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Most Americans, I submit, believe that our medical system is not only the world’s most expensive but also the world’s best. When we have a problem we want the latest and best test, medicine, and procedure. Would it surprise you to learn that the latest and most expensive test, medicine or procedure is often not the best?
In an online post, science writer Sharon Begley, who has written for the Wall Street Journal and Newsweek, provides strong evidence for just that. She says,
It isn’t just an individual study here and there that’s flawed. Instead, the very framework of medical investigation may be off-kilter, leading time and again to findings that are at best unproved and at worst dangerously wrong. The result is a system that leads patients and physicians astray—spurring often costly regimens that won’t help and may even harm you.
Biased medical information is likely a major driver of excessive costs. Anyone following my blog posts and those of my online correspondents for the last year will know that the national debt and the national budget deficit are dominated by medical costs. Debt is at a crisis stage, and most of us have agreed that healthcare entitlement reform is crucial to a solution.
I had concluded that reform of the present system, the Obama administration’s Affordable Care Act not withstanding, is impractical and that the only viable solution was a single-payer socialized, government-controlled medical system. Now however I read in the July 2011 edition of Scientific American magazine another article by Begley that offers some hope of reforming costs under the present system. She provides as an example “the largest and most important investigation of treatments for high blood pressure ever conducted, with a monumental price tag to match.” Called ALLHAT, the study of over 42,000 patients concluded that,
If patients were prescribed diuretics for hypertension rather than the more expensive medications, the nation would save $3.1 Billion every decade in prescription drug cost alone — and hundreds of millions of dollars more by avoiding stroke treatment, coronary artery bypass surgery, and other consequences of high blood pressure.
Although it is very expensive to do a study like ALLHAT, it has now been discovered, Begley says, that a careful analysis of electronic medical records, of which there is now a very good data base of millions of patients, can accurately substitute for expensive long-term comparative studies in determining the efficacy of drugs and procedures. That methodology is called CER, for comparative effectiveness research.
As an example of a successful CER project, Begley cites a study of two competing drugs for treating age-related macular degeneration, Avastin (used off-label) and the latest and greatest, Lucentis. By carefully using standard statistical techniques to control for hidden biases in the selection of their population study the researchers were able to prove that the new drug was no better than Avastin. The savings? Lucentis costs $2,200 per dose and Avastin $50 per dose.
How much good can this do? The director of the Kaiser Permanente’s research center said,
As much as one third of our [medical] spending is for ineffective or unnecessary care . . . — around $900 Billion a year, in other words.
Begley’s article is not available to non-subscribers online, unfortunately. It does have two graphs that I would have liked to show, but they only confirm what is available elsewhere. They show that the U.S. spends roughly twice as much per patient than do the rest of the developed countries (OECD countries), (half again as much as the next-lowest), and that we are near the back of the pack for data on life expectancy. (The U.K. is at the median on life expectancy.)
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Begley recognizes that there will be much skepticism in the U.S. over the use of CER analysis or any other methodologies to reduce costs. Scare tactics such as “death panels” may have already poisoned the well for any rational attempts at controlling costs, and what I call the Medical Industrial Complex is certain to continue its inexorable search for profits and growth. That after all is the nature of business. It is no accident that prescription drugs dominate the expensive ads accompanying the evening news, with its audience of more-educated viewers.
I am still convinced that the best solution to healthcare crisis is a single-payer government system delivering quality care, epitomized by the high standards of the National Institutes of Health, but a cost-cutting system based on CER methodology surely deserves attention in the meantime.
Still Skeptical After All These Years 
A cost-reduction program would help immensely. I am fortunate enough to have found a doctor willing to work with me (I am disabled with chronic migraines, as well as some lesser issues, and am literally in the middle of nowhere). When we were still in Chicago (and still covered by insurance), the doctor I had there demanded multiple tests, tests I had gone through numerous times before, because he had a set “script” he had to follow. He also subscribed ONLY the latest medications, costing my insurance hundreds of dollars, for which my doc here in Ohio has found generic replacements, or gotten me off the drugs altogether through gentler, over-the-counter medications, or simple diet and lifestyle changes. In the 3 years between the onset of my latest headache bout and my “health crash” which landed us here in SE Ohio, I would conservatively estimate my insurance wasted over $600-$700 a month. Throw in the needless test at several thousand dollars a pop, and it adds up to huge savings.
A great article, Jim (if I may be so informal). And if my Gravatar appears, that’s me and my “blogging buddy” Blackjack the goat. I’ll let you figure out who’s who! 😀 Blackjack has become a running gag in my blog comments, so I figured he was the perfect mate for my Gravatar. (My wife is smart – she wants nothing to do with my little bouts of online insanity.)
