Without major change, the American health care system
is unsustainable. The high cost of American medicine saps
our economy and, compared to every other developed country,
makes us less economically competitive. The facts are
well-known, but deserve repeating. American health care
consumes 17% of our GNP, 50% higher than any other country
in the world. We spend more than twice as much per capita on
health care as the citizens of any other developed country.
And in spite of what we would like to believe, American
medical care is not the best in the world. The World
Health Organization, using objective parameters of medical
quality including life expectancy and infant mortality,
recently rated American health care as 37th in the world.
For people with serious medical problems, like heart disease
and cancer, the situation is no better. A measurement of
health care termed Death Before Age 75 That Can Be Prevented
With Medical Treatment, evaluated 13 developed countries.
The US ranked only 12th.
The health reform proposal presently being discussed
in Congress, HR 3200, only touches on these facts. Its
major focus, instead, is on guaranteeing portability of
insurance coverage for people who are changing jobs,
eliminating exclusions from insurance coverage because of
preexisting problems, and expanding existing Medicaid and
Medicare programs. An important provision of the bill would
require all Americans to have insurance coverage and to
provide a public option towards that end. In spite of
attempts at cutting health care overhead, these proposed
measures will inevitably result in added overall expense to
our already financially strapped system.
Of course, little in the proposed bill has anything
to do with controlling the real reasons that our health care
system is so expensive or with improving the quality.
Suppose, instead of our being primarily concerned with
paying for our overpriced, underperforming health care
system, we focus on why our health care system is the way it
is. If we were to correct the causes of our cost-quality
disconnect, maybe, just maybe, we could actually create a
high quality, affordable system. And the logical place to
start is in government financed areas like Medicaid,
Medicare, and the yet-to-be-defined public option.
We as a society want to believe that all medical
decisions by doctors are made with the patient's best
interests at heart. Certainly, what is the best care
possible is the major determinant of any medical decision.
At times, though, less noble factors also play a role in
determining what tests are ordered, what procedures are
recommended, and what medications are prescribed. For
America, medicine is big business. Doctors, hospitals,
medical device manufacturers, and pharmaceutical companies
are bottom line driven and have strong economic motives to
provide excessive treatments that often provide little or no
benefit. Consumer demand also plays a role. Patients have
expectations from their doctors often not based on sound
science. Doctors frequently acquiesce to patients'
demands even when the medical care is more expensive, even
when the care is not better, and sometimes even when the
care is worse. Avoiding possible malpractice suit also
influences medical treatments, increasing health costs without
providing any clinical benefit.
If we could eliminate those factors in
medical decisions that have nothing to do with quality, we
might be able both to improve quality and cut costs. This
could be accomplished by basing payment for tests,
procedures, and medications on scientific evidence of
effectiveness. Treatments for which there was little
likelihood of effectiveness would not be paid for. What
exactly constitutes sound evidence would need to be
determined and reviewed in a timely objective fashion, and
preferably outside of direct political influence. Such
measures, already adopted in other countries with better
health care systems than the U.S., are included in cost
effective research (CER) contained in HR 3200. Some might
argue that CER will introduce rationing. But we physicians
ration care daily based on the patient's type of
insurance, on our office's ability to obtain
preauthorization from insurers, on patient's demands,
and on the patient's willingness to pay for uncovered costs.
Ultimately, all insurance reimbursement should be
linked to accountability if we ever want to control costs
and improve quality. But it can and should start with
government financed programs. Medicare and Medicaid, which
face enormous shortfalls, and the public option proposed in
HR 3200 should have reimbursement linked to CER. Requiring
medical reimbursements for treatments and procedures to be
based on scientific accountability, even with its
imperfections, would constitute a major step to improve
quality and control costs. It is time to start.
Dr Dennis Gottfried is a practicing physician in
Torrington, Connecticut, professor of medicine at UCONN
Medical School, and author of Too Much Medicine, published
by Paragon House, April, 2009.