Lab Soft News

An HIE Saga from Massachusetts; The Challenges of Interoperability

John, who blogs over at Chilmark Research, posted a note recently about his conversation with a Massachusetts urologist regarding the latter's experience with HIEs and EHRs (see: Here an HIE, There an HIE, Everywhere an HIE). He makes a lot of interesting points. Below is an excerpt

This urologist’s practice has been using eClinicalWorks (eCW) for several years now and despite their proficiency with using this EHR, the practice has never fully recovered the productivity it once had. Regardless, they have come to accept this hit on productivity as just the cost of doing business....Harry spends two days a week in surgery with most operations taking place in one of four facilities: local, unaffiliated hospital Winchester (who uses Meditech), Beth Israel Deanconess (has a home-grown EHR but encourages affiliate practices to adopt eCW), Childrens’ Hospital (a Cerner shop that also promotes eCW in ambulatory) and Partners which is now moving from its homegrown EHR solution to Epic (BTW, in a recent conversation with a contact at Partners learned that they are spending $1M/day for next five years on Epic switch - ouch!). All of these hospital organizations want a closer affiliation with these urologists in support of future value-based payments and of course just getting these physicians to do more surgeries at their respective institutions. Thus, all of them want the urologist practice to adopt their interoperability model.

Harry stated that Partners, the biggest healthcare organization in metro-Boston and arguably New England, is pushing particularly hard for them to switch to Epic as Epic does not have an HIE offering (Epic Everywhere is not an HIE in our definition nor apparently in ONC’s) and encourages its customers to put all ambulatory affiliates on Epic instead. In addition to these organizations, the Commonwealth is also encouraging this practice to join the statewide HIE. After the pain and suffering Harry’s practice went through to become proficient on eCW, they are loathed to switch to Epic. Besides, switching to Epic would limit their ability to connect with other healthcare organizations they work with as Epic does not play well with others. Harry’s situation is not unique and is likely being played out across the country, especially in urban areas where there may be a number of competing healthcare systems each trying to establish their own HIE. In such a situation what is an independent physician practice to do? Certainly they could sell the practice, as many physicians have already done, to the highest bidder. Not an option for Harry and his physician partners as they like their independence and plan to keep it that way. They could turn to the statewide HIE and hope that it will provide the depth of services (interoperability) to enable them to connect and share records in support of care coordination with all hospital systems they work with. Ideally, this may be the best approach but unfortunately they’ll be waiting a very long time for this to happen, if it happens at all. ill leaves a very critical 20% unresolved.

There's a lot in these paragraphs to discuss and I don't exactly know where to start. The first point that I will take up is John's comment: Epic Everywhere is not an HIE in our definition nor apparently in ONC’s. I agree with him that Epic does not play well with others and made the same point in a previous note: Judith Faulkner, EMR Interoperability, and Washington IT Politics. Here's a quote from it:

[Judith] Faulkner belongs on the Health Information Technology Policy Committee for one important reason. Her company, Epic, holds a near-EMR-monopoly for the larger hospitals in the U.S. (see: Does Epic Exercise a Near-Monoply for EMRs in Larger U.S. Hospitals?) A central tenet of the Epic business model is hospital client control, driven by the fact that the hospitals install the software that Epic delivers when the company delivers it. In essence, she determines the IT strategy for some of the most important hospitals in the U.S. As noted above, the hospitals are also under intense pressure to install the Epic departmental systems (e.g., lab, radiology, oncology), thus ensuring smooth integration and "interoperability" and widening the influence of the company. 

