Physicals do not have be administered exactly every 12 months. There is nothing wrong with getting checkups every 15 to 18 months –– a process I call “straddling.” For instance, many of my patients will come in for physicals this fall, and if they are healthy, we will not schedule their next physical until early 2011. Yet only 13 to 16 months will transpire between physicals, allowing the patient to “straddle” two calendar years –– from late 2009 to early 2011. They get 2010 off, and they won’t have to deal with paying out to cover their deductible in that year. This is especially helpful to individuals with high deductibles.

Lab tests can run in the hundreds of dollars. Again, with some thought and research, there are ways to save. For instance, for patients who are covering costs for bloodwork, we use the services of HealthCheckUSA, a nationwide company that offers discounted lab services at a savings of sometimes more than 50 percent. A complete health profile blood test valued at $530 at traditional labs costs only $200 at HealthCheck.

Another way to save on bloodwork is to have all basic tests run before your physical. That way, your doctor will have the test results in hand for the appointment, saving both of you the time and expense of a follow-up visit to review test results.

Your doctor can also shop around for lower costs. For tests like chest x-rays, which I always recommend for physicals, I refer patients to outpatient radiology facilities in San Antonio like South Texas Radiology, O’Neill and Associates or M&S Imaging San Antonio, where x-rays and a radiologist’s interpretation of them can be as low as $60. That’s considerably cheaper than at a hospital, where x-rays alone can run $125, and the radiologist’s interpretation could be $25 to $35 more.

These facilities are often cheaper for other tests as well. For patients who can pay with cash at the time of the test, many facilities will discount their fees. Ask your doctor for recommendations and do not be shy about asking for cost considerations.

For women 40 and up, I recommend pelvic sonograms, which are noninvasive, safe and are cost effective. I ask the radiologist to examine the pelvis and provide additional views of the kidneys, which can give us valuable information about other organs. This type of sonogram has led to the early diagnosis of liver and kidney cancers as well as ovarian cancer well before the cancers could even manifest. Insurance usually covers pelvic sonograms, especially if a woman has symptoms in the pelvic region.

I recommend colon cancer screening with a 60-inch scope for patients in their 40s. However, most insurance covers only flexible sigmoidoscopies (24-inch scope) before age 50; that test is cheaper than a full colonoscopy because it is performed without sedation in the specialist’s office rather than a surgical center. I get around this by asking the colon specialist to use the longer scope in the under-50 patients. With the longer scope, he can perform a more thorough exam. The cost of around $150 is much less than $800-plus for the full colonoscopy.

Another area where patients can find bargains is in prescriptions. Remember to ask your doctor to consider generics when prescribing medications.

For more ideas about savings in health care, check out a PriceDoc, a Web site that helps you shop around for the best pricing on medical services in your area. Angie’s List can also be a great source for information and referrals. Forbes published an excellent article in August, “How to Cut Your Doctor’s Bills.”

If costs are a concern, don’t hesitate to have a frank talk with your doctor. Remember, your doctor is your advocate. He can shop around for cost savings and refer you to labs he uses regularly for discounts. Many doctors will often lower their own fees to their patients to help make healthcare affordable. After all, his goal is the same as yours: to ensure your health.

The ideal physician should strive to keep patients well and out of his office rather than sick and in his office.

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The Mayo Brothers

Our health care system is in critical condition, and Congress and the Obama administration have the opportunity to put it back in the recovery room. Here are the key issues I would like to see in a final health care bill.

1. Shift the debate from saving money to saving lives.

Currently, our health system is designed for disease care rather than health care. Instead of focusing on keeping people healthy, the system would rather focus on treating disease and illness, often prolonging the unprolongable. For example, Medicare provides reimbursements for lab tests and x-rays only when the doctor issues a diagnosis. As a physician, I find that totally backwards –– I order tests to determine a diagnosis, rather than the other way around.

