Health Care Myths and Realities

The Journal of the American Medical Association has an interesting opinion piece from which Mr. B. has extracted the following:

What Cannot Be Said on Television About Health Care

Ezekiel J. Emanuel, MD, PhD

JAMA. 2007;297:2131-2133.

There are 3 phrases that should and can no longer be said about the US health care system without qualification, embarrassment, criticism, or even denunciation: "The United States has the best health care system in the world," "Health care is special," and "New is better."

"Best Health Care System in the World"

The United States has the most expensive system, by far. In 2005 health care cost more than $6000 per person or in excess of 16% of the gross domestic product (GDP). The nearest rival, Switzerland, spends $4077 per person per year, or 11.5% of its GDP (in purchasing power parity). Norway spends $3966 (9.7% of GDP); Germany, $3043 (10.6% of GDP); and South Korea, a mere $1149 (8.2% of GDP). However, Americans are increasingly aware that all of this money is not buying very much. Life expectancy in the United States is 78 years, ranking 45th in the world, well behind Switzerland, Norway, Germany, and even Greece, Bosnia, and Jordan. The US infant mortality rate is 6.37 per 1000 live births, higher than almost all other developed countries, as well as Cuba. Even for white individuals, the numbers are not world class—5.7 infant deaths per 1000 live births—more than double the rate in Singapore, Sweden, and Japan. Even at the individual hospital level, Americans are realizing the care they receive is not of the highest quality. The idea put forth in the Institute of Medicine report To Err Is Human that 100 000 Americans die each year from medication errors in the hospital has taken hold in the public consciousness as emblematic of the problems with the quality of health care.

Within the last few years, the tipping point has been passed. Something has radically changed when the New Yorker claims the system is a mess and when UnitedHealthcare, a corporate pillar of the status quo, opens an advertisement in the Wall Street Journal by boldly stating that:

The health system isn't healthy. There's no denying it. A system that was designed to make you feel better often just makes things worse.

The US health care system is considered a dysfunctional mess. Conventional wisdom has been turned on its head. If a politician declares that the United States has the best health care system in the world today, he or she looks clueless rather than patriotic or authoritative.

"Health Care Is Special"

To many, the specialness of health care meant that cost should not be a consideration in care. Ethical physicians could and should not consider money in deciding what they should do for sick patients. Patients were to receive whatever services they needed, regardless of its cost. Reasoning based on cost has been strenuously resisted; it violated the Hippocratic Oath, was associated with rationing, and derided as putting a price on life, akin to the economist who knew the price of everything but the value of nothing. Indeed, many physicians were willing to lie to get patients what they needed from insurance companies that were trying to hold costs down.

Today, saying that health care is so special that its cost is irrelevant serves to discredit the source. A New York Times reporter learned this lesson the hard way when he praised a study that claimed by "virtually any commonly cited value of a year of life, we found that if medical care accounts for about half the [6.97 year] gain in life expectancy [since 1960] then the increased spending has, on average, been worth it." In response, the reporter "received about 500 e-mail responses from readers, and the most common reaction was a version of a simple question: ‘Why do Americans spend so much more than folks in most other developed countries while getting worse results?’"

"New Is Better"

Americans are enamored with technology, especially health technology. The US Food and Drug Administration has been urged to use surrogate markers to approve drugs and medical devices faster so they can help sick patients. Not only is the United States an early adopter of new health care technologies, many physicians are early "proliferators" of technological innovations.

Increasingly, Americans are beginning to be skeptical about whether new health care technologies are better. The tipping point probably came with the withdrawal of rofecoxib from the US market. Today, the list of drugs and technologies for which new might not be better (and may be even worse) has expanded rapidly: postmenopausal hormone therapy, bare-metal stents, megadose antioxidants, selective serotonin reuptake inhibitors for adolescents, Swan-Ganz catheters, gabapentin for bipolar disorder, erythropoietin for anemia, and the list goes on.

[Addendum, 4:50 pm: To which list can today be added Avandia, which was hoped to be a breakthrough medication for treating type II diabetes.]

The change in language suggests Americans now recognize that the system has deep structural problems. While this recognition is no guarantee of change, it does constitute a critical precondition for comprehensive reform of the system. Reform cannot occur without acknowledging that there is a problem. The next step is for the public to see a solution that they think offers a realistic chance of making the system better.

Now here is language that one would not see in JAMA back in the good old days of rants about the evils of socialized medicine...

Mr. B.