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Real life examples add to any post and I’m grateful to have them. I agree that doctors are all too human and the patient needs to be an active participant in healthcare decisions, to the extent the system will let him.
Thanks for the feedback, John.
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Yep, great post Jim.
And…this is a subject I could give real-life examples about, but that would take way too long.
My wife has been disabled for 16 years, my father slightly longer.
Dad broke his neck at vertabrae C1, 17 years ago. He is completely paralyzed and on a ventilator all this time. His condition is actually a bit worse than was Christopher Reeves.
My mother is in the hospital now. Mom and Dad are 77 years old. I’m on sick leave from a job at a state hospital so that I can care for Dad.
My oldest daughter worked at Freeman, but now works at a doctor’s office.
My shortest piece of input; The Medical Industrial Complex sells TESTING and DRUGS, not healthcare.
Longer stories/opinions upon request.
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OMG. You surely have my sympathy, sekanblogger. I’m sure you will add more of value from your too real experience as this subject looms in politics.
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To all,
Another anecdote but along a different line. Jim knows the details but I will not elaborate here. Just let it be said that about two years ago my wife was disagnosed with a physical condition that was alarming. Since then exams, medication, tests, etc used to “monitor the situation” have cost well over $35,000 for Medicare alone.
Bottom line is nothing has changed in her condition and the liklihood of the condition becoming disabling or even life threatening is very low. Yet during one test she suffered a “near miss” disaster that would have never happened without the initial diaginosis and the followup test..
We now can measure things unimaginable just 20 years ago. Probably millions of people had what my wife now has and went on to live “normal lives” while in ignorance of a “potential” ticking time bomb in their body. Now we can see many more “potentials” than in the past if unattended would cause no harm whatsoever for the remainder of their normal lives.
but today we find them and cause great harm occassionally and spend huge amounts of money to monitor the unfixable, even today.
I won’t even comment on the call, again for a single payer system!!!!
Anson
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Sorry, Anson, but I have to point out that you personally are insulated from the pain of the present system, and so I must ask the following question. Might you feel differently about a single-payer system if, instead of the best medical insurance in the world (retired career military) you had NO health insurance, or, health insurance with a HIGH deductible and HIGH co-pay? (And before you answer, picture yourself in sekanblogger’s situation.)
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As a variant on what you said, Jim. My wife suffered from endometryosis many years ago. The growths were. at the time, benign, but per diagnoses, they had the likely potential to turn malign. (Both my wife’s father and mother died from cancer.) At the time, we were fully covered by insurance, so she had the best treatment.
Today, without any insurance whatsoever, if she were to be diagnosed with her condition now, we’d be out of luck. We might, MIGHT be able to swing some tests through a nearby free clinic, but we’d have no chance for the full treatment she got all those years ago.
No attack or offence intended, just stating how my life was versus how it is now.
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Jim,
You KNOW the answer to your question, at least from ME. Had I not had any insurance Janet’s condition would have NEVER been diagnosed in the first place. Just the exams, tests, etc to FIND the problem would NEVER have been used. Those costs alone were probably in the $4,000 range, just to find something that no one knew was there in the first place.
So by not finding the problem there would have been no “followup to monitor the new problem”. Thus NO cost to anyone. And I firmely believe she would and will continue a normal life with no disablitly as a result of the existing problem.
And if unexpectedly the problem “exploded” her death would be very quick. But as a result of the tests performed she came close to living a life of huge at least potential disability for years to come. NEITHER of us would EVER choose that last option as you well know.
With modern medicine’s ability to find problems today we are far ahead of the past. But MANY of those problems involve HUGE costs to treat. AND the treatments are sometimes and only in my view worse than a quick death, pain free in a hospice.
So there is at least part of the End of Life debate. Once a “problem” is found today, many will demand that it be “fixed” regardless of the cost, suffering, pain etc. related to the treatment, which is problematic in many cases as well.
And of course as we agree that EOL cost is HUGE just for Medicare alone. Tough issue.
Anson
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I think you are avoiding the question, Anson. Yes, we both know that over-testing is a problem and diagnosis is often problematical, leading to more and more tests, often driven by medical liability concerns. But the question was about reconsidering a single-payer system.
The present system is chaotic because nobody is in charge. With a single-payer government system there would be, but we would have to give up some autonomy. To me, it is acceptable to have someone in authority, OK, we have reached a reasonable point where further testing is statistically unlikely to improve the odds, so we stop here, or, OK, we are putting you on the old, cheaper generic drug because the newer one is marginally no different and much more expensive. A government system doesn’t have to be inefficient or neglectful. Many parts of the present system are shining examples of that. I offer Bethesda Naval Hospital, the National Institutes of Health, the U.S. Public Health Service, the CDC and the National Library of Medicine as examples.
