Almost all other nations try to curb the use of expensive, high-tech procedures such as heart surgery, to keep down medical costs.
Canada and Germany long ago decided that hard choices had to be made, and limits set on technology, even if it sometimes forced patients to wait for elective surgery or MRI exams or heart stress tests.
Not so in the United States.
Driven by the competitive forces of one of the few remaining free-market medical systems, U.S. medical centers have amassed an awesome collection of costly medical devices and specialists trained to use them.
Philadelphia, one of the world's top medical centers, has almost an embarrassment of riches - so plentiful that roadside billboards advertise the high-tech wonders available in even the smallest hospitals.
Philadelphia hospitals have 63 MRIs (magnetic resonance imaging machines) - compared with 57 in all of Germany and just 12 in all of Canada. Philadelphia-area hospitals have 71 CAT scan machines, 15 nurseries capable of caring for the tiniest of babies, and 22 organ transplant programs.
And Philadelphia has five times as many open heart surgery programs as comparable cities in Canada or Germany.
This massive array, poised waiting to be used, is expensive in its own right - an MRI machine can cost up to $3 million. Once it's in use, even more costs are generated, because doctors tend to order more tests and other procedures, requiring more nurses and technicians, before they make a diagnosis or complete a treatment.
The Congressional Budget Office estimates that technology, and the increase it fosters in the intensity of care, is a major reason medical costs are rising so much faster than other segments of the U.S. economy.
Yet there is no evidence that, for all this spending, Americans are doing any better medically.
The Inquirer recently spent time with patients and surgeons in three premier heart bypass programs - one in Philadelphia, one in Toronto, and one in Munich.
What follows is an account of how limiting the use of high technology - or failing to limit it - affects the treatment patients get.
Cavallaro, already heavily sedated, was taken on a litter to the Lankenau operating room at 7:45 a.m.
It was a large, square, brightly lit room. Cavallaro was transferred to the operating table, surrounded by surgical equipment and electronic monitoring devices stacked so high that they towered above some of the shorter members of the surgical team.
There were a defibrillator to restart Cavallaro's heart with a jolt of electricity, a balloon pump to help it pump blood, an electrical cauterizing device to stop small, severed blood vessels from bleeding, and two computerized pumps to administer drugs in precise amounts.
At the head of the table, the anesthetist station looked like the cockpit of a 747 with video tubes and dials and devices that would run four different drugs into Cavallaro's system to keep him in a deep sleep for the five-hour operation.
To the side of the operating table was a low-lying machine with dials and whirring wheels. This was the heart-lung machine, the breakthrough technologic advance that made heart surgery like this possible.
By 8:20, everything was ready for the senior surgeon, Scott M. Goldman. A nurse went over to Cavallaro, who was very drowsy.
"We're going to call Dr. Goldman now and then we're going to put you to sleep," she said. Cavallaro nodded.
Cavallaro's heart had been seriously damaged by a heart attack 18 years earlier. Further weakened by atherosclerosis, a buildup of plaque in the blood vessels, it was pumping 50 percent less blood than normal. Without surgery, Goldman said, Cavallaro had a 20 percent chance of living five more years.
With Bruce Springsteen playing on a portable CD, Goldman made the first chest incision at 9:20. It took him an hour and 20 minutes to cut through tissue and muscle, open the rib cage and reach the beating heart, moist and glistening under the overhead lights.
At 10:42, Goldman called for the heart-lung machine. Cavallaro's blood was immediately diverted through plastic tubes to the device, which oxygenated the blood and pumped it back into his body. Cavallaro's heart was stopped with the injection of a drug.
Using sections of vein taken from Cavallaro's leg and a mammary artery from inside Cavallaro's chest, Goldman constructed new routes for the blood to take around the obstructions in the three coronary arteries.
At 11:54, the heart-lung machine was shut off, and the blood was rerouted through Cavallaro's heart, which started beating on its own.
Twenty-five minutes later, Goldman was outside in the waiting area talking to Cavallaro's wife, Mary, and his daughter, Rosemarie McCloy of Trooper, Montgomery County.
"Everything went very nicely," Goldman said as the women looked up at him with concern from their seats in the hallway.
