America's Health Care Addiction

Substantive health care reform will only come with a cultural shift that recenters public expectations and puts the science of health care, and health care outcomes, back in charge

Science is what we use to keep from fooling ourselves.
-- Richard Feynman

On occasion a patient arrives in the hospital so sick, in so many ways, that as a physician it's hard to know where to begin. Health care reform feels the same way -- so many things wrong, so complex and interrelated, that delving into it can produce a catatonic sense of helplessness. Detailed media reports begin to sound like Charlie Brown's teacher, an incomprehensible garble that's over our heads.

Where to start? Because the symptoms of our ailing health care system are primarily financial -- health care simply costs too much -- most Americans believe the solution will be financial as well. The three health care reform proposals from the Senate and the House seem to confirm this, with a bevy of financial proposals like "affordability premium credits," "insurance pooling mechanisms," tax penalties for the uninsured; plans for increased efficiency and performance, and decreased abuse and fraud. To physicians like me, all of this sounds like a meth addict who finally admits to having a problem: meth is too expensive. If he could just get his finances in order, his troubles will go away.

The fleecing of America, one co-pay at a time

America, it's time to sober up. We've become addicted to high-cost, high-tech, average health care, and breaking this addiction will solve our financial problems, not vice versa.
Data from the Organisation for Economic Co-operation and Development showed that in 2006, the United States spent $6,567 per capita on health care, edging our nearest competitor, Switzerland, by 52% and putting us 90% higher than many of our global competitors. And what have we gotten for this spending spree? Average health care. No comparisons suggest otherwise. This doesn't mean we don't do some things really well; in fact, America has arguably been the world's leader in health care innovation. It's just that for broad indicators of health, we're shooting par.

How does a country with perhaps the most innovative health care system in the world produce average health care outcomes? It's simple: much of the innovation hasn't delivered. This is what the American public doesn't get, and what's hard for a physician to admit to: the benefits of modern medicine have been oversold. We've assumed that the same science and technology that so dramatically revolutionized human life in the 20th century, taking us from horses to horsepower to nuclear power, would do the same thing for human health.

It's true: we are living longer than ever. Life expectancy in the U.S. nearly doubled in the past century, but the sharpest gains came in the first half of the century, well before any significant medical advances, even before the discovery of antibiotics. In 1900 the average U.S. citizen lived to age 47, and by 1950 the average life expectancy was 67. This unprecedented change came from improvements in nutrition and control of infectious diseases (sanitation being critical) that drastically reduced infant and child mortality. Which makes sense -- if you want to change the health of a rural village in Central America, don't build them a dialysis center and an MRI: dig a latrine and drill a well.

Life expectancy plateaued from 1955 to 1975, and despite an explosion of medical knowledge and technology, thereafter the graph has resumed a softer steady pitch, with subsequent gains being largely due to improved treatment of high blood pressure and diabetes. As we turn the corner on the 21st century, U.S. life expectancy is 77, and the two most common causes of preventable disease are human-derived pandemics of smoking and obesity. Certainly life expectancy is not the sole measure of health, but superimpose the soft rise of the U.S. life expectancy curve with the steeply pitched rise in health care spending and you don't need to be an economist to see that we're not getting a lot of bang for the modern health care buck.

This dichotomy between what America spends on health care and what we get in return is moored to an unshakeable belief in the power of technology to radically change our lives, even our health. The infatuation became so deep that we stopped applying scientific rigor to the health care sciences. We quit asking the tough questions: it may be fascinating technology and great science, but is it great medicine? Every new medical device, new pill, new therapy must be better than the last one, and the steep price tag proves it. Sounds ridiculous? One need only look as far as the financial crisis, where our infatuation with the power of unfettered markets kept us from asking the honest questions: are derivatives "real" or are they just funny money?

