Letter to the Editor: health care reform: bring it on

6 mins read

In President Obama’s speech the other night, the President reminded us of the urgency of health care reform. Thus far health care expenditures have been a bottomless pit and threaten to suck the remaining oxygen out of the already faint economy. We now spend 1/6 of our GDP on health care, and for that we rank 34th on the World Health Organization list of national rankings. Unless addressed, that portion will double to 1/3 in a few years, and that is simply untenable.

While almost everyone agrees the system is fundamentally broken, many of the main players in the health care industry, from doctors to hospitals to the pharmaceutical industry are resistant to the threats implied in waste cutting. Targeting waste is essential if we are to move forward, but one person’s waste is another person’s income, and those three groups will need to take big income hits if this is going to work.

It is now widely accepted that 30% of our health care spending is wasteful. Unnecessary procedures, the overuse of expensive drugs, and the proliferation of expensive and often misleading imaging tests are all bringing the system down. The consumer may think that what we do is scientific but too often, especially when it comes to big ticket items, practices are based more on whimsy and provider preference than hard evidence, and thus far consumers and their insurers have been willing to pay.

Take heart disease, the number one cause of death in America. According to a recent Journal of the American Medical Association article only 10% of 2700 clinical practice recommendations were based on what experts regarded as hard, well tested evidence. In the case of chronic, stable angina, an extremely common condition, only 6% of recommendations sponsored by the American College of Cardiology and the American Heart Association were based on strong statistical evidence. The rest of the practice guidelines were weakly supported by trials and research. Small wonder that 1/3 of cardiac procedures, including 1/3 of angioplasties, are probably unnecessary.

Cancer care is another example. Oncologists make a large portion of their income from the chemotherapy they prescribe. Some of these drugs cost $1000’s / month and represent a substantial income stream for physicians and the hospitals that employ them even though data may not support their use. A few years ago bone marrow transplantation coupled with high dose, toxic chemotherapy was widely employed for stage IV breast cancer despite no hard evidence of its effectiveness. By the time the trials finally put the idea to rest $3 billion had been spent and 4000-9000 patients died from the treatment.

The well known but poorly understood regional variation in medical treatment is a popular bit of news thanks to Atul Gawande’s recent New Yorker article. Some communities have very high medical costs, some low. Not surprisingly this seems to follow the number of available specialists but not the degree or severity of illness in the community. In fact, when patient outcomes in those areas are compared to poorer areas with less resource and lower utilization rates the outcomes in high use regions are often worse even though patients are no sicker. Instead they are more often exposed to questionable, costly procedures, confusing (but expensive) tests, and unnecessary drugs that nevertheless subject them to side effects. It is now estimated that more Americans die from unnecessary surgery and medical treatment than in car accidents (300,000/year, JAMA).

Two next steps are critical. First we should allow the government to offer a public health care package to compete with the private insurers. This will help set reasonable rates and coverage guidelines. To those who object about ‘government medicine’ I would point out that government insurance programs far outperform private offerings in their efficiency of delivery. Private insurance programs have a 30% overhead cost: the government’s? Typically less than 10%. A public program could be the springboard for promoting efficient, well grounded best practices. And this could be a good installment on moving towards universal coverage.

Secondly, we should go forward with the Republicans’ idea to form an independent panel of medical experts to start to formulate treatment guidelines. Congress can’t do this – too many lobbyists to corrupt the process – and neither insurance companies, medical societies or individual physicians have shown the courage and leadership to take this on.

The status quo is unworkable. I am not only a practicing physician, but I am someone who buys his own insurance, and I run a small business, so I am only too aware of the costs, both short and long term, if we fail to act. I urge you to contact your representatives to let them know how important real reform is to you.
 

Steve Bien, MD
Farmington

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4 Comments

  1. I agree Steve. But the big red flag for all Americans is WHY do the Congress and Senate, NOT want to participate in the govt health care plan….we all know why….it is a poor plan, plus all the people in the Congress are of an age that the plan decides who lives and dies.

    I would love to see the govt end all these medical lawsuits. Would save all Docs, lots of money.

    I also believe we the taxpayers could save bigtime if we stopped picking up the tab for the Congress and Senates current health plans….lets put that towards something useful.

    Remember all you people who voted o in that you will be subject to poor health care and the fat cats in Washington will have great health care.

    If you owned a business that supplied health care, wouldn’t you consider dropping same and let employees
    seek govt care?

  2. If the Obama Health Care Plan is so good for eveyone and democrats in congress are pushing so hard for it why doesn’t it cover them? That’s right, the U.S. Congress, your Senators and Congressmen (“Congresspeople” is guess it is now) are EXEMPT from this great new health care plan. You Americans need this and need it now, but THEY don’t!

    How is the Maine Dirigo health care plan working? Remember the promises of “thousands” of Maine families that would be covered and it would pay for itself? It is costing millions of dollars and they need MORE of your money. Plus, it covers about 1,800 families in Maine.

    Think what will happen to a NATIONAL health care plan.

  3. It’s refreshing to see a doctor acknowledge that doctors are part of the problem. But one thing Steve Bien doesn’t mention is that in addition to unnecessary procedures some doctors just plain charge too much. Maybe we need an independent panel, NOT composed entirely of doctors, to determine what is a fair price for ordinary medical services. How much should it cost to walk through a doctor’s office door? Nothing, I would think; but some doctors think it should cost hundreds of dollars. How much should it cost to talk with a doctor for 20 minutes? How much should an injection of an inexpensive drug cost? Believe it or not, I ran into a doctor who thought that for spending 5-10 minutes with me and giving me one injection she should get $383.

    One reform I would suggest is that doctors be required to be up front with the patient about how much they will charge for this or that. If we could all make informed decisions based on knowledge of a doctor’s charges, that in itself would make pricing more competitive.

    Also, doctors should be required to write their bills in plain English, as distinct from code, so that the patient can see exactly what the doctor is claiming to have done. Remember that third party payers–whether insurance companies or government payers–don’t see what happens in the doctor’s office. If the doctor exaggerates how much time s/he spent, or how difficult a procedure they performed in the office, the third party payer has no way of knowing this; and even the patient has no way of knowing it if the bill is written in code.

    There may be other things that could be done to reduce the cost of health care at the billing end, which logically should be tackled ahead of the question of who will pay the bill.

  4. If you’re not outraged by what is going on in the town hall meeting around this country right now you’re not paying attention.

    Apparently if you oppose Single payer system you are forced out of the debate!

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