"He had no trouble coming off of the machine. He's all right. He's fine."
With tears streaming down her face, Mary Cavallaro stood and hugged Goldman, who tensed from the sudden display of emotion.
"God bless you," McCloy said.
"I think he's going to do fine," Goldman said.
Heart bypass surgery could stand as a metaphor for what's good and what's bad about American medicine:
It shows the immense power of medical technology - a technology that lets doctors shut off hearts and turn them back on, a technology that restores people crippled by heart disease to an active life.
But it costs a fortune. Last year, the United States spent more than $6 billion - nearly 1 percent of its entire medical bill - on this one procedure, an operation that wasn't even possible a generation ago.
Since it was first done successfully at the Cleveland Clinic in 1967, heart bypass has become one of the nation's most common surgical procedures.
More than 265,000 Americans had bypasses in 1991, at a cost of about $25,000 each.
Canada doesn't do nearly as many. Bernard S. Goldman, head of cardiovascular surgery at Sunnybrook Health Science Centre in Toronto, said Canada performs 65 heart bypass operations per 100,000 population, while the United States does 125.
Germany does 48 bypasses per 100,000.
U.S. doctors are much more aggressive in searching for clogged arteries and encouraging patients to undergo surgery, Goldman said, while Canadian doctors are more inclined to treat the problem with drugs and lifestyle changes such as exercise, cessation of smoking or retirement.
The victims of heart attacks - or people suspected of having a heart attack - get particularly aggressive treatment in the United States. The U.S. doctor is more likely to admit patients with chest pain to the intensive care unit, more likely to prescribe drugs and more likely to order X-ray angiography to look inside coronary arteries, according to a study co-written by Jean L. Rouleau of the University of Sherbrooke, Quebec.
The study, reported last month in the New England Journal of Medicine, also found that U.S. heart attack victims are almost three times more likely than Canadians to go on to bypass surgery.
Does this mean Americans are getting too many operations, or Canadians are getting too few? No one knows.
Despite the extra care American heart patients receive, Rouleau's study concluded that they did no better than Canadian patients. They were no more likely to avoid a second heart attack or to live longer. The only disadvantage of their conservative treatment was that Canadians were slightly more likely to experience the chest pain angina pectoris.
Goldman said the Canadian heart patients who don't get bypass surgery still enjoy a high quality of life, though they must take drugs or limit their activity more than those who have had the surgery.
He scoffed at reports in the United States that some Canadians live painful, debilitated lives - or even die - while waiting for surgery.
He said Canadian doctors are less likely than their American counterparts to encourage surgery for elderly patients with other incapacitating diseases such as arthritis.
"You've had an explosion of technology (in the United States) that has to be used and paid for," Goldman said. "And you have a completely entrepreneurial practice mode that is also sharply driven by litigation, that pushes the system. . . .
"People demand care and doctors and hospitals are delighted to give care."
Scott Goldman, Cavallaro's surgeon and chief of the division of thoracic and cardiovascular surgery at Lankenau, agreed that American patients are more likely to demand surgery than Canadians.
"I spend more time talking people out of surgery than urging patients to get it," he said.
"People don't want to put up with symptoms in this country. . . . They are more likely to want an operation and they want it yesterday."
Last July, heart attack patient William E. Sequin, who lives in the small Canadian resort town of Orillia, about 100 miles north of Toronto, underwent X-ray angiography to see if his coronary arteries were blocked.
The 65-year-old factory worker didn't have to worry about the cost of his care because Canada's national health insurance, funded from taxes, pays all doctor and hospital bills.
Sequin was becoming increasingly incapacitated by heart disease. He no longer could walk more than a block or two without stopping or taking nitroglycerin pills to open his blood vessels and temporarily restore blood flow to his heart.
The X-ray angiography showed that all three of Sequin's coronary arteries were blocked. Not enough blood was getting through to nourish his heart.
Eight days later, Sequin was sitting in the elegantly appointed offices of the chief of cardiac surgery at Sunnybrook, one of Canada's largest medical teaching institutions.
Bernard S. Goldman told Sequin he needed bypass surgery but that his condition was neither an emergency nor urgent. He was not in imminent danger of a heart attack. He was classified as an "elective priority."
