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