There has been a long-running belief that greedy insurance companies deny patients needed care to maintain profits but in hindsight it seems to have been just the opposite; health care was expensive because of defensive medicine policies needed to ward off lawsuits that could happen even if the care was fine but did not work.

Another example is dialysis for kidney patients. About 400,000 Americans are on it and many of them started sooner than ever before. There is no measurable difference in how sick patients are at the time of initiation or in the reasons for dialysis initiation other than doctors made a choice. The average cost per patient annually: $72,000.

The reason is because doctors decided to embrace higher levels of kidney function as being appropriate for dialysis initiation. Insurers just go along with the doctor recommendations, which has led to millions in ballooning health care costs and resulted in government-mandated health care. 

To verify the trend outside the general population, a study in the Journal of the American Society of Nephrology used the electronic medical records of 1691 veterans in whom the decision to start dialysis was made at a VA medical center from 2000 to 2009. They found that, like the broad population, patients in the study were starting dialysis with higher levels of kidney function in more recent years. Over time, there were no measurable differences in how sick patients seemed to be at the time of initiation to explain this trend or in the documented reasons for dialysis initiation. For example, neither the percentage of patients who were acutely ill nor the distribution of different types of clinical signs or symptoms present around the time of dialysis initiation changed appreciably over time. Cardiopulmonary and gastrointestinal signs and symptoms and weakness and/or fatigue were the most commonly documented. Also, while treatment decisions were occasionally driven by level of kidney function in the absence of other clinical signs or symptoms, this practice was no more common in recent compared with earlier years.

"Our findings seem to highlight the influential role of opinion-based clinical practice guidelines in promoting earlier initiation of dialysis across a wide range of different clinical contexts over this time period," said Ann O'Hare, M.D.

The authors noted that studies on the benefits and harms of dialysis compared with other approaches to managing cardiopulmonary, gastrointestinal, and other symptoms of patients with advanced kidney disease are needed.