Introduction

Experts assert that one-third of healthcare can be omitted without adverse health outcomes.

I migrated to North America in 1974. After completing the required training for practice in Canada and the USA, I started my medical practice as an internist/pulmonologist in Milwaukee, Wisconsin, in late 1976. After 52 years of practice, primarily ambulatory primary care practice in the last decade of my professional life, I retired in December 2017.

I was born in India and grew up in Kenya (East Africa). I was 5 years old when my family arrived in Kenya. My primary school education started in a small town called Thompson’s Falls in colonial times, now known as Nyahuru. My family moved to Mombasa when I was around ten years old. After a 2-year stay in Mombasa, the family moved to Nairobi. Duke of Gloucester School was the high school in Nairobi (Kenya’s capital), where I completed Cambridge Overseas Certification and an additional 2 years of premedical courses prior to entrance to Guy’s Hospital Medical School in London, U.K., in 1958. (I was lucky to be the recipient of the British Colonial Government of Kenya Open Scholarship awarded to the top student from all Kenyan schools.)

I qualified as a medical doctor in 1963. U.K. medical schools emphasized bedside medicine as the bedrock of our clinical training. My internship and residency in U.K. National Health Service hospitals provided me with insight into delivering care when there were resource limitations. One glaring example was that we had to use emergency bed service to find a bed elsewhere when we had no beds available for emergency admissions in our hospital. Patients were transferred from our emergency room to hospitals in surrounding communities (up to 30 miles away!) where there was bed availability. In some instances, patients were in holding areas in the ER for hours until a bed became available.

After further graduate training in the U.K.,  I practiced in Nairobi, Kenya, for a few years in the late 1960s and early 1970s as an internal medicine consultant. There was no medical insurance at the time, and for that matter, even now, very few people in Kenya are able to afford health insurance. Patients and their families had to bear all the health care expenses themselves. It was a very common occurrence for patients not to fill expensive prescriptions and for patients to deny some of the few expensive tests that were available at the time. They were just interested in the least expensive interventions and the cheapest medications that they could afford. For some dreadful illnesses, extended family members and a few charities contributed towards the medical expenses. All the doctors gave free care to a significant number of patients where there was extreme financial hardship. Rationing of health care was therefore a fact of life because of limited resources, but more importantly because of affordability. Most people had meager salaries, and there was never a room to save or budget for health care expenses for the majority of the citizenry. While ascertaining the medical status of the patient during their visit, we had to be mindful of the patient’s financial status and capabilities before finalizing the treatment and follow-up plans. Rationing of care—limiting the testing to an absolute minimum and prescribing the cheapest medications—was an automatic routine on the part of the patient and doctor.

In the early years of my practice here in the USA,  I was struck by the abundance of supplies, support staff, and wastefulness. Excesses and exuberance were pervasive in the delivery of care without regard to the costs of care. Patient expectations as compared to British and Kenyan patients were high, and the cost of care was immaterial for both patients and providers. There was health insurance, and in most instances, bills were paid by third parties. Do anything and everything was the prevailing culture, even when care was futile and harmful both to the patient and society at large. From early on, I had an uneasy feeling that what we were doing was unsustainable in the long term. Conversations and discussions amongst colleagues were about the “Wild West” culture in the delivery of health care at all levels. I felt that there had to be a tipping point for meaningful, comprehensive health care reform to emerge so that affordable, basic, decent healthcare would be available for everyone in a wealthy country like the USA. The tipping point never arrived, and there were piecemeal patches of reforms. Also, until very late in my medical career in the USA, I failed to appreciate the libertarian streak amongst Americans—individual interests are paramount no matter the cost of care—until I started following the career and writings of Uwe Reinhart in the last 15 years.

Uwe Reinhart (a German migrant), a doyen of health care economists and a professor at Princeton University, died in November 2017. He was widely admired for his intellect and for his expertise in health economics. He was outspoken and candid, and in one of his witty remarks, he said the following about seniors and Medicare: ”Just try taking Medicare away from the elderly. In the decades I have lived here, I have discovered this about America’s rugged individualists. When the going gets rough, the rough run to the government.”.

Now that I have ended my medical career in 2017, I have reluctantly come to the sad realization that no meaningful universal health care reforms will occur in the USA in the foreseeable future and that patients in the USA will continue to face the same pressures that my very first patients in Nairobi faced. Uninsured patients (10%–15%) of the population and underinsured patients (40%–50%) of the population are simply not able to afford out-of-pocket expenses for the health care they need. Indeed, surveys have shown that 50% of the general population is afraid of the cost of care. Many avoid or delay visits to doctors. Some do not fill Rx prescriptions because drug costs are prohibitively expensive. Others economize by taking medications on alternative days or a few days a week instead of taking them daily. I saw this from the front row seat as a primary care physician in my daily interactions with patients and their families. A very high number of patients are “self-rationing” their care depending on their financial predicaments. 

I have had exposure to medical care delivery in the U.K., Canada, Kenya, and India. Throughout my stay in the U.S.A., I had periodic and frequent interactions with very dear physician friends practicing in Canada, the U.K., and Kenya. We have had frequent visits with each other and traveled together often. Many family members and friends, including some of my previous patients in Kenya and their family members, have called me for a “second opinion” and sent me their medical records, lab studies, and CDs of their imaging studies. The trust and confidence they have expressed have been a humbling experience for me, for which I feel so blessed and grateful. To my surprise and contrary to my expectations, through these informal consultations, I realized that most self-paying patients abroad receive similar care to what we deliver in the U.S.A. The lab and imaging costs were, of course, a lot lower. However, in many instances, the testing was excessive, unnecessary, and harmful.