Elective priority patients are supposed to be operated on within six weeks, Goldman said, but Sequin put the surgery off for personal reasons, and then Goldman went on vacation. In the United States, Sequin probably would have been operated on within a couple of weeks, if not immediately.
It wasn't until Sept. 28, almost three months after his talk with Goldman, that Sequin received a letter from Sunnybrook saying that he had been scheduled for surgery.
Sequin arrived at Sunnybrook on Oct. 14, eight days before surgery, for the patient orientation program, similar to those provided by many hospitals in the United States, including Lankenau.
Seventeen men and women, most of them patients, were seated at three long tables. They ranged in age from 32 to 72.
"We know there's a lot of anxiety about the surgery," said clinical nurse specialist Darlene Rebeyka, after welcoming the people to Sunnybrook. "It's the fear of the unknown. Sometimes people have a lot of unrealistic information from friends."
She gave everyone a booklet put out by the hospital. She played a videotape, which showed energetic people doing calisthenics, swimming, playing golf and having a grand time after bypass surgery.
The authoritative and friendly face of Bernard Goldman came on the screen. He talked about the technical aspects of heart surgery, and someone else provided reassuring statistics. Ninety-eight percent of patients survive surgery. Chest pain and all other symptoms are eliminated in 90 percent of patients. Two-thirds of patients no longer need heart drugs.
As the tape ended, eight women entered the room and identified themselves as part of the team that would care for the patients when they returned for surgery. There was an ICU nurse and a floor nurse and a nutritionist and a pharmacist and an occupational therapist and a social worker and a research nurse and someone to coordinate the services.
After the presentation, a few questions were asked, the patients were urged to call if they had concerns and then everyone left.
Sequin drove home, greatly reassured. As far as he was concerned, the medical care system in Canada was just fine.
The waiting list Sequin was on is part of Ontario's cardiac care network. It was started two years ago after widely publicized reports that a handful of patients had died while waiting for heart surgery.
The government also authorized an additional bypass program in Toronto, the one Goldman now heads at Sunnybrook. The government agreed to pay Sunnybrook for 635 procedures a year, increasing the number of heart operations in Toronto by 20 percent.
The cardiac waiting list ranks patients in four categories: Emergency (surgery should be done within 24 hours), Urgent (within 14 days), Elective Priority (within six weeks) and Elective (within three months).
Patients are periodically checked to make sure their conditions remain stable. Those who have deteriorated are moved to the top of the list. Because Sunnybrook is highly regarded for its heart surgery, and attracts a lot of patients, its three-month waiting period is longer than Ontario's average of about nine weeks.
Few patients needing heart surgery are so sick that they must have it immediately.
"Hysteria is built into the U.S. system, with patients being rushed into surgery," Sunnybrook's Goldman said.
Despite the expanded heart program in Ontario, five Sunnybrook heart patients have died while waiting during a recent 18-month period. In that time, 800 patients got surgery.
How would Anthony Cavallaro have fared in Canada? He would have been classified as an urgent patient, just as he was at Lankenau, and operated on within 14 days, according to waiting-list protocol, Bernard Goldman said.
In Philadelphia, Cavallaro waited only two days.
William Sequin was relaxed on the morning of his surgery, having just gotten a shot of morphine and another drug.
He was lying in bed, arms folded behind his head, joking with his five grown sons and daughters.
Two of Sequin's sons had driven him to the hospital the day before, making the 100-mile trip in a little over two hours. Sequin had decided to go to a Toronto heart hospital because it was the closest to his home. He was free to pick any hospital he wanted, but only three hospitals in Toronto could offer him bypass surgery.
Germans are similarly free to pick hospitals, but they also have limited choices. Munich has only three adult heart programs.
In the United States, hospitals doing bypass surgery are much more plentiful. When Cavallaro picked Lankenau, he chose from a list of 16 adult heart programs in the Philadelphia area.
The litter for Sequin arrived at 1:10 p.m. After he kissed each of his children, Sequin was taken to a large operating room on the seventh floor with big picture windows.
The equipment - monitoring devices and cathode tubes stacked one on top of the other, drug pumps and the low-lying heart-lung machine to the side of the operating table - looked just like the setup in Lankenau.