A second important point is that the urologist, after installing an office EHR, concluded that his practice would never fully "recover" and achieve its previous level of efficiency and productivity. I have blogged previously about the rapidly disappearance of private physician practices (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; Why Is the Federal Government Hostile to Private Physician Practices?; More Data on Physicians Leaving Private Practice; Discussion of Findings). There are many reasons why physicians would leave private practice or not enter one at the conclusion of training. However, John't note suggested to me one more reason for this shift. Both physicians and hospitals are being pressured to install EHRs. It may be the case, as with the urologist described above, that physicians in private practice have come to the conclusion that their efficiency is irretrievably harmed by these systems. Therefore, they logically make a decision to take salaried hospital positions where their compensation is less directly linked to their personal productivity and efficiency.

Department of Biomedical Informatics at Pitt Has Open Post-Doc Position

Dr. Mike Becich has passed on to me the following information about a funded post-doc position in the Department of Biomedical Informatics at the University of Pittsburgh Medical School. Here's more information about DBMI.  --BAF 

The Biomedical Informatics Training Program at the University of Pittsburgh is in the process of recruiting a post-doctoral research scholar in biomedical informatics (NLM funded). Research areas represented by the Pitt faculty include:

• Bioinformatics
• Intelligent medical training systems and user modeling
• Knowledge representation and interoperability
• Machine learning and data mining
• Clinical translational bioinformatics and biostatisticsNatural language processing
• Medical imaging development and evaluation
• Outbreak and disease surveillance
• Human-computer interaction/User-centered design

Requirements to apply:

• Post-graduate degree (MD or PhD) and training in Biomedical Informatics, Computer Science, Biostatistics, or a related discipline.
• NLM fellowship eligibility (US citizen or permanent resident only).
• Ability to independently perform research in one of the above areas of biomedical informatics with mentoring from a faculty member.
• Ability to write and publish journal articles.

To apply, navigate to this web site and complete the online application. 

Mayo Telestroke Program Deemed Highly Successful

Some very useful telemedicine applications are emerging and being evaluated, particularly those utilizing smart phone apps. The Mayo telstroke program in Arizona was used as a testbed to assess one such app, as discussed in a recent article (see: Mayo telestroke study affirms accuracy of ResolutionMD smartphone app). Below is an excerpt from it:

The evidence is building that smartphones are suitable for remote viewing of medical images by consulting specialists. The latest comes from the Mayo Clinic Telestroke Network in Arizona, which found that the ResolutionMD Mobile smartphone app [a diagnostic medical image viewer]...was adequate for evaluating remotely located stroke patients.“CT head interpretations of telestroke network patients by vascular neurologists using ResolutionMD on smartphones were in excellent agreement with interpretations by spoke radiologists using a picture archiving and communications system and those of independent telestroke adjudicators using a desktop viewer,” concludes a [recent] study....“Essentially what this means is that telemedicine can fit in our pockets,” Mayo Clinic Telestroke Medical Director Dr. Bart Demaerschalk [said] “For patients this means access to expertise in a timely fashion when they need it most, no matter what emergency room they may find themselves.” Mayo Clinic neurologists in Phoenix can remotely consult with emergency departments at 12 rural hospitals, mostly in Arizona, that have fixed telemedicine platforms or telemedicine robots. Typically, the stroke specialists have face-to-face video chats with remote ED physicians and view brain scans on a standard desktop or laptop PC to look for signs of hemorrhage or blocked arteries. For this study, the Mayo neurologists and radiologists at Yuma (Ariz.) Regional Medical Center compared brain scans for 53 patients on traditional PACS displays and with the FDA-cleared ResolutionMD app. The reviewers were in agreement on 92 to 100 percent of what are considered the most important radiological features, according to the report. Quick diagnosis of stroke and administration of clot-busting drugs can save lives and the remote nature of the telestroke interventions help prevent costly, dangerous patient transfers by ambulance or airlift from rural facilities to urban trauma centers. Being able to make accurate diagnoses from mobile devices can save even more precious time when on-call neurologists are not in front of a PACS station.

