Read this book.
If you are in the American healthcare system, this is the single most important book you will ever read. If you are in a healthcare system that is moving towards "privatization" or "free market reform", this may be the most important book you will ever read. If you are a behavioral scientist interested in the role of behavioral factors in medical populations, this is the most important book you will ever read.
A science journalist with a real science background (an M.S. in Biology) and now a Fellow at the New America Foundation, Brownlee has brought together many strands of research to provide us with a picture of the core dilemma in the american health care system - why do we spend so much more than other industrialized countries while not producing better outcomes? At 16% of Gross Domestic Product (and climbing), the American healthcare system is 60-100% more expensive than any other industrialized country and yet we do not live as long as citizens there. Where all these countries cover 100% of their citizens, the American system leaves about 15% of its population (about 47 million people) uncovered at any one time (and even more if you include loss of coverage for extended periods, but not a whole year). Fifty percent of bankruptcies in the U.S. are due to medical bills. Americans avoid switching jobs for fear of losing coverage for pre-existing conditions. The U.S. manages to achieve these colossal failures while still expending 62% of all costs through the government (if civilian government employee's coverage is included as part of the government supported costs).
While there are many contributing problems (profiteering by insurance and drug companies, a system which rewards physicians for doing more rather than just what is proven effective, malpractice anxiety leading to defensive practice, lack of coverage for primary preventive and mental health care which could avoid more expensive emergency care, etc.), Brownlee demonstrates that the core issue is a lack of clinical research to guide physician's decision-making. Where ambiguity exists (and it exists in up to 80% of healthcare), variability in "standard" care is great, and unnecessary care and expense mounts. As a comic strip character once observed: "We have met the enemy, and he is us."
Starting with the studies by John Wennberg and the Dartmouth Center for Evaluative Clinical Sciences, Brownlee reviews the high level of variability (up to seven fold) in the use of various procedures across the U.S. Wennberg's observation is that in U.S. healthcare, "geography is destiny". The kind of treatment you receive depends upon where you live, not what your illness is. And the characteristic most strongly associated with unnecessary care is the number of specialists. If we build it, they will come. The normal operation of a free market is distorted in healthcare by: socialization of costs; the desperation of patients and families; the vast difference between "buyers" (patients) and "sellers" (practitioners, hospitals, drug companies) in understanding what actually works and the tradeoffs in outcomes; and the placebo effect and spontaneous remission. But isn't it part of our duty to protect patients from unproven, and potentially harmful, interventions? If outcomes were improved in the more aggressive geographic areas of the country we might be able to claim that the less costly areas are undertreated, but they are not. In fact, in most comparisons, patients are, if anything, worse off with the more aggressive care. Remember that Hippocratic dictum: "Primum, non nocere" (First, do not harm)? The propensity of U.S. healthcare is to "do something" rather than accepting the patient's status as perhaps better than the potential harm occasioned by aggressive intervention. For those of us raised in the era of "If it might help, do it", this is tough medicine to swallow. But it is necessary medicine.
Brownlee acquaints the reader with many of the more egregious failures of the system: back surgery for chronic low back pain; mastectomy (vs lumpectomy) in breast cancer; bone marrow transplantation in breast cancer; PTCA for event, or even chest pain, reduction in coronary heart disease; fen-phen for weight loss; carotid
endarterectomy in asymptomatic patients; surgery for prostate cancer, etc.
One implication of all this is that the highest priority for medical research should be clinical trials that clarify the effectiveness, safety and efficiency of various treatments. The hostility of the NIH to this task is captured by a quote from its director: "We don't do Coke versus Pepsi". Fine. If the NIH is uninterested in improving American healthcare (it's congressionally mandated mission), defund the NIH and put the money into the Agency for Healthcare Policy and Research - the folks who blew the whistle on back pain surgery and were subsequently assaulted by the Orthopods bribing Congress. The priorities for public funding should exactly answer us about "Coke versus Pepsi", because that's where lives are won or lost. Cellular, subcellular and genetic research has such a low rate of clinical payoff that it ought to be the minor theme.
