"Doctors are not the problem," said Michael Moore while publicizing Sicko. But some doctors are part of "the problem." Their behavior is threatening the entire $2 trillion health economy, which in turn threatens to become 20% of our entire GDP. Their actions have affected our health and have altered the way we spend tens of billions - or hundreds of billions - of medical dollars.
When most Americans talk about health reform, they're talking about reforming the way we pay for health care. That's critical, and Michael Moore and others have succeeded in making this a high-visibility issue. But health financing reform can't succeed unless there is also an effort to create health care reform- with our country's physicians leading the way.
Attacking drug companies for their greed has become almost commonplace in the last few years. But the problem created by drug company money runs wider and deeper than just pharmaceutical costs, as staggering as those are. An interlocking web of drug manufacturers, physicians, and universities is altering all of our medical care - and everyone's personal health - by influencing the clinical research that often determines how doctors treat patients.
Dr. Marcia Angell, a former editor of The New England Journal of Medicine, wrote this in a recent must-read piece for the New York Review of Books:
"It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine."
That is a stunning statement. It was made in the context of reviewing several books about pharmaceutical companies' influence on clinical drug trials. The United States spends nearly a quarter of a trillion dollars each year on pharmaceuticals. Even more importantly, these trials and the resulting guidelines influence the entire course of care for a number of major and minor health conditions. If the process is corrupt and untrustworthy, the financial and public health implications can't be overstated.
Some of her fellow physicians will say that Dr. Angell's statement was extreme, even intemperate. But her piece presents compelling information, and events of the past year have taught us that we ignore dire warnings at our own peril.
Clinical trials are not the only area where physician behavior can be a reason for concern. According to the Dartmouth Atlas of Health Care and other health studies, there are wide variations in the kind of treatment given to similar patients. Some doctors perform a lot more surgeries, tests, and other expensive procedures than others, without any measurable improvement in results. Much of the problem lies in our reimbursement system, which pays more to providers who deliver costly services more frequently. The result is patterns of overtreatment that vary by region and by doctor.
Recent proposals to extend Medicare at affordable rates to people under 65 could be a great step forward in health reform. But even more modest proposals are threatened by the cascading increases in health care costs. When these costs grow 150% faster than the Consumer Price Index - and that's considered a good year! - that's confirmation that there is a systemic problem.
What are the implications for health reform? First, the economic survival of even our current patchwork system depends on new initiatives to determine when treatments are necessary and when they are not. Patients don't benefit from receiving unnecessary procedures. They are more likely to experience inconvenience, iatrogenesis (doctor-caused illness), discomfort, and prolonged symptoms. Second, the financial relationships between drug companies and prominent physicians need to end, as Dr. Angell wisely suggests.
Our country's doctors are to be respected, but a minority of them is bankrupting the system for personal ends. While their numbers may be relatively small, the cost of their actions is high. Meanwhile, many of the "good" doctors are providing care using questionable guidelines developed under the influence of the drug companies.
The true cynics of medicine, the "Bernie Madoffs with an MD," are few - but they're highly influential. They're the ones who tout unproven medications for personal gain. Then there are the overtreaters. They're more like mortgage bankers - the ones who had incentives to write more loans rather than good loans.
We don't need a war on doctors, and nobody's suggesting one. Doctors labor every day on healthcare's front line. And only doctors will be able to develop a consensus on appropriate vs. excessive treatment. But we need to help the majority of doctors redesign the way they "do business." That includes changing incentives so that a small minority of physicians don't benefit from doing the wrong thing.
We need health reform urgently - but we can't build lasting change until we fix the systemic problems that have given rise to our nation's "Dr. Madoffs" and "Dr. Countrywides."
RJ Eskow blogs when he can at: