Substantive health care reform will only come with a cultural shift that recenters public expectations and puts the science of health care, and health care outcomes, back in charge
Science is what we use to keep from fooling ourselves.
-- Richard Feynman
On occasion a patient arrives in the hospital so sick, in so many ways, that as a physician it's hard to know where to begin. Health care reform feels the same way -- so many things wrong, so complex and interrelated, that delving into it can produce a catatonic sense of helplessness. Detailed media reports begin to sound like Charlie Brown's teacher, an incomprehensible garble that's over our heads.
Where to start? Because the symptoms of our ailing health care system are primarily financial -- health care simply costs too much -- most Americans believe the solution will be financial as well. The three health care reform proposals from the Senate and the House seem to confirm this, with a bevy of financial proposals like "affordability premium credits," "insurance pooling mechanisms," tax penalties for the uninsured; plans for increased efficiency and performance, and decreased abuse and fraud. To physicians like me, all of this sounds like a meth addict who finally admits to having a problem: meth is too expensive. If he could just get his finances in order, his troubles will go away.
The fleecing of America, one co-pay at a time
America, it's time to sober up. We've become addicted to high-cost, high-tech, average health care, and breaking this addiction will solve our financial problems, not vice versa.
Data from the Organisation for Economic Co-operation and Development showed that in 2006, the United States spent $6,567 per capita on health care, edging our nearest competitor, Switzerland, by 52% and putting us 90% higher than many of our global competitors. And what have we gotten for this spending spree? Average health care. No comparisons suggest otherwise. This doesn't mean we don't do some things really well; in fact, America has arguably been the world's leader in health care innovation. It's just that for broad indicators of health, we're shooting par.
How does a country with perhaps the most innovative health care system in the world produce average health care outcomes? It's simple: much of the innovation hasn't delivered. This is what the American public doesn't get, and what's hard for a physician to admit to: the benefits of modern medicine have been oversold. We've assumed that the same science and technology that so dramatically revolutionized human life in the 20th century, taking us from horses to horsepower to nuclear power, would do the same thing for human health.
It's true: we are living longer than ever. Life expectancy in the U.S. nearly doubled in the past century, but the sharpest gains came in the first half of the century, well before any significant medical advances, even before the discovery of antibiotics. In 1900 the average U.S. citizen lived to age 47, and by 1950 the average life expectancy was 67. This unprecedented change came from improvements in nutrition and control of infectious diseases (sanitation being critical) that drastically reduced infant and child mortality. Which makes sense -- if you want to change the health of a rural village in Central America, don't build them a dialysis center and an MRI: dig a latrine and drill a well.
Life expectancy plateaued from 1955 to 1975, and despite an explosion of medical knowledge and technology, thereafter the graph has resumed a softer steady pitch, with subsequent gains being largely due to improved treatment of high blood pressure and diabetes. As we turn the corner on the 21st century, U.S. life expectancy is 77, and the two most common causes of preventable disease are human-derived pandemics of smoking and obesity. Certainly life expectancy is not the sole measure of health, but superimpose the soft rise of the U.S. life expectancy curve with the steeply pitched rise in health care spending and you don't need to be an economist to see that we're not getting a lot of bang for the modern health care buck.
This dichotomy between what America spends on health care and what we get in return is moored to an unshakeable belief in the power of technology to radically change our lives, even our health. The infatuation became so deep that we stopped applying scientific rigor to the health care sciences. We quit asking the tough questions: it may be fascinating technology and great science, but is it great medicine? Every new medical device, new pill, new therapy must be better than the last one, and the steep price tag proves it. Sounds ridiculous? One need only look as far as the financial crisis, where our infatuation with the power of unfettered markets kept us from asking the honest questions: are derivatives "real" or are they just funny money?