Jim
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Jim,
Well I did answer your first question. NO, I would not have had the intial testing done had I been without insurance and therefore……
Single payer, absoultely not. I assume you mean government as the single payer. Now look at Europe, etc going bankrupt in part because of such systems, systems that are far below ours in terms of access and quality of care for those that can afford insurance. But what about the 45 million without insurance. A good job that provideds the insurance is the answer. But in both cases, the COST of medical care will eventually drive all to much less insurance and thus less quality care.
You then proceed to provide examples of good government health care. You iincluded CDC in that list. Now you well know I recently spent 5 weeks inside that “tent” at the CDC. I would not go to them for advice on a hang nail much less something really wrong with me. Take the many thousand employees at the CDC and you would have a hard time finding 20 truly excellent physicians on top of today’s medical “arts”. EVERYONE that I saw and spoke with were simply government bureaucrates much more concerned about “consensus and budgets” than the development of the real ability to “fix” health problems.
The Pentagon produces “programs to fight” and the CDC does the same for “programs to heal or prevent”. Look at the cost of both institutions and tell me that are efficient or even competent in many cases. LIberals attack the DOD because it is bigger and they don’t want to fight. But the underlying inefficiency and bureaucratic BS is the same in ALL government agencies in my view.
Government health care is mediorce health care and it costs a fortune as well.
Just consider what it would look like and how much it would cost if we abolished Medicare and simply built and staffed a bunch of Bethesda Naval Hospitals around the country to take care of all folks over 65???
Anson
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Anson,
You say Europe is going bankrupt because of such (medical and bureaucratic) systems. I get that, but your statement ignores the fact that they are delivering health care for about half the cost of our system, which we can’t afford. You again make the point about quality of care “for those that can afford insurance”, but of course the whole point of this discussion is the 45 million who, as you recognize, don’t have insurance. You say the answer is to get it from employers, but employers are abandoning the provision of that benefit as the costs rise.
I understand that bureaucracies are inefficient and that much waste was on display during your tour at the CDC, but I don’t buy that as a reason to denigrate all that the CDC does. They have long-term policies and research that can’t be found anywhere else and the Medical Industrial Complex has no financial incentive to prepare for healthcare exigencies and the state of public health. I believe what you saw was due to the unexpected nature of the crisis – bureaucracies are ponderous, but once moving they can accomplish much, IMO.
“Government health care is mediorce health care and it costs a fortune as well.” – Again, if theirs costs a fortune, ours is costing two fortunes.
“Liberals . . . don’t want to fight.” That statement puzzles me. How about LBJ’s “guns and butter too”? How about Obama’s surge in Afghanistan and the killing of Osama bin Laden? I mean no disrespect, but your arguments would be more persuasive if you backed them up with specific examples.
Jim
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JIm,
Com’on, at least twice. You said, “They (meaning CDC I assume) have long-term policies and research that can’t be found anywhere else.”
I thought the same thing but once I arrived I found a totally different situation. Zip, nada, nothing in terms of long term research. CDC does not have the labs NOR the people on staff to do so. I too was very surprised to find that out.
Supposedly the National Institute of Health does ALL of that at the federal level or so I was told by senior folks at CDC. Well I haven’t been to NIH but I can only imagine what I might be told. Maybe “that’s CDC’s job” which would not surprise me given the confusion in federal roles and responsibilites.
The you claim that European socialized health care does indeed cost a fortune but ours costs two fortunes. Well socialize OUR health care for OUR 300+ million (as compared to Europes population) and at the same time preserve our current level of access and quality for some 255 MIllion (subtracting the 45 million with no insurance) and look at the cost, access, etc. The whole world would not be able to pay such costs (maybe exaggerating slightly.
Anson
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Anson,
I went to the Wiki page for the CDC and found some stuff. Apparently they do 85% of their work through subcontracts, but they do have a bevy of experts to oversee that. What they do seems like a very necessary function to me, but I admit that I have no direct evidence about the quality or efficiency of their work, except to say that the press hasn’t seemed to find any problems.
Here are excerpts:
I’m not trying to be difficult about the issue of healthcare, just to understand your position. As best I can make out, you would be unwilling to compromise on some decrease in the quality of your healthcare in order to make it affordable to everyone.
You said in your last paragraph, ” . . . subtracting the 45 million with no insurance . . . ” But that’s one of the big problems. What about that? Shall we repeal EMTALA? If not, then you have to continue to let them go to the ER’s. But iwe can’t afford to do that. I’m all for solving the medical care problem without turning it over to government, I just don’t see how to do it. When you show me how, I will jump on your bandwagon.