The operation took a little more than four hours. When it ended, Sequin was taken to an eight-bed coronary care unit and put in a corner bed, next to a picture window with a view of the city's skyscrapers in the distance.
Sequin's experience was not unlike that of retired Munich tailor Jakob Dobler, 68, who had come to Grosshadern Clinic at the University of Munich for a bypass operation.
Dobler also had to wait months for his surgery because he was not considered sick enough for a high-priority classification.
Just as at Sunnybrook, three months is the average wait at Grosshadern for elective heart surgery, said Bruno Reichart, the hospital's chief of heart surgery.
Dobler, a short, balding man with eyeglasses and a shy smile, said he had not had serious symptoms while waiting for his surgery. But now that it was about to happen, he was anxious to get it over with.
Dobler was sitting up in bed in a narrow room in the university hospital. The room was simple and clean, with a telephone and a connecting bathroom but no decorating flourishes. Two other patients shared his room.
Dobler had entered the hospital eight days earlier to start preoperative tests. He'd taken many of the tests before, but Reichart wanted to repeat them. So many weeks can pass between a patient's diagnosis and surgery that surgeons want to make sure nothing has changed.
Dobler belongs to one of Germany's 1,200 nonprofit "sickness funds," which cover 90 percent of Germans and pay for comprehensive in-hospital and outpatient medical care. The sickness funds are supported by contributions averaging 12.5 percent of a worker's salary, with the employer paying half this bill. The government pays the premiums for the unemployed.
A few floors below Dobler, Manfred Eisenbach also waited for heart surgery. Forty-eight years old and the owner of a roofing company in Plettenberg, a small community 400 miles northwest of Munich, Eisenbach is one of the 10 percent of Germans who opt out of the sickness funds to buy private insurance.
Private insurance in Germany makes less difference in the care patients get than it does in the United States. Privately insured Americans have many more options than low-income people on Medicaid or those with no insurance at all, who are severely limited in their choices.
In Germany, sickness-fund patients can choose any primary physician they want and go to any hospital, just like the privately insured patients can. The advantage privately insured patients have is that they get slightly more comfortable private or semi-private rooms and can choose to be treated by the chief of the department.
Private patients also get somewhat faster service. In Munich, their average wait for elective heart surgery is one month, instead of three. If the need for surgery is urgent, however, private and sickness-fund patients have equally fast access to care, Reichart said.
As it turned out, Dobler and Eisenbach both ended up with the same surgeon - Reichart, the chief of surgery.
Dobler's five-hour operation went without incident. After surgery he was taken to the intensive care unit. The next day he was transferred to a nearby hospital to recover; his bed in Grosshadern Clinic was taken by a 17-year-old heart-transplant patient.
Although practically unheard of in the United States, the inter-hospital transfer of patients just before or after major surgery is not uncommon in Germany. There is such a demand for surgery at Munich's three heart centers that surgeons will operate even if they have to send patients to another hospital to recover. Sometimes surgeons will transfer patients who are still on ventilators.
Reichart said everyone who needs heart surgery gets it, though perhaps not as fast as they'd like. Rather than wait, many patients will fly to Switzerland or other countries that can offer heart surgery with less delay. The bills are paid by the German sickness funds.
Backlogs for heart surgery will be significantly relieved, Reichart said, when his program doubles in size next year. Currently, his team does 2,000 heart operations a year, including transplants. He said it took him a year to persuade government and university officials to spend $16.8 million on expansion.
Reichart argued for more capacity so he could reduce the waiting time to one month, and also so he could serve many of the patients who go out of the country for surgery.
The price of a bypass operation varies little among Canada, Germany and the United States - $20,000 to $30,000, depending on how complicated it is.
Heart specialists the world over use identical techniques, equipment and
surgical teams. Once inside the operating room, it's virtually impossible to tell which country you are in, everything is so similar. Even the brand names of the equipment are often the same.
Yet the total heart bypass bill in the United States is far greater,
because the United States does twice as many per capita.
Canada and Germany both limit the number of hospitals allowed to perform bypass surgery as a way of keeping costs down. They also limit the hospitals' heart surgery budgets.
