The most expensive diseases

How to trim the bill
So how can the U.S. trim its ballooning health care bill? Experts generally agree that the answer lies in changing the financial incentives surrounding health care, to make it more efficient. One idea, being championed by Fendrick, is to make drugs free in cases where the benefits are so huge that they translate into money in the bank. For instance, cholesterol drugs are so good at preventing second heart attacks that giving them to people who have had heart attacks or persistent chest pain might save money.

Then, Fendrick argues, patients should be made to pay more as cost-effectiveness decreases. That means many people would still take Lipitor and Zocor, but many would have the same co-pays as they do now.

However, drugs are only a tiny sliver (about 11 percent) of overall costs. Elliott Fisher, a professor of medicine at Dartmouth University's influential health costs group, says that the two most expensive decisions a doctor makes are to send a patient to the hospital and to schedule a new appointment. Yet the benefit of more doctor visits is pretty much unproven, he argues. In fact, switching from specialist to specialist may just provide more opportunities for doctors to "drop the ball," he says. Areas with more intensive health care often wind up with patients who are less healthy.

"The U.S. could theoretically send one-third of the health care workforce to Africa," says Fisher, "and improve the health of both continents."

Even the most proven, effective treatments are only given to patients half of the time. Giving more of these basic treatments — such as administering blood thinners to prevent stroke or ensuring that patients undergo regular cancer screenings — might increase the efficiency of the health system. Says Fisher, "There are lots of failures to do the right thing when we know what the right thing is."

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