Bone marrow transplants for breast cancer: Health, American Style

The use of autologous bone marrow transplants (ABMT) in the 1990s for treatment of advanced breast cancer exemplifies the many factors that make Health, American Style so expensive but also inept. The story begins in 1990, when a study showed that for women with cancer extending into a number of lymph nodes, treatment with ABMT offered a 40% improvement in three-year survival rates compared to standard chemotherapy. The study was hobbled by methodological issues that seriously weakened or even nullified the results, and insurers refused to pay for it. But for physicians and patients dealing with the terrible predicament of advanced breast cancer, ABMT -- despite its significant toxicities, infection risks, and published mortality rates of zero to seven percent -- appeared to be a promising treatment. Individual women sued their insurers to get one, and for reasons that were more often legal than scientific -- so called "judge-made insurance" -- many of them won. Under intensive lobbying pressure and seeing a legal precedent forming, some states enacted laws mandating insurers pay for ABMTs. Rather than bear the legal expenses, in time insurers began paying for ABMTs, but only if patients agreed to enter a randomized control trial.

Eventually ABMTs became unconditionally covered, "standard therapy" if you will, despite further evidence that the initial study was deeply flawed, and that the improved response with ABMT seemed to last only a few months and came at a cost of serious side effects. High quality randomized control studies initiated to answer this critical question were hampered by very low enrollment: women (and many oncologists) were so enamored by (and hopeful for) ABMT that they refused to take the risk of entering a trial and ending up in the standard therapy arm. In the end, only one in ten patients who had an ABMT in the 1990s did so within a clinical trial, perpetuating our ignorance of whether the treatment was a sham or a ray of hope. So it wasn't until the year 2000 that there were enough good studies to conclude that the treatment was ineffective.

This is the story of ABMT for breast cancer, and also American health care: faddish, technology-avid, heavily lobbied and political; ruled by an innate feeling that the more complex the care, the better it must be. With the best of intentions, over a ten-year period we spent an estimated $3.4 billion on a treatment that didn't work. Embracing hope, to borrow from the Obama campaign, we turned a blind eye to science, and the forty-one thousand women who were treated with an ABMT suffered for that delusion. As an internist, I helped take care of some of these women: they suffered.

Vioxx, leaf blowers, and the allure of liqui-gel

Remember Vioxx, the new arthritis medication developed by Merck and first brought to market in 1999? Because it had a reduced risk of stomach ulcers compared to other arthritis medications, it looked to be a good drug for patients with chronic arthritis pain, those with rheumatoid arthritis for example. No one, including Merck, directly claimed that Vioxx worked better than standard pain medications like ibuprofen or acetaminophen, but a media blitz depicted a revived Dorothy Hamill triple-lutzing across the TV screen, and Americans clamored for Vioxx to the tune of over $2 billion dollars a year. When the drug was pulled in the fall of 2004 because of an increased risk of stroke or heart attack, the tab was over $10 billion.

The flip side of the belief that complex, high-cost care guarantees superior health care is that simple, inexpensive measures must be "cheap" and ineffective. Not so. Take heart disease for example. A recent paper in the New England Journal of Medicine attributed only seven percent of the decline in deaths from coronary artery disease since 1980 to angioplasty and bypass surgery combined. For a techno-fascinated country, it doesn't necessarily make sense that controlling risk factors and taking a few pills could work as well as a complicated, definitive-sounding "Roto-Rooter" procedure like angioplasty, or open heart surgery for that matter.

Metaphorically speaking, we're a country that will pick a leaf blower over a rake any time. Even though a rake lasts indefinitely, always starts, carries no electric or gas bill, provides exercise to the user, and dethatches as it goes. We're a people that believe Advil and Motrin work better than generic ibuprofen, even though it's the exact same drug at one-third the price. Oh, the power of a candy-coated shell, the allure of liqui-gel!

Why water the flowers AND the weeds? Putting science back in charge of a consumer-driven health care system

If American health care is over-hyped, and over-valued, then health care reform that simply pays less for everything is doomed to failure. Legislation that waters both the flowers and the weeds less may allow you to save water, but it makes you a lousy gardener.

To that end, there are some hopeful signs in the current Congressional health care proposals, and also in the American Recovery and Reinvestment Act (ARRA) passed in February of this year. All of these include funding to evaluate the effectiveness and appropriateness of individual health care services and procedures. As encouraging as it is to see that perhaps we're finally ready to apply scientific scrutiny to the science of health care -- so-called "evidence-based medicine" -- it remains unclear how we will implement this newfound knowledge.