Bone marrow transplants for breast cancer: Health, American Style
The use of autologous bone marrow transplants (ABMT) in the 1990s for treatment of advanced breast cancer exemplifies the many factors that make Health, American Style so expensive but also inept. The story begins in 1990, when a study showed that for women with cancer extending into a number of lymph nodes, treatment with ABMT offered a 40% improvement in three-year survival rates compared to standard chemotherapy. The study was hobbled by methodological issues that seriously weakened or even nullified the results, and insurers refused to pay for it. But for physicians and patients dealing with the terrible predicament of advanced breast cancer, ABMT -- despite its significant toxicities, infection risks, and published mortality rates of zero to seven percent -- appeared to be a promising treatment. Individual women sued their insurers to get one, and for reasons that were more often legal than scientific -- so called "judge-made insurance" -- many of them won. Under intensive lobbying pressure and seeing a legal precedent forming, some states enacted laws mandating insurers pay for ABMTs. Rather than bear the legal expenses, in time insurers began paying for ABMTs, but only if patients agreed to enter a randomized control trial.
Eventually ABMTs became unconditionally covered, "standard therapy" if you will, despite further evidence that the initial study was deeply flawed, and that the improved response with ABMT seemed to last only a few months and came at a cost of serious side effects. High quality randomized control studies initiated to answer this critical question were hampered by very low enrollment: women (and many oncologists) were so enamored by (and hopeful for) ABMT that they refused to take the risk of entering a trial and ending up in the standard therapy arm. In the end, only one in ten patients who had an ABMT in the 1990s did so within a clinical trial, perpetuating our ignorance of whether the treatment was a sham or a ray of hope. So it wasn't until the year 2000 that there were enough good studies to conclude that the treatment was ineffective.
This is the story of ABMT for breast cancer, and also American health care: faddish, technology-avid, heavily lobbied and political; ruled by an innate feeling that the more complex the care, the better it must be. With the best of intentions, over a ten-year period we spent an estimated $3.4 billion on a treatment that didn't work. Embracing hope, to borrow from the Obama campaign, we turned a blind eye to science, and the forty-one thousand women who were treated with an ABMT suffered for that delusion. As an internist, I helped take care of some of these women: they suffered.
Vioxx, leaf blowers, and the allure of liqui-gel
Remember Vioxx, the new arthritis medication developed by Merck and first brought to market in 1999? Because it had a reduced risk of stomach ulcers compared to other arthritis medications, it looked to be a good drug for patients with chronic arthritis pain, those with rheumatoid arthritis for example. No one, including Merck, directly claimed that Vioxx worked better than standard pain medications like ibuprofen or acetaminophen, but a media blitz depicted a revived Dorothy Hamill triple-lutzing across the TV screen, and Americans clamored for Vioxx to the tune of over $2 billion dollars a year. When the drug was pulled in the fall of 2004 because of an increased risk of stroke or heart attack, the tab was over $10 billion.
The flip side of the belief that complex, high-cost care guarantees superior health care is that simple, inexpensive measures must be "cheap" and ineffective. Not so. Take heart disease for example. A recent paper in the New England Journal of Medicine attributed only seven percent of the decline in deaths from coronary artery disease since 1980 to angioplasty and bypass surgery combined. For a techno-fascinated country, it doesn't necessarily make sense that controlling risk factors and taking a few pills could work as well as a complicated, definitive-sounding "Roto-Rooter" procedure like angioplasty, or open heart surgery for that matter.
Metaphorically speaking, we're a country that will pick a leaf blower over a rake any time. Even though a rake lasts indefinitely, always starts, carries no electric or gas bill, provides exercise to the user, and dethatches as it goes. We're a people that believe Advil and Motrin work better than generic ibuprofen, even though it's the exact same drug at one-third the price. Oh, the power of a candy-coated shell, the allure of liqui-gel!
Why water the flowers AND the weeds? Putting science back in charge of a consumer-driven health care system
If American health care is over-hyped, and over-valued, then health care reform that simply pays less for everything is doomed to failure. Legislation that waters both the flowers and the weeds less may allow you to save water, but it makes you a lousy gardener.
To that end, there are some hopeful signs in the current Congressional health care proposals, and also in the American Recovery and Reinvestment Act (ARRA) passed in February of this year. All of these include funding to evaluate the effectiveness and appropriateness of individual health care services and procedures. As encouraging as it is to see that perhaps we're finally ready to apply scientific scrutiny to the science of health care -- so-called "evidence-based medicine" -- it remains unclear how we will implement this newfound knowledge.