The most important news here is that the ResolutionMD Mobile smartphone app was deemed equivalent to traditional PACS displays for the interpretation of CT head images of patients being evaluated for a stroke. Time is of the essence for possible stoke patients who derive great benefit from the injection of clot-busting drugs such as tissue plasminogen activator (TPA) within 4.5 hours. However, the sooner the better in terms of its administration (see: Stroke Treatments and Drugs). Clearly this finding is of great importance for small rural hospitals that may have limited or no access to neurologists and neuroradiologists, particularly on an urgent basis.

Informed Consent as it Relates to Reporting Genomic Results to Patients

The question of how and when to report genomic results to patients and informed consent relating to such results is becoming much more complicated and controversial (see: Patients Should Always Receive Their Genomic Information According to Recent Report). This previous note made reference to a statement by the American College of Medical Genetics and Genomics (ACMG) suggesting that patients should always have access to their genomic information. However, the consenting of genetic testing and the return of these results is much more complicated than normal lab testing. This point was emphasized in a recent article (see: Returning Genetic Incidental Findings Without Patient Consent Violates Basic Rights, Experts Say). An excerpt of it is presented below:

Genetic testing has long required patient consent and patients have had a "right not to know" the results. However, as 21st century medicine now begins to use the tools of genome sequencing, an enormous debate has erupted over whether patients' rights will continue in an era of medical genomics....In a [recent] paper..., [the authors] push back against...[the ACMG] recommendations [that patients always have a right to review genomic results], and offer compelling reasons why patient autonomy must remain firmly in place as science advances...."There are many circumstances in which a patient may decline such testing and information, even if the results could open avenues for intervention. The patient may already be battling another disease, such as advanced cancer, or be late in life and see more burden than benefit in added genetic information. The patient may also fear that 'extra' results in their medical record will invite risk of discrimination."....The authors cite long-standing policy discouraging childhood testing for adult-onset conditions. "Delaying testing and return of genetic information not medically useful in childhood allows the child to reach adulthood and then make a choice based on his or her own values...."As the list [of possible genetic tests] expands, so will the scope of testing without consent…."The authors urge the importance of patients' rights, especially in an era of genome sequencing when extensive genetic information can be generated on any patient.

There is certainly no question that a patient has the right to refuse the performance of genomic testing for whatever reason in the first case because of patient autonomy. A second, and perhaps more interesting question. is whether a patient has the right to selectively receive only a portion of the results of such testing. In its consent form, the consumer genetic testing site 23andMe states that the client, once consenting to genomic testing preformed on his oral mucosa cells, does not have the right to refuse to be informed of any of the test results. I can envision a situation, for example, where the client would stipulate the following to the company: inform me about X and Y but do not report any negative health results. This would be a data management nightmare for the company and it appropriately refuses to do so.

Here's what I envision as one of the major problems of patient consent for genomic testing from the perspective of patient autonomy. Many patients, having given consent for genomic testing and the reporting of such results, will not have a firm grasp of exactly what he or she is consenting to. As in the case of 23andMe, such reporting can't be limited solely to good news. So the concept of informed consent, as we understand it, may not be relevant for genomic testing. It is often impossible to "inform" the patient of the potential significance of all of the information that can be measured and interpreted with a DNA sample. We need to replace the idea of informed consent for genomic testing with some new concept that takes into consideration that much of the significance of DNA testing, both now and in the future, is "unknowable" and therefore can't be consented to in the normal way to by a patient.

Why Having A Pet Tends to Improve Your Heart Health

There is a correlation between having a pet such as a dog or cat and an improved health status. Exactly how this works was the subject of a recent article (See: American Heart Association: Pets, especially dogs, are good for the heart). Below is an excerpt from it:

