Diagnosing and Curing Our Sick Health System

You couldn’t invent a worse health care system than the nightmare we have created in the US. Our medical costs are almost twice as expensive per person as in most other similar countries, but produce only mediocre outcomes.

There is massive over-treatment of people who don’t need it, while many who desperately do have no coverage at all.

The payment incentives for doctors are perversely misaligned to produce the wrong mix of practitioners and an excessively technical, procedure-driven form of practice. 

Primary care doctors are terribly underpaid; rare and overworked; and have far too little time to know their patients well enough to prevent over-treatment. In the rush to get the patient out of the office, it is always easier to prescribe an unnecessary pill or test than to explain just why it is unnecessary.

In contrast, there are far too many specialists who are overpaid, especially when they order unnecessary tests and do unnecessary treatments reimbursed at unnecessarily high rates. And medical students leave school with such enormous loads of debt that choice of specialty is mostly determined not by preference or societal need, but by which kind of practice is most lucrative-ie, does the most unnecessary and overpriced tests and treatments. If this sounds crazy, it is because it is crazy.

Patients often find themselves receiving a multiplicity of tests and treatments delivered in uncoordinated fashion by a multiplicity of different specialists who have little or no contact with one another. Everyone is treating lab values or scan findings, with no one knowing the patient well enough to judge whether the often weird conglomeration of atomistic interventions will do more harm than good.

I recently saw a great cartoon. A patient is surrounded by doctors, all turned away from him viewing their respective computer screens. The caption: patient-centered medicine.

No wonder, then, that medical mistakes have become the third leading cause of death in the US. I recently described how you need to take a doctor with you to a doctor’s visit if you are to protect yourself from the almost ubiquitous tendency toward medical mistakes.

And we spend far too little on the most important things outside direct medical treatment that in fact account for 80% of how healthy we are- eg, exercise, diet, reduced smoking, removing poverty, improving education. The best example-the costly war on cancer has done much less to improve our health than the cheap war on tobacco. We should be spending lots more on public health and social programs to promote exercise, reduce obesity, and correct income inequality and lots less on harmful medical over-treatment.

Almost everyone without a financial stake looking at the US system comes to the same diagnosis that it is crazy, dangerous, and unsustainable. But the built in structural irrationalities are nonetheless sustained by the combined financial and political might of the mighty medical/industrial complex-the hospitals, the doctors, Big Pharma, device makers, insurance companies, and the politicians, lobbyists, and government bureaucrats who serve them.

The original Obama reform proposals were shot down precisely because they threatened to create a rational, fair, more effective, much cheaper system-all at the expense of the entrenched and greedy special interests. Even the watered down bill is under constant attack and threatened both by the new Congress and the Supreme Court.

The only hope is that we work to design a rational system more designed to help patients than to protect profits.

The first step is already being taken. The ‘Choosing Wisely’ initiative is a laudable effort by more than 50 medical and surgical specialties in 15 countries to identify and publicize areas of practice that are excessive and worthy of reconsideration.

We should correct the ridiculous imbalances in physician payments so that more doctors are attracted to primary care and fewer specialists are incentivised to order so many unnecessary tests and treatments. Capitation is more efficient than fee-for-service.

Practice guidelines should not be written by groups that have a financial and intellectual vested interest that will have them benefit or lose from the recommendations. For example, urologists are needed to help develop guidelines on prostate cancer, but should not call the final shots because they will gain or lose depending on the decisions made.

Accumulating evidence suggests we need to tighten disease definitions across all of medicine and surgery. Diagnoses are now routinely made too loosely because of an odd combination of medical good intentions, excessive technical prowess, and the profit motive.

Pharma and device makers must be tamed by restricting their political clout; their massive, misleading, marketing; and their monopolistic price gouging.

Insurance coverage must be simplified and made more competitive and transparent-as would have been done were there a public option.

Doctors must be given sufficient time to know their patients and help them participate in medical decision making. This is much more costly per visit, but much, much less costly over the lifetime of the patient.

Hospital and doctor pricing should be as transparent and competitive as is the case with any other commodity-up front and on the Internet. 

We should close loopholes that allow some supposedly “non-profit” hospital systems to earn hundreds of millions of dollars a year in real but untaxed profits used to pay their executives multimillion dollar annual salaries.

We need to develop a rational approach toward end of life decisions that now often torture patients unnecessarily, eliminate the dignity of death, and cost a fortune.

The press must continue raking up the muck on the the costs and harms inherent in the current mess and identifying who is benefiting from it.

Many tens of billions of dollars are spent every year by the medical industrial complex to perpetuate bad and expensive medicine. Our politicians are already bought and paid for. The smart money is on Goliath.

The only hope arises from an outraged public and informed patients. Right sometimes does make might and David sometimes wins. Ask Big Tobacco.