Although the ARRA established a council of clinical experts to compare the effectiveness of various treatments, the council won't be able to establish clinical guidelines or to "mandate coverage, reimbursement, or other policies for any public or private payer." An information sheet on the House plan reads, "Under this proposal, doctors, nurses, and patients will make medical decisions, not big insurance companies or the government." But wait a minute! This is how we got into this mess in the first place. We live in a consumer culture, where the customer is king. This is the health care system we've demanded and allowed: glitzy and impatient; created to fight disease, yes, but also to soothe our insecurities about our own health and mortality. When it comes to health care, Americans want everything, the works: an antibiotic "just in case" the bronchitis isn't from a virus; an MRI of the back, not because the clinical scenario is worrisome, but because we've been reading about spinal cord tumors on the Internet.

If we can't have everything, because the science shows that "everything" (like bone marrow transplants for breast cancer) offers no benefit but some risk, or because the new pill (Vioxx for example) offers marginally more benefit for summarily more cost, is this "rationing" health care? People shudder at the term, but we all make daily decisions based on what we can and cannot afford. As we've now proven, any limited supply must be either rationed, or exhausted.

When the white coat becomes a straitjacket: physicians prove incapable of reigning in health care costs

So who is it that's going to say "no"? Physicians haven't been able to for a variety of reasons. As human beings and as businesspeople, we want our patients to like us. We want them to be relieved, comforted, satisfied. Acting aggressively gives us a proactive, competent air, and it validates the patient's symptoms, in the same way that not ordering an X-ray can seem to trivialize the patient's problem. Rather than being relieved that it wasn't pneumonia, a patient may leave the office grumbling, "They didn't even do an X-ray." Giving patients what they want -- meeting their expectations, efficacy and costs be damned -- keeps them happy, if not healthy; and happy patients don't sue.

Yes, some physicians practice the unproven for profit, gaming a system which stupidly pays more for doing more, regardless of the efficacy of "more". But most physicians dabble in the gray zones of medicine because doing something avoids having to discuss the sobering details of the latest medical research ("Here's why you don't need this test"), the likes of which contribute to a sense of professional ineptness. A published review of the most recent science on diabetes reads with colloquial frankness, "Enough already! Randomized trials show that tight glucose control in patients with long-standing type 2 diabetes isn't beneficial." The headline asks physician readers, "How Much Evidence Do We Need to Change Practices in Which We Firmly Believe?"

If physicians and patients are incapable of following evidence-based, rational, clinical guidelines, then the only thing that will put a stop to our health care spending spree is for the entity who is paying for it -- be it private or government insurance -- to stop paying for it. For competitive or legal reasons (both in the case of bone marrow transplants for breast cancer), private insurers have had difficulty saying "no" to unproven therapies. And for as long as affordable health care is seen as cheap health care, no one will sign up for what they perceive to be a "Penicillin&Gauze" insurance option. I'm no fan of big government, but perhaps a government insurance option based on the best available medical research, where hard science dictates the behavior of bureaucracy rather than the other way around, would create a new, more realistic playing field.

Purging unhealthy health expectations

While it's uncertain what, if any, kind of health care reform legislation will be passed, Congress cannot mandate what our country may need most: a cultural shift in the expectations of what modern medicine can and cannot do for us. This may be no easy task. Look at us: we're a nation that's outlawed Lawn Jarts, but not cigarettes; a country that's gone cuckoo for Cocoa Puffs and diet pills but not for healthy food; a drive-up-window-society simultaneously hooked on physical convenience and fitness centers.

We all want a health care system that will continue to innovate and evolve. When I was in training in the early 1990s, patients infected with HIV came into the hospital with a high fever and no blood pressure and died in a hurry. HIV medications changed all that, a miracle in our time. We need to keep chasing down miracles, but we won't build a futuristic health care system by bankrupting the current one. We'll get there by paying for proof, by developing a keen eye for treatments that are both great science and great medicine, and by admitting to our anxiety-ridden souls that life will forever have limits and uncertainty.

Comments

[Patrick Malone - Huffpost Blogger]

This is a powerful piece that makes an eloquent argument for the primacy of public health measures in promoting healthier lives. You also edge close but never quite bite down on the "single payer" argument for finance reform. What better way to crack down on ineffective, wasteful treatments than to have a "Medicare for all" single payer system where uniform rules for payment are set -- and are thrashed out among doctors who have no financial incentives one way or the other? Another advantage of 'single payer' is that the data on what works and what doesn't gets easily pooled centrally so that studies can be more efficiently run on outcomes. They do that now in Ontario with drug efficacy studies.

