening earlier than Europe. There are European countries with better rates of colorectal screening, but that's a patient compliance issue as much as anything else (and 10 years from now standard of care is unlikely to be imaging-based for that screening for most pts).

[FirmwareBurner]

>Also, I think a CT for head injury is fairly standard practice. I think they do that in Europe.

Chiming in here from a rich EU country. CT for head bumps at the ER is not standard unless the doctor deems it absolutely necessary in grave injuries since the public system is already clogged up. Only X-ray on the spot is standard.

When I had my bicycle accident they did no CT scan, only head Xray. They said they'll do a head CT only if concussion symptoms don't go away or worsen after a few days.

In poor EU countries, you don't even get an Xray if your skull isn't cracked wide open because there's already 100 people in the ER waiting with even bigger issues than you. My dad slipped and fell on a concrete floor and the ER sent him home after looking at him for 3 seconds telling him "it looks fine". If he went to a private hospital he'd get all the imaging he wants since he'd be paying out of pocket and they'll never say NO to money.

I feel like Americans live in a parallel universe where healthcare has infinite money so they throw expensive checks procedures at the wall since insurance pays anyway, but that's not the case in public systems where money is tight than the government demands frugality from hospitals and doctors.

[rayiner]

I agree our private sector is inefficient. But our public sector is too (hence my transit and educational examples). We suffer from cost disease across our entire economy, both in public and private spheres.