An animal companion may not just warm your heart, but also help you maintain a healthy heart....Pet ownership, particularly dog ownership, is probably associated with a decreased risk of heart disease," [said the] director of the cardiac care unit at Baylor College of Medicine....[T]here are 78.2 million owned dogs and 86.4 million owned cats in the United States. Thirty-nine percent of U.S. households have at least one dog, while 33 percent have at least one a cat. The AHA's committee reviewed previous research on how pets affect human health, and they found studies that showed owning a pet was associated with fewer heart disease risk factors and increased survival among patients. In particular, owning a dog was shown to reduce cardiovascular risk, perhaps because dog owners are more likely to engage in physical activities just by walking them. One study of over 5,200 adults showed that dog owners were more active than non-dog owners, and were 54 percent more likely to reach recommended levels of physical activity....[A cardiologist said that] "there are plausible psychological, sociological and physiological reasons to believe that pet ownership might actually have a causal role in decreasing cardiovascular risk." [He also] pointed out though if people buy a pet but sit around all day, smoke, eat whatever they want and don't monitor their blood pressure, heart benefits aren't likely."

So walking your dog improves one's health by providing an incentive to walk him around the block a few times a day. This probably won't help if the owner engages in other unhealthy habits. You all know what they are. I also believe that caring for a pet has unique psychological benefits such as relieving stress. These benefits have been shown to be more effective than ACE inhibitors in lowering blood pressure (see: Pet Dog or Cat Controls Blood Pressure Better than ACE Inhibitor):

[A professor of medicine] assessed the effect of social support on heart rate, blood pressure and renin reactivity in response to mental stress in a group of 48 stockbrokers, all of whom were being treated with lisinopril, an angiotensin converting enzyme (ACE) inhibitor used to treat hypertension. She found that in 24 participants selected at random to add a dog or cat to their treatment regimen, these cardiovascular measures remained significantly more stable during stressful situations than in 24 participants in the non-pet-owner group, who served as controls.

The bottom line is that rather than spending money on drugs and surgery for yourself, redirect it to the veterinary bills for your dog and cat. It's a better investment.

Epic Founder Faulkner Gives Hospital Executives Exactly What They Want

Judith Faulkner, founder and CEO of Epic, is warming up to the media according to an interview in Forbes by Zina Moukheiber (see: An Interview With The Most Powerful Woman In Health Care). Here's the reason that she offers in the interview:

I’m recognizing that when we were small, we could stay under the radar, but now it’s harder. I get so many requests for interviews. If I talk to everyone, we can’t do our job with our customers and work on our software. It would be hard to stay focused.

Here's one of the many reactions to the piece by David Shaywitz, also of Forbes (see: Two Quick Reactions To Epic Faulkner Interview: SV Should Show Judy More Love; We Should Shouldn't Let Hospitals Off Hook)

Interoperability issues associated with Epic may reflect tacit preferences of hospital systems.  Tory Wolff and I have discussed the interoperability challenges associated with Epic, and it’s potentially negative impact on the innovation ecosystem (see here and here).  Faukner’s comments don’t particular assuage my concerns, but certainly highlight Epic’s laser-focus on delivering what customers want – and make no mistake, the customer isn’t the patient but the hospital.  This is critical to appreciate.  Thus, while it’s easy (and appropriate) to critique Epic for impeding data sharing, it’s probably also important to remember that if hospitals were all that keen to share data better, I suspect Epic would rapidly find a way to accomplish this. It’s almost as if Epic provides hospitals with plausible deniability.  While it may be convenient to blame EMRs in general, and Epic in particular, for data access challenges, I suspect we also need to dig deeper, and hold hospital systems themselves far more – what’s the word? – accountable.

I couldn't agree with Shaywitz more. In fact, here's a quote from my note of September 14, 2011 (see: Judith Faulkner, EMR Interoperability, and Washington IT Politics)

Now comes a little secret that is not discussed much. Hospital CEOs and CIOs have little interest or enthusiasm for multivendor interoperability, either within their hospitals or hospital systems or across the outside hospital systems that they compete with. Customized interfaces between heterogeneous systems are a pain in the rear-end for the CIOs. They would thus rather have shrink-wrapped integration delivered by a vendor like Epic, the so-called "enterprise solution." Moreover, CEOs don't want to encourage broad patient and clinical data portability because it gives the payers (insurance companies and the federal government) a strategic advantage during negotiations about reimbursement.

