Medical technology and American doctors' willingness to use it aggressively gave Chardae Henry, born weighing less than 2 pounds, her bumpy entry into the world.
It gave back to John Rigione, 74, his breath and strength, by opening the clogged arteries around his heart.
It gave Faye Godfrey, 47, a better picture of the torment inside her back and the hope that it might be healed, and she got that picture painlessly and with no wait.
But as the United States ponders how to reshape its health system, the staggering cost of the kind of intensive treatment afforded these diverse patients is coming under new scrutiny. The nation may no longer be able to afford the damn-the-money treatment that has defined American medicine and distinguished from that practiced in the rest of the world.
Could Chardae's two-month stay in the hospital, for which Medicaid probably paid more than $50,000, been prevented by greater investment in prenatal care? Was the roughly $30,000 Medicare and Blue Cross paid for Mr. Rigione's heart bypass operation money well spent? Did Ms. Godfrey really need the $850 magnetic resonance imaging scan of her spine at a Towson center, paid for by Flex Choice, her health maintenance organization?
Because the treatments of those three patients seem to have been successful, the questions may seem presumptuous. But this country has far more infants in intensive care, more patients undergoing heart surgery and more MRI machines on a per capita basis than any other. Health economists have zeroed in on the intense use of new technology and surgical procedures as the biggest and most intractable factor in the rising cost of care.
"American doctors are trained to do things, and we get very enthusiastic about it," says Dr. Robert H. Brook, a California geriatrician and RAND corporation researcher who has studied unnecessary surgery. "We're trained to be wasteful. No one in this country has ever been trained to practice cost-effective medicine." "All the evidence points to the conclusion that the American health care system provides a more intensive range of services per patient than the other rich Western nations," says Dale A. Rublee, a researcher with the American Medical Association in Chicago.
The payoff for this aggressive medicine is not always clear. While offering far more conservative care and spending far less money than the United States, some other countries appear to achieve as much or more in better health and patient satisfaction.
Consider Japan and Germany. In 1990, Japan spent $1,171 per capita on health care, Germany $1,486 -- while the U.S. spent $2,566, eating up additional billions that might have been invested in better schools or newer factories.
But the other countries have significantly lower infant mortality rates and longer life expectancies than the United States. And in a 1990 poll, asked what changes were needed, just 6 percent of Japanese and 13 percent of Germans said there was a need to "completely rebuild" their health systems, compared with 29 percent of Americans.
The causes of America's interventionist medicine are complex. Hospitals compete in a virtual arms race of medical technology. Doctors fend off lawsuits and boost their incomes by overtreating: Medicare, for instance, pays a doctor $31 to examine a patient and give him advice -- but $291 if he performs a scan of the patient's head, and $2,161 if he performs bypass surgery.
Compared with many countries, the United States skimps on prevention, from stop-smoking programs to drug treatment to gun control, leaving it the health system to remove cancerous lungs, revive overdosed addicts, sew up gunshot victims.
American doctors err on the side of doing something, rather than doing nothing, a trait that seems imbedded in the country's frontier history, faith in technology and optimism about the potential for cures, argued medical journalist Lynn Payer in her 1988 book, "Medicine and Culture." She contrasted American medicine's penchant for high doses and radical surgery with health care in Britain, France and Germany.
But if American doctors do more, it is partly because American patients demand more. A 1987 poll showed that they agreed 71 percent to 26 percent that "health insurance should pay for any treatments that will save lives, even if it costs $1 million to save a life." Such notions might well clash with the queuing and rationing common in many other countries.
Because other countries use so much less of neonatal intensive care, bypass surgery and MRI, many health policy specialists say these treatments represent avoidable costs. But a harder look suggests trimming costs in these areas will not be easy.
Chardae Henry in the NICU
No one could say Chardae Henry didn't need her treatment. But many would argue that the need for it could have been prevented -- by a shift of health dollars from the high-tech, high-cost nursery to low-cost, low-tech prenatal care, which can prevent premature births.