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Neurologists can no longer ignore the headlines about rising healthcare costs. Setting aside the politics and the biases, it is undeniable that the costs of healthcare in the United States continue to rise at an alarming rate that will either bankrupt us or force us to ration. We have all seen the numbers. U.S. healthcare costs accounted for 16% of total GDP in 2008, well above all other large countries, with France a distant second at 11% of GDP. Worse yet, healthcare costs are rising faster than GDP and, if unchecked (an impossibility), are predicted to bring down the U.S. government and the competitiveness of our businesses. Although access to better care has been a source of pride for Americans, objective measures do not support that care in the U.S. is any better, with life expectancy and other measures of health in the middle of the pack, close to countries like Cuba. As the costs of insurance increase, more are becoming uninsured and public pressure on government plans may force regulations that reduce benefits for the elderly and the poor, as we have seen already. The Affordable Care Act may help, but even if it survives a host of challenges, the provisions are unlikely to generate substantial reductions or even stabilize healthcare costs.

Although limited, evidence suggests that neurological conditions are disproportionately driving up healthcare costs. Most of this is not our fault. People are living longer, leading to absolute increases in dementia, stroke, and movement disorders (among others). Also, we have been very successful in converting previously fatal conditions into survival with chronic disability, and long-term care is very expensive. These forces are not negative, but point to a growing role for neurological diseases in healthcare expenditures.

Waste is an important contributor to U.S. healthcare costs. Donald Berwick, describing his recent observations as Director of the Centers for Medicare and Medicaid Services (CMS), estimates that waste accounts for 30% of Medicare and Medicaid expenditures.1 Similarly, the Institutes of Medicine Roundtable on Value and Science-Driven Health Care estimated that waste accounted for $765 billion of an annual $2,500 billion spent in the U.S. on healthcare (Figure).2 Several of the categories of waste are directly impacted by physician behavior, in particular unnecessary services, the largest single category of waste, estimated to account for $210 billion each year.

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Figure  . Estimates of total U.S. healthcare expenditures ($ Billions) by category of waste.2

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In this issue of the Annals of Neurology, Burke and coauthors provide a startling demonstration of the physician's role in rising healthcare costs.3 Using nationally representative data, they find that the costs of inpatient stroke care have climbed by 42% between 1997 and 2007, an increase of $3,800 per case. The largest single driver of costs was imaging, with two thirds of patients receiving MRIs, nearly all of whom also had a head CT. Although MRI has been promoted as the imaging modality of choice in recent U.S. stroke guidelines, CT remains the only accessible modality for emergency imaging at many facilities. For the vast majority of patients, the added value of MRI in patients who have already received a CT in the acute setting is questionable; it is unlikely to alter the care plan. Vascular imaging of the brain and carotids can be done more efficiently and cheaply by adding CT angiography to CT, or by ultrasound. No question, it is very satisfying to see that infarction on an MRI but does it matter in terms of patient care? More importantly, would the ca. $700 be better spent focusing on maintaining better secondary prevention, a major problem after stroke that could be addressed with more aggressive disease management?

The issue of duplicative imaging in stroke is just one example of wasteful care. Each of us can probably come up with five or more others that arise frequently in our daily practices. Quite simply, it is very easy to order more tests and to treat with more expensive therapies. We and our patients are reassured by additional studies, even if they are low yield, and marketing and being good American consumers drives enthusiasm for the newer and more expensive drugs. The ever-present fear of litigation resulting from a missed diagnosis or a poor outcome, leading to high malpractice premiums and widespread practice of defensive medicine is another significant driver of cost in the U.S. healthcare system. Overcoming the biases and the medical-legal environment that lead to consumption of unnecessary services will be a difficult task for physicians and those overseeing our systems of care, as we have seen already. Beyond cost consideration, we must also remember that low yield diagnostic studies are more likely to reveal false positives than valuable information that alters practice, and that newer drugs, devices, and procedures may be no better—or even more harmful—than tried, true, and cheaper alternatives.

As stewards of the healthcare system, we have a responsibility to keep the public as healthy as possible. Although it is much simpler to consider solely the interests of the patient in front of us (who may also be harmed by unnecessary services), the responsibility for public health dictates consideration of how our decisions affect those not directly in our care, particularly when reimbursement practices bias us to do more. Given the economic realities of our healthcare system, if practitioners do not become engaged in the discussion, study, and teaching of cost, others will ultimately place limits on our autonomy, and their decisions may not be as measured as our own. We should track waste as another measure of quality of care. We should be thinking about ways to innovate to lower total costs while still improving outcomes, or at least keeping them the same. We also need to be prepared to advocate for changes that will improve the health of our patients and the population that could become our patients. The failure to find a political solution to rising healthcare costs only increases our responsibility to become leaders and not victims.

S. Claiborne Johnston, MD, PhD and Stephen L. Hauser, MD Editors

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