So, when the feds raise the topic of interoperable EMR software, most hospital CEOs and CIOs will stand up and cheer. However, when they go out to purchase EMR software, they largely select Epic, particularly the larger ones that can afford it. Faulkner provides the non-interoperable product that they really want. She can also runs political interference for them. She donates generously to the Democratic party, she is tight with the Wisconsin congressional delegation, and takes no prisoners in her political feuds (see: Epic Flexes Its Political Muscle in Wisconsin with Boycott). And she can now try to block any inconvenient initiatives in the arise in the Health Information Technology Policy Committee.

Epic will provide some measure of interoperability to her hospital clients but slowly and most efficiently among Epic client hospitals. This is what her hospital clients want and this is what she will give to them. Here are the (slightly garbled) Epic "rules of the road" in terms of working with other HIT vendors, quoted from the Forbes interview:

We don’t let anyone write on top of our platform, come read our code and study our software. I worry about intellectual property at that point. With our customers, we make sure we have signed agreements. They know they have to respect our software. Customers can do it in a controlled environment, but not the whole world. You’ll see us do more and more of that.

Should Hospitals Develop Lab Formularies Like Those in the Pharmacy?

I recently learned about the concept of a lab formulary, an analogue of the pharmacy formulary. The latter is a list of the stock drugs carried by the pharmacy in a hospital. Prescriptions for hospital patients can only be written by physicicans for the drugs listed in the formulary. The comparable notion on the lab side is that only tests contained in the lab formulary can be ordered by physicians. Here is an article that describes the concept in greater detail (see: Constructing A Lab Formulary). Below is an excerpt from it:

Given healthcare's increasing emphasis on cost control and quality measurement, laboratorians need to reconsider their roles within healthcare organizations. A lab that provides what appears to be a commodity service may be at risk of being marginalized at best or outsourced at worst. But a laboratory that plays a highly visible role in promoting high-quality clinical care can strengthen its status within a hospital or healthcare system. One approach worth considering is to think of the laboratory test menu as a "laboratory formulary" analogous to the drug formulary maintained by a hospital pharmacy. Despite what outsiders might think, the role of the hospital pharmacy goes far beyond simply stocking drugs and fulfilling orders. For one thing, it is not feasible to stock every drug in every formulation that a physician might order. For another, it would not be in patients' best interests for pharmacists to fulfill blindly all orders they receive. 

...[T]he appropriate role of the laboratory professional goes far beyond simply maintaining analytic quality and fulfilling laboratory orders. It includes determining what test methodologies will be offered and in what forms, specifically point of care, in-house laboratory and referral laboratory. It also includes redirecting physicians when they order tests that the laboratory knows to be suboptimal....The stereotype of a lab professional, whether technologist, clinical lab scientist or pathologist, is one of an introvert who likes to hide away in the lab... But the stereotype still risks being self-fulfilling....As lab professionals find creative ways...to share diagnostic testing expertise with medical staffs, we, too, will see an increase in professional status. And more importantly, patients will benefit through more efficient and accurate diagnostic testing.

I have not heard any strident calls for the use of a lab formulary so perhaps I am stirring up controversy where none exists. One of the major drivers for the development of pharmacy formularies has been the need to switch physicians to the less expensive generic drugs to contain drug costs. If a particular generic drug is the only option available in a hospital, this goal can be more rapidly achieved. The ire prompted by such a shift from the clinicians is transferred from the pharmacist to the hospital pharmacy committee that maintains the formulary. Since there is no "generic equivalent" to lab tests, such a goal can't be used as an incentive for the development of a lab formulary.