[Helanren]

Great article, and unfortunately unlikely to have any impact at all until/unless something catastrophic happens. For the exact same reasons you mention: modern day American culture is addicted to fast food/fast results/fast everything technologically driven consumerism. And addictions are very hard to cure.

[Craig Bowron - Huffpost Blogger]

Thank you, and I wouldn't disagree--except to say that the end of an addiction starts with a clear recognitio­n/convicti­on that a problem exists. For the chemically dependent, that often means hitting the proverbial "rock bottom." Concerning health care, I hope that we figure it out sooner than that.

[rad21]

Since President Reagan, protections for the consumers has been weakened if not stripped. So now the individual / corporation with the greatest financial backing / connections has the clout and makes the loudest noise.

In the case of healthcare, who is there to challenge the data and the conclusions of the "scientific trial" when the conclusion stand to benefit so many individual physicians and interest groups including big pharma and / or bio-engineering groups? The Federal govt. that has to pay for the "new advances" used to be the body of consequence to demand hard data. That has now been eliminated with the use of political or media pressure on various government agencies. Perhaps the recently created CER (comparative effectiveness research) may provide a forum for critical analysis of self-serving authors and scientists.

[Craig Bowron - Huffpost Blogger]

With a decrease in federal funding for scientific research, more and more of the hard data available to the medical community to make treatment decisions is derived from industry sponsored studies. The studies aren't shams--they can produce useful information--but they are often biased and sometimes are designed to ask only the questions that the industry wants to answer. And because the industry runs the studies, they can pull the funding if they don't like where the preliminary findings are taking them. All of this is complicated by the fact that medical journals have a predilection for publishing positive studies over negative studies, thereby over-emphasizing successes, and minimizing failures.

[jsgaetano]

After seeing how thoroughly Conservatives destroyed the financial industry, when I hear people talk about "innovation", I start seeing warning signs.

The kind of innovation conservatives want, the world doesn't need.

[ImmanuelGoldstein]

Simply put it's impossible to solve this problem because the minute you start talking about the issue you are pasted with the label of 'rationing', which plays into the Big Lie that we don't ration anyway. We just ration stupidly and inefficiently.
There is no real culturally or politically possible solution at the present time in this country. Real solutions are going to be FORCED on us by systemic bankruptcy and collapse. I firmly believe it's the only way reform will occur. Not what I would have chosen as a solution ,but I see the handwriting on the wall and frankly I can't imagine any other outcome.

[figneutron]

ImmanuelGoldstein, I agree. The present money-driven institutions known as the media and the Congress are the only forums for public debate of health care reform and other momentous issues. This means there can be no open discussion of public policy governed by the facts. Here, money buys "truth." Those with funds can hire an expert to testify to anything you want them to say. Plus, there will be parties in the debate who hold that facts are irrelevant: "Who needs experts? Who needs Big Government studies? Let the people with their God-given wisdom decide!" I fear we are on the threshold of a new Dark Age in which hopeful fantasies and comforting delusions will rein, and the witch doctors casting spells of cutting-edge medical technology will lead. Only when this insanity eventually triggers financial and institutional disaster will there be a chance to solve our critical health care problems. I wonder how long we can wait.

[Craig Bowron - Huffpost Blogger]

Unfortunately, I think you could be right. The paradigm shift may ultimately have to come at financial gun point. It's why Lawn Jarts got outlawed rather than cigarettes: they are a more immediate, palpable threat.

[TMann99821]

I live in KY but my company is headquartered in AL so I have BCBS of AL. However, since I live in KY, I would not be able to get BCBS of AL on my own. Why not break down the state barriers and let people shop for health insurance outside their own state? This would cause more competition and would probably lower the cost. Couldn't we just try this for one year and see what happens? No, the Liberal's want to give us a 1,000 page bill that is full of penalties and taxes. These bill's are not intended to give people better health care. They are intended to make people dependant on the government.

Health Care Providers also contribute to the rising cost of health care. I have a condition that requires me to see a Dr. once every four months. I have tried different Dr.'s and when they see I have good health insurance, they want to know when I had my last physical, when I had my last tetnus shot and run numerous blood test.

