Improving Our Tangled Healthcare Mess
THE WHITE House and its congressional allies tout strong medicine for America’s ailing healthcare system: We must cover everyone, emphasize prevention, and tame physician greed and the resulting unnecessary care. This drastic action, through a massive expansion of Washington’s role, will rein in costs. The situation is so dire, the president has explained, that we can’t wait another year.
In a slim 1952 book, “The Cost of Health,” Dr. Ffrangcon Roberts tracked British hospital expenditures from 1900 to 1950, noting their exponential growth. Roberts, a radiologist, explained the phenomenon as follows: “Medicine, having harnessed itself to science, has acquired the property of perpetual expansion with accelerating velocity; it feeds upon itself and is in turn fed by professional ambitions and trade interests; this process is further accentuated by its own success in that it promotes the prolongation of life in a state of medicated survival rather than cure.”
Of course, the British spending figures of Dr. Roberts’s analysis are a mere blip compared with American health costs today, which account for one-sixth of our national economy (more money, in fact, than the entire annual economic output of China). His prediction of “perpetual expansion“ was accurate. He also noted how the justifications for the British National Health Service - universal access to medical care with an emphasis on prevention in order to save money — were completely wrong.
Roberts recognized only two ways to address rising expenditures: by rationing care or by keeping national productivity high enough to sustain them.
Currently, the vogue is to invert the containment approach: rather than expecting prosperity to sustain healthcare expenses, we apparently need rationing to sustain prosperity. Policy makers, however, deny wanting to ration; they just want to help us find Goldilocks’s “just right” amount of healthcare. This ideal will emerge from so-called comparative effectiveness research.
As physicians, we’re all for guiding clinical decisions with better information. A new drug isn’t necessarily a better one; the latest scanner doesn’t always outperform a less cutting-edge diagnostic tool. But comparative analysis is often limited: much variation in care can’t be readily explained; new tests and therapies emerge rapidly, and research questions are often obsolete by the time the studies are complete; studies can be narrow in their focus. In one paper, a clinician found that 86 percent of his patients with depression wouldn’t be eligible for an antidepressant study because of exclusion criteria.
If “broken” means imperfect, the American health system is broken and will always be. The death rate remains one per person, and end-of-life illness — one of the main drivers of costs — is never pleasant. Yet medicine is incomparably better for patients today than when the two of us entered medicine, not because of improved reimbursement schemes or altruism, but because of professional ambitions and trade interests harnessed to science that delivered the ever-improved tools — drugs, devices, and imaging — we use in practice.
Does that doom us, as Roberts predicted, to either rationed care or ever-rising costs? Not necessarily. There is a third way: We need to reform American healthcare as we have the other five-sixths of the economy, by emphasizing choice and competition. Today, the system is a jumbled mess of government interventions: tax preferences for employee-based insurance that cost the treasury one-quarter of a trillion dollars a year; payment intermediaries and government-set reimbursements; regulations governing everything from physician ownership of hospitals to requirements in some states that second opinions about surgery be covered by the most basic insurance. The result is a lack of price transparency, limited choices, and a dearth of competition. Rather than attempting to cure this disease with more of the same, Congress should empower citizens to manage their own healthcare.
As in Roberts’s time, our politicians weigh different action. But if we want the best doctors to attend to us, we might well ask armchair academics and politicians to stop impugning their integrity and tying up their hands.