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 control.
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 of treatments.
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 cheaper.
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 www.health.harvard.edu/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 gray area.
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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