[chlai88]

Great points, profiteering on an altruistic issue such as health care only results in inefficiencies, wastage and overspending if not regulated. But patients are also susceptible to the latest fads & they are the unsuspecting allies to this waste. Reforms should not simply stop at mandates, regulations and spending, but also "evidence-based" care as mentioned in the article as well as consumer education.

[anfractuous]

I can't count the number of times I would watch the 10 o'clock news and the "Health" segment would feature a marvelous new diagnostic tool, which could screen for some particular illness years before it would fully manifest. Whether it was a strip of paper or a 3 ton machine, my reaction was that no one would ever encounter it in their doctor's office: because no physician, in the course of a routine exam, would ever run a patient through such an expensive gantlet of tests, with no prior expectation of a result. I would be most curious to find what happens to all these forgotten miracles.

The current state of knowledge is so sparse or contradictory, that "preventive medicine" is as ill conceived as chemotherapy.

[jmpurser]

You make good arguments for what I call "second stage health care reform" where we look at WHAT we pay for. As I see it real comprehensive health care reform in this country will break down into:

FIRST STAGE: Reform access control. That's what the current battle is all about. Even the white house has renamed their "health care reform" to "health insurance reform". This is the fight to get health care TO all Americans and unfortunately we lost it. The battle was over the day President Obama took single payer off the table and replaced it with an undefined but misnamed "public option". With that move he told us all that his only real concern was that nothing should harm insurance company profits. Maybe we can go back and fix this later. Maybe not. But for now the battle is lost.

SECOND STAGE: Reform what we pay for as the above article argues for so well.

THIRD STAGE: Reform how much we pay for health care. This is where we fight it out with big pharma, the AMA, and everyone else about how much this stuff should really cost. I have no idea how big a battle this will be.

[PlaceboStudman]

Dollars to donuts we never get past stage one. We never have before. I highly doubt anyone will have the political will to get to stage 2 let alone stage 3, if history is any indication

[jmpurser]

Agreed. But the language gets so confused if you don't separate the issues I find it helpful to think about the issue in layers.

[Craig Bowron - Huffpost Blogger]

My thoughts on your idea of the First Stage:
I can't speak for everyone working in health care, but the majority of physicians I work with--regardless of their political affiliatio­n--believe that everyone should have a basic level of health care/health insurance. That's because under the current system, no one can be turned away at the emergency room door for any reason. So in essence, every American already has access to health care--it's just delivered at the last minute, and in the most expensive way, and that won't change unless we get up the moral (amoral?) gumption to start showing the sick but uninsured to the ER door. Or until everyone is granted a basic level of health care coverage.
To my view, your second and third stage are one in the same: we need to apply value shopping to health care.

[seawolf77]

Doctors in this country are like marina owners. Everyone of them thinks they are money and they just about all stink. They charge too much, deliver too little, and think they've done you a favor when you only have to come back twice for the same thing.Doctors and lawyers should be put back where they belong in this society and not the exulter place they occupy. Lawyers are basically parasites that arbitrate dispute. On the porn show in CNBC the whores said their clientele is mostly lawyers. I rest my case. Doctors used to be good people, really they were, nut now they are parasites too, looking for the most profit and the least efficacy. And of course they are selling their snake oil to old white Republicans who want to live forever and don;t care how much it costs casue their kids will pay for it. Out of control costs and a refusal to share or dilute their care. Ya think?

[Karl Gilbertson]

I think blanket euphemisms and perpetuation of stereotypes are two of the best ways to halt constructive arguments and introspection.

[caterpol]

"This is what the American public doesn't get, and what's hard for a physician to admit to: the benefits of modern medicine have been oversold."

Okay agreed, some of the well-insured spend a lot of resources on ineffective treatments in this country. But the majority of sick people aren't trained doctors and therefore can't be relied upon to make an educated choice-----that's why they consult/pay an expert.

So who did the overselling? And what motivated this somebody to do it?

I would assume that selling anything is motivated by profit not altruism. And asking a non-medically trained patient to choose the most effective treatment is asking far too much.


It irritates me that you equate sick people with meth addicts whose only complant is the cost of meth. Even if that were true, who's the drug dealer? Where is their responsibility in this scheme?

