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The problems with the American healthcare system are brilliantly laid out in this new book. But overtreatment isn’t the whole story, and fixing the system is another matter, says Douglas Kamerow
Yet another book about the healthcare “system” everyone loves to hate? Yes, indeed, but this is a good one. Journalist Shannon Brownlee systematically documents the problems of health care in America, deftly mixing statistics with telling anecdotes and quotations. Along the way she also profiles healthcare heroes and villains at greater length.
If you ask doctors why health care costs so much in the United States, we’ll tell you that it is the for-profit medical system and litigious lawyers that are the problem. Drugs cost too much because of the rapacious drug companies. Administrative costs are too high and are multiplied by the vast number of health plans and insurance companies. And because we’re worried about lawsuits, we practise defensive medicine and order too many tests so we don’t miss anything.
Brownlee enumerates and rejects most of these explanations. She uses overtreatment as her organising principle and the ultimate cause of all the problems with US health care. She spends a good deal of the book explaining what drives unnecessary care in the US, starting with John Wennberg’s variation studies. His brilliant insight about and documentation of the shocking variability of care and costs within small areas and across the country immediately raised the question of whether some areas were getting too much medicine or whether others were getting too little. Almost always, it seems, it’s the first.
This leads to a discussion of the assessment of appropriate care and the dirty little secret that “stunningly little of what physicians do has ever been examined scientifically.” Brownlee ticks off a list of surgical procedures, screening tests, and medical treatments that have been widely accepted only then to be proved useless or harmful once studied: radical hysterectomy, frontal lobotomy, x ray screening for lung cancer, proton pump inhibitors for ulcers, hormone replacement therapy for menopause, and more. She goes into great detail to tell the sad, expensive story of high dose chemotherapy with bone marrow transplantation for advanced breast cancer. Many of our treatments are still based more on sound reasoning than sound evidence—and on hope rather than knowledge.
Although the rise of evidence based medicine has helped reduce overtreatment a little, the US legal system still punishes doctors for not doing “enough” (meaning everything possible), despite evidence based guidance to the contrary. As one of the few countries in the world that permits advertising of drugs directly to consumers, the US has to contend with the resulting obsession among patients with new and ever more expensive drugs, often with questionable benefits. Furthermore, the lack of electronic medical records and coordinated care leads to medical errors, misprescribing, and more overtreatment.
In a system dominated by subspecialists, each with a range of expensive tests and procedures to order or perform, it is no wonder that an estimated 20% to 30% of the resulting tests are needless. The law of supply and demand doesn’t, of course, apply to medicine; in fact, supply drives demand. The presence of more hammers only makes more things look like nails. Waste, inefficiency, millions spent on marketing and administration—it’s all here and well documented. America has a perfect storm of circumstances, all of which lead us to ever more utilisation without a commensurate improvement in outcomes.
Overtreatment isn’t the whole story, though. There are also plenty of incentives for insurance companies to deny care that may be needed so as to maximise profit. Michael Moore’s recent film Sicko (BMJ 2007;335:47 doi: 10.1136/bmj.39262.638588.59) features a number of people with insurance who are denied appropriate care and a man whose job it was to deny them that care. Certainly the millions of uninsured people in America aren’t being overtreated; their problem is getting routine treatment of any sort. So I would quibble with Brownlee’s title but not with the substance of her book.
The big question, of course, is what to do about all this—a much more difficult problem than documenting it. Brownlee makes sensible recommendations. Praising the recently reformed Veterans Health Administration, she proposes that it take over the hospitals that can’t or won’t fix themselves. She advocates better coordination and accountability, universal electronic medical records, and more widespread use of evidence based medical care.
More evidence is needed about what works and what doesn’t, and that requires the type of research that the National Institutes of Health doesn’t usually fund. Brownlee tells the story of how a small US government agency was almost put out of business in the 1990s because its evidence based guidelines upset powerful enemies in the healthcare industry. She suggests that the Agency for Healthcare Research and Quality be given more funding and a mandate to develop and disseminate comparative information about drugs, procedures, and treatments.
These are all very good ideas. The beginnings of a blueprint for change are undoubtedly in this book, but it is very difficult indeed to imagine where the political will and funding will come from to effect the massive reforms that are needed.
Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer
Bloomsbury, £12.65/$25.95, pp 352
ISBN 978 1 58234 580 2
Competing interests: DK worked at the Agency for Healthcare Research and Quality from 1994 to 2001.