If the taxpayer is to be burdened with the cost of health it should be better that what we already have. We must have a system that advocates reasonable age- and gender-specific health screenings for all people beginning as early in life as possible. Recently, recommendations have come out against prostate cancer screening, colonoscopies, and routine physicals, largely for cost reasons rather than any concern about health. One article even recommends mammography beginning at age 50 instead of 40 years, contending we can save billions. But at what price –– a woman’s death? In other words, it is cheaper to let you die.

2. Find a way to control the costs of all health services.

Health care in the United States costs more than it does any other country. Why? Because we can and do charge more –– not because it costs more. Here’s one example: Treatment for breast cancer in the U.S. can run north of $60,000 while the same treatment in Buenos Aires is only $4,500. And yes, health care businesses tend to focus on profits rather than providing actual health care.

We are looking for ways to reduce cost by reducing services, when we should instead be looking for ways to reduce the cost of services. For example, an MRI of the brain can cost between $480 and $2,200 –– in the same unit with the same protocol. If insurance pays for it, the price can be discounted to around $950; if Medicare pays, it can cost $600. But if a patient walks in with no insurance, he may be expected to pay the whole $2,200. Cost musts be uniform and transparent. If cost is the problem, then it is cost we should fix. End of story.

3. Administrative costs must be contained.

Administrative health care costs exceed 35 percent of the entire health bill –– that’s 30 cents of every dollar. That includes the obvious excesses, like enormous marketing budgets for the latest brand-name drugs and multimillion dollar bonuses and compensation packages for health-care executives. But it also includes the costs in doctor’s offices, such as staff members who do nothing but process insurance paperwork and all of those nameless, faceless people at the insurance companies who accept or deny your claims. Patients receive little benefit from these exorbitant administrative costs.

4. Outlaw exclusions for preexisting conditions.

Insurance companies must be required to cover all individuals regardless of their history or preexisting conditions. Additionally, insurance premiums should reflect costs over an entire risk pool of patients, whether it be a national or statewide pool.

5. Fix the way physicians are paid.

The current system pits the physician’s financial interest against the best interests of his patients. Most doctors are currently paid through a “capitation” model, in which an insurance company or HMO pays them a set fee per patient (or per head, hence the term “captitation”) per month. Doctors are expected to take care of all patients and even cover costs of extra tests and specialists. But the truth behind this model is that doctors make more money by doing less for their patients. This system does save money, but it has a huge cost in lives.

Another problem is that doctors get paid more for doing things (procedures) to people than doing things for people (consultative services). This has driven new doctors away from primary care specialties –only about 2 percent of new graduates are entering primary care. New models of reimbursement –– like the salary models at the Mayo Clinic ––  must be examined and put into practice.

6. Provide access to everyone.

Our leaders must build a system that allows access to everyone. It must also allow choice –– if individuals want to opt out and seek care from physicians through regular insurance, they should be allowed to do so. Right now, who gets health care is decided by who does or does not have insurance coverage. Another way to say is that the system caters to the haves (those with resources) rather than the have-nots (those who are underprivileged). I believe we would be better off if we provide services to those who want to be healthy –– for instance, those who want to exercise, control their weight, not smoke, and get checkups –– versus those who do not get it.

7. Malpractice reform is necessary.

Tort reform is talked about a lot, but it may not be the best solution. In Texas, tort reform has succeeded, thanks to caps of around $250,000 on noneconomic damages. Yet in many cases where the lawsuit is meritorious, the injured party is undercompensated. What may surprise many people is that more than half of all the money expended in the legal process before tort reform went to the legal process instead of to the injured party. One of the big problems is that many jurors do not understand the technical and legal issues in medical cases. Setting up a system in which a group of knowledgeable arbitrators can hear these cases would go a long way to stopping all of that waste.

8. Use preventive care to deal with end-of-life issues.

Many people die in nursing homes after a long, slow decline, and everyone says, “It’s a blessing, he/she is no longer suffering and is better off.” But I would argue that a long, slow decline is not good enough. We should be doing everything we can early enough in life to ensure that we stay healthy and active as long as possible.