Another strategy countries use to keep down the cost of high-technology procedures is to restrict the income of specialists who perform them.
In the United States, Lankenau's Scott Goldman, with a particularly busy practice, makes $700,000 a year before taxes.
Sunnybrook's Bernard Goldman, also at the top of his profession in Canada, makes only about $280,000. Some heart surgeons in Canada make more than salaried academic physicians like Goldman. But few make much more, because the government sets physicians' fees.
Reichart and other department chiefs in Germany, who bolster their salaries with privately insured patients, can do as well as top American doctors. But, on average, German heart surgeons make far less, because hospital salaries are low. They make about $80,000 a year, well below the U.S. average for heart surgeons of $296,000.
Most German heart-surgery patients, such as Dobler, recuperate in rehabilitation hospitals, which are more like resort hotels than hospitals.
They spend a month or longer in idyllic country settings, exercising, eating healthy meals, and developing healthful lifestyles.
Typical of these facilities is the 540-bed Hoehenried Clinic, located on the shores of the Starnberger, a lovely lake about an hour's drive from Munich.
With the Alps to the south and the mansions of Germany's well-to-do all about them, heart patients spend each day in the pursuit of good health.
They live in Spartan rooms with a single bed, a desk and a picture-window view of the Starnberger and the Alps. But most of their time is spent walking on the grounds or exercising inside the low-lying modernistic facility, with its arboretums and long, glass-walled halls.
Hoehenried Clinic has a large indoor swimming pool, six gyms, a bowling
alley, two biking rooms each with 40 stationary bikes and, lest anyone forget that it is a medical facility, an eight-bed intensive care unit.
The staff consists of 50 doctors, 30 physiotherapists, two occupational therapists and eight psychologists, who, among other things, conduct stress- reduction and meditation classes.
A typical day at the center begins at 7:15 a.m., with exercises on the lawns followed by breakfast. Residents return to their rooms, where they meet with their doctors for changes in their drug and exercise prescriptions. After that, they attend group discussions on healthy lifestyles, followed by such exercise programs as swimming, bicycling, and rowing on the lake. In the afternoon, it's distance-walking on the wooded grounds or across rolling manicured lawns, alone or in supervised groups. Evenings are devoted to health lectures and educational and recreational movies.
Germany has 15 centers like Hoehenried, specializing in rehabilitation for different diseases - cardiovascular, gastrointestinal, orthopedic and neurologic.
These centers are an outgrowth of the long-standing popularity of health spas in Germany, said Hubert Hofmann, medical chief at Hoehenried.
Some doctors contend that the centers are a frivolous luxury in a country with limited funds for social programs. Others argue that rehab centers ultimately save Germany money because they help restore the health of workers and return them to work.
It costs about $120 a day to stay at Hoehenried, but that doesn't bother its residents. They don't pay anything. The full cost is borne by Germany's employee pension funds.
While Germans revere spas and rehab centers, Americans revere technology.
The U.S. health care system promotes the use of costly technology by paying generously for the procedures without limiting their use.
Just about everyone knows that lives are being saved with kidney dialysis and kidney transplantation, that eyesight is being restored with cataract operations, that MRIs are finding brain tumors and slipped discs missed by other diagnostic methods.
But few people realize how much these procedures inflate the nation's health bill.
Improved cataract surgery, made possible by advances achieved in the 1980s, costs about $3,000 per operation. It's become the most common surgical
procedure on Americans over 65. A total of 1.35 million Medicare recipients underwent cataract surgery last year - costing the government $3.4 billion.
For many, the operation significantly improves eyesight and quality of life, but for others the benefits are marginal or could be had more cheaply with stronger eyeglasses.
Sometimes a new procedure is limited to a relatively small number of people, but is so expensive that the total cost to society is high.
The two treatments for advanced kidney disease - kidney dialysis and kidney transplantation - cost the government $6.6 billion in 1991. This is almost twice the total cost of cataract surgeries, although it benefits one-eighth as many people.
Both dialysis and transplantation are financed by the federal End Stage Renal Disease Program, signed into law in 1972. Technological improvements in the treatment of this one disease have boosted the nation's health spending by almost 1 percent.
