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Intensity, Not PricesGerard Anderson and colleagues (May/June 03) conclude that U.S. medical care costs so much more than in other countries because "it’s the prices, stupid." I tried to answer that same question more than two decades ago during a sabbatical funded by the Commonwealth Fund. I compared Western European and U.S. teaching hospitals, as well as policies regarding physician supply, and came to a slightly different conclusion.1 Where the United States seemed to deviate from other industrialized countries was in its intensity of care, as reflected by the high proportion of hospital beds that were devoted to special care (such as coronary and intensive care) and the fraction of its physicians who were specialists, not generalists. I suspect that the same holds true today, as reflected in the very high rate of coronary angioplasties here compared to other countries. It is true that the prices for performing procedures and caring for patients in intensive care are higher than less aggressive care, but I would argue that the intensiveness drives the prices, not vice versa. In my 1984 paper on physician supply I suggested that the best recipe for high national medical care spending would include a high concentration of physicians and specialists; fee-for-service payment of physicians, with its pro-technology biases; patient self-referral directly to specialists; physicians permitted to practice a specialty independent of the specialty certification process; a high dependence on specialists for primary care; and broad national health insurance. I argued then that the United States fulfilled the first five conditions, and I don’t think things are much different now. Perhaps the answer is, "It’s the intensity, stupid."
University of California, San Francisco NOTE
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