I can envision that one major rationale for the development of a lab formulary: the desire to place some limits on the inappropriate ordering of expensive molecular and genomic tests. However, even the most expensive of these tests may be appropriate under the right circumstances. Rather than a blanket ban on such tests, it would seem more appropriate to publish the clinical criteria for the ordering of such tests and then require the approval of a pathologist when these clinical criteria are not met. In other words, publishing criteria for ordering expensive lab tests, and then enforcing them, would be a suitable substitute for a lab formulary.

The Institutionalization of Healthcare; Consequences of Big Medicine?

I posted a note five days ago about how the cost of healthcare seems to be gradually declining (see: Decrease in Healthcare Costs May Persist as Economy Revives). A reader, Ajit Alles, responded with a comment that decreasing expenditures of health my result in a lower quality of care, which I responded to in another note (see: The Correlation between the Cost of Care and the Health of a Population). He has responded to this second note with the following comment:

As follow-up, I agree that we spend way too much on end of life care, but that won't be reduced without a cultural shift. People expect miracles from medicine based on what they hear on the news and see in TV dramas. We could spend less and get better results, but people have to first start accepting that modern healthcare has limitations, not the least of which is funding. The new push for genomic healthcare is a good example of unrealistic ideas being pushed for profit. If everyone thinks that they are going to get personalized gene targeted healthcare they are dreaming! I know I'm a curmudgeon in this regard, but we first need to have good basic healthcare before we get cadillac genomics....We in for-profit medicine must share the blame for pushing "new and improved" medicine that is unaffordable and only (marginally) benefits the few people who can afford it. I recently heard of a family that wants some genomic test done on their child with cancer. The test looks at sequence variation in multiple genes and provides a "report" of very limited utility since most of the variations have no specific treatment. The test costs about $25000 and is not covered by insurance ....The family can afford to pay for this so it's being done with the encouragement of the oncologist. There are others who peddle proteomics reports to desperate patients. Enough said. This is the road to ruin.

I would like to respond specifically to his suggestion that "[those of us] in for-profit medicine must share the blame for pushing new and improved medicine that is unaffordable and only (marginally) benefits the few people who can afford it." I agree that many providers participate in "for-profit" medicine. However, the nature of the healthcare enterprise is now changing to what has been called "Big Medicine" or "Big Med" (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Transition to "Big Med": Need for Emphasis on Standardization and Cost; Health Systems Use Their Regional Dominance to Muscle Insurance Companies). With the rapid decline of private physician practices, many of the key decisions about the future of healthcare will be made by the federal government, large hospital systems, health insurance companies, and Big Pharma. So while we indeed have a for-profit health system in this country, most of the resources will flow from institutions like the federal government and health insurance companies to large institutions like large hospital systems. The great majority of physicians will be hospital employees. I refer to this as the institutionalization of healthcare delivery. We need to better understand the consequences of this shift.

I think that this change will have a major effect on the incentives experienced by physicians. In previous notes, I have made the point that cancer patients receive better care if the treating oncologist is salaried and does not benefit directly from selecting the most expensive treatment. This idea becomes apparent, as one example, in the treatment of ovarian cancer patients where a private oncologist is incentivised to maximize revenue from patient "chair time" whereas salaried academic oncologists seem to be more inclined in select the preferable intraperitoneal infusion of chemotherapeutic agents (see: Patients with a Cancer Should Seek Treatment in Cancer Hospitals). This is the best therapy but complicated and with lengthy patient visits. Here's are a couple of additional articles about how oncologists are compensated for additional reading (see: Will the Sequester Cause Oncologists to Lose Money Prescribing Chemotherapy?; Who Pays Your Oncologist?).

For private oncologists, the so called "oncology concession" goes to their group practice and they themselves directly benefit financially from their clinical decisions (see: The Oncology Concession Under Attack by Health Insurance Companies). For a salaried oncologist, the "oncology concession" goes to the hospital whose executives may choose to pay their oncologists the internist market salary, retaining the difference. The hospital may then choose to reward its executives at a higher level for developing a bigger cancer center (see: Cancer Business Highly Remunerative for Sloan-Kettering Executives).