This is just one example of how technological advances increase the cost of care.
A more recent high-cost procedure - bone marrow transplantation for breast cancer - costs $150,000 per patient. Insurance companies are balking at this expense, and many are denying payment on the grounds the procedure is unproven. Should it prove worthwhile and become widespread, its cost to society would be considerable. With 15,000 potential candidates a year, the annual cost could come to $2.25 billion.
MRI machines came on the scene less than a decade ago. They are costing the U.S. health care system more than $5 billion a year.
The MRI is much more effective than conventional X-rays in imaging joint injuries, bone marrow disorders, soft-tissue tumors and muscle problems, but many doctors think it's being used far too often. With a typical MRI scan costing about $1,000, they feel cheaper diagnostic methods would be adequate in many cases.
Even very low-cost tests, if done on enough people, can greatly inflate medical expenditures.
Mammograms cost about $100 each, but with 20 million American women getting these breast X-rays each year, they are costing society $2 billion a year.
Few would deny that this would be money well spent if it saved many lives. But a landmark international conference by the National Cancer Institute last month concluded that mammography was frequently useless.
Though it cuts deaths from breast cancer by 30 percent in women over 50, it has little or no effect on the death rate for younger women, according to the scientists assembled by the NCI. Five million of the women who are mammographed each year in the United States are under 50. That amounts to $500 million wasted on useless tests, if the scientists are right.
Now, the American Cancer Society is promoting the use of a new, $20 test for prostate cancer, a disease that is responsible for 2 percent to 3 percent of male deaths in this country, about 35,000 deaths a year.
Called PSA (prostate-specific antigen), the test has caused controversy
because it fails to pick up cancer in 40 percent of cases and wrongly identifies an additional 25 percent as having the disease.
Mass screening for prostate cancer, with all the follow-up care and studies to rule out the false positive tests, would cost up to $20 billion a year, says Ian M. Thompson, chief of urology at the Brooke Army Medical Center in San Antonio, who studied the matter. That would be more than 2 percent of the nation's total health bill.
In medical research, financial rewards and prestige go to those who discover new procedures, not those who evaluate existing ones.
But restricting the use of screening tests until they are clearly proved
worthwhile can bring substantial savings.
The Canadian health system does pay for mammograms in older women, who do clearly benefit. But it has been saving millions every year by not giving mammograms to younger women.
Canadian researchers were the first to suggest that screening younger women did not save lives. This is now gaining wide acceptance.
Of course, if recent mammogram study results had gone the other way, thousands of Canadian woman might have died prematurely because their government was slow to adopt the test.
So what's a country to do?
"The high cost of medical care is reaching the point where the U.S. medical system cannot afford to provide instant gratification," said Paul Griner, president of the American College of Physicians.
"The country is going to have to set priorities, hopefully priorities that won't result in terribly long queues like in Canada and Great Britain."
Harvard School of Medicine professor Howard H. Hiatt said the long-held principle of doing everything possible for the patient is a luxury society can no longer afford.
"As we develop more and more practices that may be beneficial to the individual but not to the interests of society, we risk reaching a point where marginal gains to individuals threaten the welfare of the whole."
Hiatt wrote this in a controversial paper published 18 years ago. In a recent interview, he said he thought society had now reached the point where its welfare is being threatened.
Says William L. Kissick, professor of health care systems at the University of Pennsylvania's Leonard Davis Institute and author of the forthcoming book Medicine's Dilemmas: Infinite Needs vs. Finite Resources:
"No society in the world has sufficient resources to provide all the health services its population is capable of utilizing."
It's now several months since Cavallaro, Sequin and Dobler underwent bypass surgery, and each is doing fine.
Sequin is taking frequent walks in the hilly area around his home in Orillia, something he couldn't do before the surgery.
Dobler, after spending four weeks in a rehabilitation hospital, returned home to Munich and is making biking tours to keep in shape.
Cavallaro visits a cardiac rehab center near his Norristown home three times a week, to work out on a treadmill and stationary bike. He's looking forward to going to the shore, where he will spend his summer fishing and crabbing.
* Tomorrow: Hard choices ahead for the United States.