Although the ARRA established a council of clinical experts to compare the effectiveness of various treatments, the council won't be able to establish clinical guidelines or to "mandate coverage, reimbursement, or other policies for any public or private payer." An information sheet on the House plan reads, "Under this proposal, doctors, nurses, and patients will make medical decisions, not big insurance companies or the government." But wait a minute! This is how we got into this mess in the first place. We live in a consumer culture, where the customer is king. This is the health care system we've demanded and allowed: glitzy and impatient; created to fight disease, yes, but also to soothe our insecurities about our own health and mortality. When it comes to health care, Americans want everything, the works: an antibiotic "just in case" the bronchitis isn't from a virus; an MRI of the back, not because the clinical scenario is worrisome, but because we've been reading about spinal cord tumors on the Internet.
If we can't have everything, because the science shows that "everything" (like bone marrow transplants for breast cancer) offers no benefit but some risk, or because the new pill (Vioxx for example) offers marginally more benefit for summarily more cost, is this "rationing" health care? People shudder at the term, but we all make daily decisions based on what we can and cannot afford. As we've now proven, any limited supply must be either rationed, or exhausted.
When the white coat becomes a straitjacket: physicians prove incapable of reigning in health care costs
So who is it that's going to say "no"? Physicians haven't been able to for a variety of reasons. As human beings and as businesspeople, we want our patients to like us. We want them to be relieved, comforted, satisfied. Acting aggressively gives us a proactive, competent air, and it validates the patient's symptoms, in the same way that not ordering an X-ray can seem to trivialize the patient's problem. Rather than being relieved that it wasn't pneumonia, a patient may leave the office grumbling, "They didn't even do an X-ray." Giving patients what they want -- meeting their expectations, efficacy and costs be damned -- keeps them happy, if not healthy; and happy patients don't sue.
Yes, some physicians practice the unproven for profit, gaming a system which stupidly pays more for doing more, regardless of the efficacy of "more". But most physicians dabble in the gray zones of medicine because doing something avoids having to discuss the sobering details of the latest medical research ("Here's why you don't need this test"), the likes of which contribute to a sense of professional ineptness. A published review of the most recent science on diabetes reads with colloquial frankness, "Enough already! Randomized trials show that tight glucose control in patients with long-standing type 2 diabetes isn't beneficial." The headline asks physician readers, "How Much Evidence Do We Need to Change Practices in Which We Firmly Believe?"
If physicians and patients are incapable of following evidence-based, rational, clinical guidelines, then the only thing that will put a stop to our health care spending spree is for the entity who is paying for it -- be it private or government insurance -- to stop paying for it. For competitive or legal reasons (both in the case of bone marrow transplants for breast cancer), private insurers have had difficulty saying "no" to unproven therapies. And for as long as affordable health care is seen as cheap health care, no one will sign up for what they perceive to be a "Penicillin&Gauze" insurance option. I'm no fan of big government, but perhaps a government insurance option based on the best available medical research, where hard science dictates the behavior of bureaucracy rather than the other way around, would create a new, more realistic playing field.
Purging unhealthy health expectations
While it's uncertain what, if any, kind of health care reform legislation will be passed, Congress cannot mandate what our country may need most: a cultural shift in the expectations of what modern medicine can and cannot do for us. This may be no easy task. Look at us: we're a nation that's outlawed Lawn Jarts, but not cigarettes; a country that's gone cuckoo for Cocoa Puffs and diet pills but not for healthy food; a drive-up-window-society simultaneously hooked on physical convenience and fitness centers.
We all want a health care system that will continue to innovate and evolve. When I was in training in the early 1990s, patients infected with HIV came into the hospital with a high fever and no blood pressure and died in a hurry. HIV medications changed all that, a miracle in our time. We need to keep chasing down miracles, but we won't build a futuristic health care system by bankrupting the current one. We'll get there by paying for proof, by developing a keen eye for treatments that are both great science and great medicine, and by admitting to our anxiety-ridden souls that life will forever have limits and uncertainty.