How you can rein in health care bills — yours and society's.
Our carbon footprints are calculations of the greenhouse gases
we're individually responsible for. Reduce yours, and you can
take some satisfaction in having done something, however small,
to reduce emissions and slow global warming.
Now might be a good time to start thinking about our health care
footprints. Reforming health care and extending medical insurance
to all Americans have become national priorities, despite — or
maybe because of — the weak economy. But those efforts are likely
to founder unless spending on health care is brought under
Serious reform and belt tightening can't happen without new
policies from Washington, but individual responsibility and
action can both set an example and make a contribution. It all
adds up. Besides, even people with good health coverage are
paying a larger fraction of their health care bills these days,
in the form of co-pays, deductibles, and other out-of-pocket
expenses. There's a direct personal interest in reining in costs,
not just a societal one.
We polled our editorial board to get some ideas about what people
might do as individuals about health care spending. Dr. Soheyla
Gharib suggested the term health care footprint to us. Here are a
dozen suggestions for making yours a bit smaller:
1. Develop a good working relationship with a primary care
physician. A primary care doctor who knows you, your medical
history, and your circumstances stands a much better chance than
a relative stranger of making decisions and giving you advice
that will keep you healthy, out of the hospital, and in no need
of specialized medical care. She or he can take care of you
in context. The catch is that primary care physicians
are in short supply. And primary care may be evolving into more
of an ensemble approach, with the physician being the head of a
large supporting cast. In a few years, the relationship you have
with the physician may be less primary than, say, the one you
have with the health coach — someone who works with the physician
and whose job it is to cajole, remind, and motivate people to
take better care of themselves.
2. Don't use the emergency department unless absolutely
necessary. Call your doctor or his service and try to get
some advice over the phone — or, better yet, in person. Emergency
care is fantastically expensive partly because the doctors and
nurses often need to order a lot of tests so they can make
diagnostic and treatment decisions quickly.
3. Get — and stick — with the program. Most of American
health care these days is devoted to treating chronic conditions
— like arthritis, diabetes, heart disease, and high blood
pressure — and to care at the end of life (see #11). Taking
medications as prescribed, getting regular check-ups (regular eye
examinations if you have diabetes, for example), and adhering to
lifestyle changes can keep those diseases under control at
relatively (we stress relatively) modest cost.
4. Don't go directly to a specialist without checking with
your primary care doctor, even if your insurance allows it.
Medical care is increasingly specialized, but as much as
possible, you should let your primary care physician coordinate
that care. If she or he doesn't know what's going on, it can lead
to wasteful — and possibly harmful — overtesting and duplication
5. Ignore the drug ads. The heyday of pharmaceutical
advertising may be winding down (remember the Dorothy Hamill
Vioxx ads?), but there are still plenty of slick
direct-to-consumer come-ons being broadcast and published. New
drugs may have real advantages over older ones, but the virtues
of the old standbys, which don't have big ad budgets behind them,
often get overlooked. Older drugs are frequently just as
effective (if not more so) and safer — and almost certainly
6. Go generic. Spending on pharmaceuticals has slowed
down, in large part because of competition from generic drugs,
which cost less than their brand-name equivalents. Most insurers
have higher co-pays for brand-name drugs, so using generic
medications can mean a cost savings both for you and for the
health care system. But check with your doctor and your
pharmacist about what's available as a generic. It can be
confusing. For example, there's a generic form of mupirocin
ointment, but as a cream, the antibiotic is available only as
brand-name Bactroban. We've posted a list of other examples of
this kind of inconsistency on our Web site at /health.
7. Fight inertia. If you're taking a medication, discuss
with your physician how long you've been taking it, whether it's
working, and if it isn't, not taking it anymore. Many people take
medications for years without knowing if they are helping in any
way. Antihistamines, nasal steroid sprays, and antireflux
medications are prime candidates for this sort of pharmacological
inertia. You can avoid this problem by talking to your doctor
about a trial period when you start a drug. Get some instructions
about signs that would show if the drug is working, and see the
doctor if it's not.
8. Screen the screening tests. Screening tests can save
lives by catching a disease at an early, more treatable stage.
But a screening test can also cause a lot of mischief: false
alarms, a false sense of security if a disease is missed, and
unnecessary diagnostic testing and treatment. There are more
doubts about some well-established screening tests than many
people realize. For example, many men believe they must get the
prostate-specific antigen (PSA) test for prostate cancer. Not so,
say the federal government's prevention guidelines, which
characterize the evidence as insufficient to recommend PSA
testing. And in 2008 the guidelines were revised to say men ages
75 and older shouldn't get a PSA test. These are just guidelines:
men need to discuss the pros and cons of PSA testing with their
doctor — with the clear understanding that they are entering a
9. Question the need for expensive tests. Don't push to
get new, expensive tests just because you think new is better.
And if a doctor orders an expensive test like an MRI or CT scan,
you can ask why it's necessary and how it will make a difference.
The number of imaging tests being done in the United States has
exploded and by some reckonings, almost a third of them are
unnecessary. Some tests, like CT scans to evaluate coronary
artery disease, are being debated because it's unclear how much
they really add to standard tests. Health care experts Ezekiel
Emanuel and Victor Fuchs have pointed out that the
hospitalization rate in the United States is actually lower than
in many European countries. We also go to the doctor less often
on a per capita basis. It's the expensive inputs into our health
care — all the drugs, tests, high-tech treatments, highly
compensated specialists — that drive up the collective medical
bill, not so much the volume.
10. Wait, and it may go away. Often it's critically
important to get medical care straightaway. Prompt treatment of a
heart attack or stroke can save your life or prevent devastating
disability. But people frequently get tests and treatments for
aches, pains, and other discomforts that might have gone away on
their own because the illness-producing stress of work or school
lets up, for example, or the immune system fights off the
infection. If you are feeling sick, by all means get evaluated,
but if your doctor suggests the test of time, take the test.
11. Discuss end-of-life issues with your family and
physicians. Medical care near the end of life is a
big-ticket item. Roughly a fifth of the money that Americans
spend on health care goes for care in the last year of life.
Living wills and advance directives don't necessarily save money
— people sometimes want more care, not less, as they become more
frail — but they may help. And so may talking about your
preferences. A study published in The Journal of the American
Medical Association in 2008 found that cancer patients who
had discussed end-of-life care with their physicians received
hospice care sooner and had lower rates of ventilation,
resuscitation, and admission to an intensive care unit. Because
they talked to their physicians, these people were treated the
way they wanted to be and avoided a waste of precious resources.
12. Stay healthy! Not needing health care is perhaps the
surest way of spending less money on it, both yours and
society's. So don't smoke and get help quitting if you do. A good
diet (replacing refined starches with whole grains and lots of
fruit and vegetables) will lower your cardiovascular risks.
Exercise helps with — well, you name it. Sleep is fast becoming
the third pillar of wellness. Studies have shown that averaging
eight hours a night may prevent colds and keep arteries open.
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