In her new book Overtreated, science writer Shannon Brownlee presents a well-researched, insightful argument for the root cause of America’s healthcare crisis: Market forces in the system result in powerful incentives to deliver too much care. She demonstrates how the system promotes intrusive, expensive treatments over simpler, more effective ones, and documents how those same market forces financially punish providers that deliver care which actually improves the health of their patients. A related problem is that America has largely delegated basic research to drug and medical device companies, which invariably drives the use of expensive new treatments over less profitable ones. The ultimate result of all of this is clear: We spend over twice as much per capita as other industrialized nations on health care, 46 million of us are uninsured, and the data place us somewhere between Costa Rica and the Czech Republic in standard wellness statistics.
Brownlee’s book was inspired by the work of Dr. John Wennberg of Dartmouth Medical School. Dr. Wennberg and his team have documented how the number of tests and treatments varies dramatically in different communities, while demonstrating how increased usage often correlates to higher rates of death and negative outcomes.
Consider the story of high dose chemotherapy for the treatment of breast cancer. The procedure was based on the intuition that if a little chemo is good, more is better. The problem is that high doses of chemo destroy the body’s immune system, requiring bone marrow transplants. After positive press coverage, pressure from patient advocate groups, and several high profile lawsuits, insurers began to pay for this expensive procedure in the early 1990’s, and doctors and hospitals were more than happy to go along with what became one of their biggest cash generators.
The problem was that the treatment was ineffective. Clinical trials completed and published late that decade showed conclusively that high dose chemo was no more effective than standard treatments. Faced with the evidence, the practice was largely stopped – but not before thousands of women suffered tremendously from the side effects of this procedure while millions of dollars were wasted.
The book contains other examples, documenting how increased usage of CT scans, expensive new drugs and invasive surgeries do not correlate to improvements in survival rates or better health.
What is the solution? Most Americans would be surprised to learn that the most cost effective, highest quality health care provider in the nation is a unionized system run by the government: the Veterans Health Administration.
This is a recent phenomenon. During the debate over health care reform in the early nineties, opponents could justifiably cite VHA as a negative example of socialized medicine. There were serious efforts to abolish the VHA and put veterans on Medicaid.
Instead, President Clinton hired Dr. Kenneth Kizer, a respected public health expert, to turn the system around. Dr. Kizer’s background was important: public health looks at health care as an integrated system. The VHA also has a crucial advantage: they have their patients for a lifetime. This gives them powerful financial incentives to actually improve the health of their clients. Kizer borrowed heavily from industry and implemented quality improvement systems, openness in reporting, facilitated the use of innovative information technology, and most significantly, created a teamwork based environment that stresses collaboration between doctors and other healthcare workers.
The results speak for themselves. Between 1995 and 2004, the cumulative increase in the VHA’s cost per enrollee was 0.8%, compared with 40.4% for those covered by Medicare. For six consecutive years, VHA received the highest consumer satisfaction ratings of any health care system. Error rates for prescription accuracy in VA hospitals are around 0.003 percent, compared with 3-8 percent for other hospitals. Experts agree VHA has become the industry leader in safety and quality.
The conclusions are inescapable. Market forces are the root cause of America’s health care crisis, and the most cost effective, highest quality health care in the nation is being provided by the system that is the most “socialistic”. One can give ideological arguments against these conclusions, but the facts are indisputable.
The example of VHA provides a template for a system where America’s world class doctors and nurses could be allowed to provide excellent health care without bankrupting the country. The only impediments are those ideological arguments, and the political power of those who profit from the current system – power bought through millions in campaign contributions.
Does America have the leadership to ignore the special interests and save us from the crisis?
7 comments:
Eighty percent of our health care costs in America are related to chronic disease, largely driven by three behaviors: over eating, under exercising and smoking.
We do not have a healthcare crisis..we have a health crisis.
Leave the free market of the healthcare system alone.
A human right is a moral right of paramount importance applicable to every human being. There are several reasons why health care should not be considered a human right.
Firstly, health care is difficult to define. It clearly encompasses preventive care (for example, immunisation), public health measures, health promotion, and medical and surgical treatment of established illness. Is the so called human right to health care a right to basic provision of clean water and adequate food, or does everyone in the world have a right to organ transplantation, cosmetic surgery, infertility treatment, and the most expensive medicine? For something to count as a human right the minimum requirement should surely be that the right in question is capable of definition.
Secondly, all rights possessed by an individual imply a duty on the part of others. Thus the right to a fair trial imposes a duty on the prosecuting authority to be fair. On whom does the duty to provide health care to all the world’s citizens fall? Is it a duty on individual doctors, or hospital authorities, or governments, or only rich governments? It is difficult to see how any provision of benefits can be termed a human right (as opposed to a legal entitlement) when to meet such a requirement would impose an intolerable burden on others.
Thirdly, the philosophical basis of all human rights has always been shaky. Liberalism and humanism, the dominant philosophies of Western democracies, require human rights. Religion requires a God, but this is not in itself evidence of God’s existence. Most people can see some advantage in maintaining the concept of civil and political rights, but it is difficult to find any rational or utilitarian basis for viewing health care in the same way.
To propose that health care be considered a human right is not only wrong headed, it is unhelpful. Mature debate on the rationing and sharing of limited resources can hardly take place when citizens start from the premise that health care is their right, like a fair trial or the right to vote. I suspect that the proponents of the notion think that to claim health care as a human right adds some kind of weight or authority to the idea that health care, and by extension healthcare professionals, is important. A more humble approach would achieve more in the long run.
My sister had an emergency operation in Canada. If she had lived in the United States her emergency may have finacially ruined her family.
Except for greed, why would anyone want their friends, family, or neighbors to loose everything due to a medical emergerncy?
This type of thinking is beyond my ability to reason.
Great post Mr. Olsen!
Market forces my eye! There are only two countries in the world where the consumer pays LESS than in the United States. It's the fact that government and health providers pay for us that we don't care how much care we get. We pay on average only 10% of direct health care costs. If we were paying for it ourselves, we'd be a little bit more discriminating.
Yes, Frank, how much better a health care system would we have if citizens were to be “discriminating.” Lets encourage a system where people don’t seek medical attention until their injury is critical, or their disease is life-threatening. What folly.
Interesting that you would note that we have nearly the highest per-capita health care spending in the world--well ahead of all those socialized health-care systems of Europe. And yet, the health of the average citizen in the U.S. is worse than those served by those nationalized health care systems. Hmmm...Maybe health care is better served when people are more concerned with actually helping people, and less concerned with lucre.
C'mon Derek, don't put words in my mouth. If you read my post on Simple Utah Mormon Politics, you'll see that I advocate Health Savings Accounts, which incentivize policy holders to get the best out of their health care.
Also, I DIDN'T say highest per-capita spending (although you may be right, that wasn't my point) I said the consumer pays less (as a percentage) than in all other countries but two. But with incentives such as HSA's health care will improve and the costs will go down.
Frank, How do I save if I can't even keep my head above water with incrweasing property tax costs, and fuel costs. So many people who don't realize how diffacult it is save enough money for the mortgage in a monthly period.
I'm a hard worker, undereducated, and highly experienced in my field and yet finding employment that would pay me enough to save for medical savings semms at this time of my life to be a steo beyond my reach.
Oh, and then there's tithing.
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