Solitude and melancholy were the new normal for me, as they were undoubtedly for so many others all over the world during the COVID-19 pandemic. During my long solitary walks listening to podcasts by health experts as well as reading a lot of books by eminent health care experts, I have learned and relearned a lot about healthcare reform challenges from the providers’ perspectives, as well as the enormous challenges that so many hard-working American families are likely to face in the future with their healthcare needs. Even before the COVID-19 pandemic, US healthcare was a frustrating, even infuriating, system for most patients and their families to navigate. With my research and drawing upon my real-world experience in both the US and abroad, I feel I can freely express my thoughts about avoidable healthcare as an individual retired physician. Rather than crude and haphazard ways of avoiding all care, which many patients currently do, I feel that patients, their families, and other health advocates and coaches can be empowered to make rational choices in avoiding low–value care and minimizing financial stresses for themselves and their families. To be clear, there are numerous ongoing initiatives by providers, insurers, and healthcare systems to promote high-value care and discourage low-value care. However, the pace of progress is extremely slow, understandably because of the numerous stakeholders in committees and professional societies who have to agree on the criteria for low-value and high-value care. Subsequent implementation and buy-in by providers lead to further hurdles. There is a great deal of momentum among providers to move to an alternative payment model from the “Fee for Service” (FFS) model, wherein every medical service is individually billed. It is widely accepted that a lot of excessive care is being delivered in the FFS model. There is therefore a movement based on the concept that “Less can be More”. i.e., less medical care can be better for patients than more medical care. There are very many thoughtful healthcare leaders in this movement who have critically analyzed the data and come to the conclusion that almost one-third of the care can be omitted without any adverse consequences for patients. Applying the strictest criteria for high-value care, I believe that almost half of the care currently delivered in the USA can be omitted with no difference in outcomes. Patients will even do better by avoiding the risks associated with unnecessary procedures, surgeries, and inappropriately prescribed potent medications. Patients, their families, and patient advocates should be encouraged to do research on their own when they have to make decisions about consenting (or not agreeing) to tests and procedures recommended to them. But for this to happen, they will need access to trustworthy sources of information and to patient decision-making tools. However, I need to point out at the outset an inexplicable paradox, as stated by Dr. Robert Pearl in his book “MISTREATED.“. The majority of Americans have a negative view of the health care industry in general, but “80% of all patients reflect positively on the health care they personally receive… Both among doctors and patients alike, perception trumps data.” 

I might add that “More is Better” is the prevailing perception in the U.S. among both patients and providers. It is not uncommon to hear at social gatherings about somebody going to the ER with a simple problem of dehydration and a fainting spell. Generally, there is satisfaction on the part of the patient for receiving a multitude of tests costing thousands of dollars (as long as the patient did not have to pay!) and for being reassured that nothing serious was found. 

Incidentally, this happens outside the US as well. As noted by Ezekiel Emanuel in his book “Which country has the best health care system”?, the Swiss, who have the second most expensive health care system next to the USA, are happy with the access, freedom, and choice they have in their system and are not concerned about receiving inappropriate care. A Swiss expert (quoted in Ezekiel Emanuel’s book) noted that the Swiss system is likely to “crack” at some point because most working Swiss families will have to endure increasing deductibles, copays, and out-of-pocket expenses in the near future, just like American families who are already facing this challenge.

With the “More is Better” model of care, in addition to higher medical care expenses, there is also a significant additional risk of harm accruing from medical procedures. Just to point out two common risks: health care facility-associated severe infections are always an ever-present risk for any patient undergoing a procedure, and complications arising from adverse drug reactions from excessive utilization of antibiotics and potent medications.

Unsurprisingly, those fortunate enough to have excellent health insurance coverage will not find the concept of “Less is More” appealing. Many feel that care is being “rationed” and that they are being shortchanged when reasonable and appropriate care is recommended. There is utmost bias also toward early diagnosis and “catching things early,” particularly in cancer care, and for aggressive screening and testing protocols to treat a disease in its earliest stage, despite the quantifiable risks of this approach and the potential for great harm with just a possibility of minuscule benefit.

So the vast majority of patients and doctors will find these observations highly controversial. I will just reinforce the main objective: my intended audience is patients and families who are under severe financial duress when faced with making decisions for their medical care. They simply don’t have the means to receive care as it is currently delivered. Patients simply avoid or delay ALL care (including valuable, necessary care) and take their prescribed essential medications on an intermittent basis because of high deductibles, co-payments, and huge annual out-of-pocket (OOP) expenses. There is an unmet need for patient education and empowerment to meet the challenge of the unaffordability of healthcare for a substantial portion of the populace. If they are well informed about benefits and tradeoffs, they can substantially reduce unwanted care and thus minimize their financial stresses.

It is also my earnest wish that a healthy debate can be stirred up in countries in Africa and India where the practice habits of private practitioners are following the pattern of health care delivery in Western countries, with payments to physicians based on fee for service. Many, if not most, middle-class patients are privately paying patients in these countries, and I believe they will benefit enormously by agreeing only to high-value care interventions.

Archie Cochrane had a significant impact on my views regarding evidence-based healthcare delivery. The Cochrane collaboration, named after Cochrane, is well-known and widely used globally by healthcare professionals. I recommend reading about Cochrane in Chapter 3, especially for lay readers..