I believe that health system executives will be more highly compensated and physicians will be less so as a result of institutionalization. After all, it is the executives who are making macro compensation decision and it would be natural for them to reward themselves. Moreover, these same executives will also have critical decision-making power in terms of how "new and improved" medicine is delivered. I believe that most of decisions will be based on how such care is compensated by the various institutional payers.

Is Any Hospital Using the "Hybrid" Digital Pathology Business and Workflow Model?

In a previous note, I discussed the hybrid teleradiology business model (see: Hybrid Model of On-Site and Remote Radiology for Enhanced Patient Workflow). In a nutshell, it works in the following way:

• A radiology department at a 370-bed acute-care hospital in Carmichael, California, utilizes both its on-site radiologists and remote radiology ("nighthawk") consultants to improve the quality of care and workflow.
• Cases are turfed to the outside consultants when the local radiology expertise is unavailable (e.g., neuroradiology), when the local number of radiologists is insufficient to handle the current case load, and during the night and weekends when the local radiology department is not fully staffed.

It occurred to me that this model would be ideal for smaller hospitals today who have deployed a digital pathology system or are interested in doing so. When outside consultation is required for a surgical pathology case, it could be scanned after primary review by the local pathologist. The volume of such cases would thus be small and a high-volume, high-throughput, expensive scanner would not be required. Moreover, such a surgical pathology consultation would require only an outside secondary opinion and thus, given my understanding of today's regulatory environment, would be acceptable to the FDA.

The Digital Pathology Association is planning a webinar next month focusing on the various business models that can be used to deploy digital pathology technology. Are there any readers of this blog who have successfully deployed such a hybrid model and wish to be considered as a faculty member for this upcoming webinar?

The Correlation between the Cost of Care and the Health of a Population

In a recent note, I reported that the cost of healthcare in the U.S. was beginning to decline, perhaps due, in part, to reasons other than the drop in the economy (see: Decrease in Healthcare Costs May Persist as Economy Revives). A reader of Lab Soft News submitted the following comment in response to the post:

Costs are down, but has health taken a beating? If people are seeing less of their physicians are they then showing up sicker? Does this give us a healthier population?

I have come to believe that spending more on healthcare does not necessarily result in greater health for a population. The U.S. ranks 40th in life expectancy when compared to other countries according to a 2012 WHO study (see: List of countries by life expectancy). We also spend far more per capita and as a percentage of the GDP on healthcare than all other countries (see: List of countries by total health expenditure (PPP) per capita). I understand that are are other factors at play here such as the homogeneity of populations. Moreover, much of our per capita expenditures for healthcare also come in the form of end-of-life care which is expensive and doesn't always have a positive outcome for the patient (see: The Cost of End-of-Life Care). Here's a quote from the final section of this article:

Near the end of life, clinical priorities change and measures of care should be adjusted accordingly. When illness becomes irreversible, clinical deterioration may no longer justify escalation of care, so risk-adjusted cost analysis may become less relevant than better definition and proper attribution of overaggressive end-of-life care. To avoid desperate overtreatment, better implementation of palliative care is needed, and hospital investment in such services appears fruitful.

A substantial portion of our cost-of-care is related to chronic conditions which could be ameliorated by having patients taking more ownership of their health and introducing more preventive health measures (see: The Need for a Preventive Medicine Infrastructure in the U.S.). The Affordable Care Act (ACA; Obamacare) does earmark some funds for preventive medicine so we can hopefully look forward to some improvements in this aspect of healthcare (see: Preventive Care and the Affordable Care Act). This will require a substantial change in direction of providers away from disease and toward wellness. 

The conclusion that can be drawn from all of this is that spending more on healthcare does not necessarily result in better health. Stated a another way, we can reduce our healthcare costs without having health "taking a beating."