[Craig Bowron - Huffpost Blogger]

Absolutely. Patients go to their physicians seeking expert advice, but for all the reasons I mentioned in my piece, physicians have many disincentives to do so (time being a MAJOR factor: it's easier to write a prescription for an antibiotic than to explain why it almost certainly won't help, and may hurt). So physicians have done some of the overselling; and direct to consumer advertising has been a major contributor.
I am not calling anyone a meth addict: it's simply a metaphor to describe someone who has grossly misjudged the root of his or her problem.

[MJinCanada]

Very interesting article.

Here's a point to ponder for health care reform: I live in Saskatchewan, which has had universal health care since 1962. Canada has had universal health care since 1965. In no significant way has this hampered medical innovation and research; Toronto's Hospital for Sick Children is right up there among the best hospitals in North America. Last weekend, a friend gleefully reported that her nephew is doing very well after a double lung transplant (he has CF).

But we don't have octomoms or breast enhancement surgery for 14 year olds. Most doctors don't prescribe antibiotics for colds. Many of the new medications developed in the US don't get the green light here until they go through our clinical trials. Because there's less profit to be made, we get a more functional system.

For example, last year my brother went to see his doctor about pain in his hip. After a brief examination, she said, "Take out your wallet." Mystified, he pulled his wallet out of his back pocket. She looked at it critically and told him to take out all the old receipts and unnecessary stuff (it was nearly 2 inches thick) and see if that fixed his hip problem.

[Orwellian]

Canadian physicians do not quite pull in the coin that your doctors do, even though they do far better than many, and most still drive really. nice. cars. This allows medicine to put the focus more on care rather than profit. Those doctors that want those massive profits move to the States. That's not to say that a doctor that wants massive profit can't also be an excellent doctor.

On another note, I played family host to two separate U.S. teenage boys for two different summers in a row, and was informed by both of their parents that each was on a myriad of anti-depressents. After got over my worry over what I had gotten myself into, they both ended up being wonderful, normal and lovely kids. With lots and lots of pills that I don't see here that often. I wondered why. Perhaps it was just coincidence, and they both needed them all. Who am I to argue with a prescribing physician.

[medicontheedge]

we have become a nation who want and expect a "fast food model" of healthcare at ALL levels, especially for the little problems that we really don't need intervention for at all. i work in an emergency department....

fully 60% of the "customers" we see absolutely DO NOT belong in the ED, by any stroke odf the imagination... i am NOT speaking of lay person better safe than sorry.... i mean broken fingernails.... blisters from flipflops, fake abdominal pain to get a "free" pregnancy test...

and the hospitals are NOT going to change this attitude, cause even with writeoffs... we are making a ton of money on this BS... tho, i must say, i DO like getting my fat paycheck....my point is.... it is way quicker, and in the patients eyes, CHEAPER FOR THEM in the short term, to get ALL care in the ED,as opposed to seeing their own doc....

a whole lot of people have NO idea what their haelthcare actually costs... it is time to change that, everyone, regardless of WHO pays for their healthcare, NEED TO SEE THE BILLS....

[freshnotbitter]

Interesting post. doubly interesting because as I read the post and write this comment, the Senate Finance Committee has just shot down the public option.

A properly chartered public option would go a long way to stop the course of ineffective (and expensive) medicine recounted in this post.

A public insurer would not be sued and forced to offer ineffective breast cancer treatments because it would be run by a panel charged with deciding through scientific methods whether a treatment was effective or not and it would have sovereign immunity in courts.

Our elites should think twice about defeating the public option. It doesn't have to be a peril to their Park Avenue treatments.

[Dynamohum]

I greatly appreciate the article you wrote. No one is really including this in the debate on Capitol Hill, the White House, or the American Public. We need to begin a dialogue on these issues yesterday!!

A a 26 year survivor of HIV and a 15 year survivor of AIDS I have to agree that the medicines developed have saved my life. However, those same medicines have given me horrible cholesterol, CAD, liver damage, lipoatroph­y/lipodist­rophy, neuropathy and a broken femur(destroyed bone density from HIV drugs). No one seems to want to discuss these issues, yet so many long term survivors I know have survived the onset of chronic conditions that can be traced to the HIV medication.