The goal should that one night when we’re quite old, we go to bed fully functional, perhaps embracing our loved one, and gently wake up dead. If our health care system were designed to get people to that point, we would all be better off when the end finally does come. I, for one, hope that happens to me, and I’d like to see that for everyone.

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Hemingway's Ambulance

I couldn’t agree more. But the whole health care debate going on right now seems to be looking for ways to reduce cost  by reducing services when we should be looking to reduce the cost of services.

The good news is that costs can be reduced without stifling research in pharmaceuticals and medical device development or without forcing insurance companies out of business. The easiest way to contain costs to is to make sure people are healthy and to intercept diseases early enough to treat them successfully. In fact, it would be helpful to look at the real costs of preventive care versus a serious illness.

In my family practice, I focus on prevention by conducting comprehensive physical examinations and various screening tests to determine how healthy my patients really are. Some patients come in every year, others every 18 months or two years. Let’s say that a patient comes in at age 30 and then has comprehensive physicals every 18 months until age 60. That would be 20 physicals at approximately $2,000 each, or $40,000 total. And let’s toss in around $5,000 for preventive or interceptive treatment for anything that comes up, since most serious diseases –– like cancer –– if detected early, can be easily prevented or managed. That’s a grand total of $45,000.

Now, let’s look at the costs of full-blown diseases. Has anyone checked the price of chemotherapy lately? Chemo for breast cancer can run $80,000, and that would be after surgery, hospitalization, imaging, radiation, and other specialists, which could all total $150,000 or more.

Death from colon cancer is the third most common cancer death in both men and women. It can be prevented or detected early by performing colonoscopies. Treatment of this disease if not caught early results in major surgery, lifestyle changes –– such as colostomy (a bag that collects body waste from a diversion of the colon to the abdominal wall) –– and expensive chemotherapy for many patients. Again, the cost for treatment can run higher than $150,000. Yet precancerous polyps can be easily removed during screening colonoscopies conducted every 5 to 10 years for around $1,200, before they have a chance to grow into colon cancer.

The number one overall killer is heart disease. Sadly, heart attacks can be inexpensive because often the first symptom of heart disease is death. For those who are fortunate enough to make it to bypass surgery, the costs alone can be as high as $25,000 to $30,000 for an uncomplicated case. Angioplasty costs are around $15,000 to $18,000 per case. That doesn’t include all of the follow-up medications, appointments, and other procedures, months of recovery and rehab, or serious lifestyle changes. Prevention of this disease obviously begins with diet, exercise, cessation of smoking, and stress management, most of which are relatively inexpensive.

Screening is also necessary to identify other major cardiovascular risk factors such as high blood pressure, high cholesterol, and diabetes. Other tests, such as cardiac stress testing and echocardiography, which is a soundwave study of the heart, can also assist heart doctors in predicting a patient’s chances of dying of this disease.

You’ll hear many allegations that screenings are not necessary and drive costs up. Granted, performing an echocardiogram every couple of years can cost around $300 to $650, but that is lot cheaper than triple bypass surgery. The American Heart Association estimates that in 2009 alone, cardiovascular disease will cost $475.3 billion, an astounding figure that includes direct costs (such as doctor’s fees and hospitalization) and indirect costs, which includes lost productivity from the illness or death. If you want to do some math for comparison, multiply our $45,000 preventive physical cost by all 305 million Americans and we’d end up with $13.725 billion over 30 years, a mind-bogglingly huge savings.

I can guarantee this: We and our loved ones will experience outcomes that we will regret if we do not do everything in our power to prevent or intercept disease. How are we going to feel when we learn that someone in our family has a terminal illness like lung cancer, which could have been detected much earlier through a simple annual chest x-ray? No cost can match that, the price of loss.

We have a once-in-a-lifetime opportunity to create and bequeath to our children the best and most affordable health care system in the world. I believe it must be a system designed to maintain health. After all, we can save both money and lives through preventive care.

For more on Gregory M. Jackson, M.D., visit his blog, “Reality Check: How to Live Better Longer.”

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