It will be interesting to see what happens to the ACA in the Supreme Court.
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If I might stick my nose in for just a couple quick thoughts, then Ill step back and resume following this informational and interesting dialogue.
Anson – Please forgive my ignorance on this topic. Is there only one CDC “main” or “primary” location? It was my understanding that the first C in CDC is “Centres”, plural. Is it possible there are labs elsewhere from the site you visited, where testing might be done? (I’m not trying to apologise for them, just trying to fill in my admittedly patchy knowledge.)
To Both Jim and Anson – Rather than a wholesale, “from the ground up” redo, what would you think about a multiple-path fix? Leave the current insurance methodology in place with only minor fixes (limits on testing, emphasis on cheaper drugs, limits on litigation to lower doctors’ insurance costs) and add to it a plan to cover those unfortunate saps like me with no insurance at all? Even just basic emergency coverage, with some additional for a yearly checkup or whatever, would be a great help to people at the low end of the income scale (again, like myself).
Thank you for your patience. Now back to the debate.
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John,
Yes, the CDC has 10 other “centers” besides Atlanta. There is a full rundown on Wikipedia: http://en.wikipedia.org/wiki/Centers_for_Disease_Control_and_Prevention
As for a minor fix, including tort reform which the GOP has pushed, my sense of it is that it would be way too small. If you will look at my “Icebergs and Ice Cubes” post you will see that the funding problem is not insurance coverage, it is runaway costs and a corrupt system. The patch would help you, but it won’t bail out the budget.
Jim
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Jim,
As you suggested, I will reiterate what I sent you in an e-mail. (I think I joined this Blog account properly
I don’t think anyone could change Anson’s mind as he, like many, just don’t like the government in spite of what it provides for them and our society.
I am sure Anson can provide examples of problems with the English system, but I bet that as many, if not more, examples of problems can be found with our for profit insurance system. I don’t understand how anyone can believe that a system in which the insurer must make a profit in providing their health care can be better a system in which no profit is required. I wonder if Anson realizes that the administrative cost for Medicare is to 5 percent as compared to 15 to 20 percent of the medical insurance companies.
Regarding care, over the past few years I have had the opportunity to visit England and to work with Americans working there. They are under the same English health care system as the co-workers. Last year one of the men, who has become a friend, was diagnosed with breast cancer. Today he has nothing but great things to say about the care and treatment he received. Fortunately they were able to remove the cancer and he is doing very well. Asked if he ran into bureaucratic problems that many say exist in the English system he simple states: “Nonsence” He told me that, based upon his observations over the years, his experience was quite standard.
Being a person who has the benefits of Medicare, I really wish all Americans could have the same benefits. In this regard, I am also grateful that my children do not have to worry about my or my wife’s future health care.
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Thanks for the real-life example, donv. In my opinion that is worth a ton of speculation. Another sometime commenter, HLGaskins, has had similar good experiences with the Canadian medical system.
Jim
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John,
I am sure that I speak for Jim as well, but please join in and challenge or support however you so choose herein. None of us have complete solutions for anything. But at least Jim and I have observed the poltical scene for many years now and of late at least been using our experience (but not necessarily wisdom) to try to cope with huge problems today in America and the world. And we can easily go all over the map in doing so.
First for the CDC. ANY Federal agency will state its mission and goals, publicly, in a favorable, almost “world saving” manner. Any bureaucracy will reach for more than it can possibly grasp simply because the nature of a bureaucracy is to “grow” (ie: get more money and hire more people).
Given the chance I am sure that the CDC would “volunteer” to investigate disease in outter space as long as they got more money to do the “research”.
Now I thought as you guys do that CDC was the pinnacle of wisdom for “disease” anywhere in the world. But what I found in 5 weeks within the headquarters (Atlanta) of the agency is far different. I now see the CDC as sort of the federal “arm” of the public health service. Now how many times have you gone to the local PHS office for medical assistance or advice. I never have.
If the black plague broke out in Joplin I would probably listen to what they had to say but……
A lot more could be written on the subject but having worked for them and been paid accordingly I am not going on a campaign against them. But I can at least say that I was very surprised when I saw how the CDC really worked in an “emergency” which was not an emergency of any sort in the first place.
Now for the much bigger health care issue. In general 255 Million Americans have the access to and ability to pay for the best health care system in the world. 45 Million have some access but do not receive the “top quality” care demanded by all. If it is there it is my “right” to get it so to speak.
The ENTIRE debate since Obama came to office has been how to bring the 45 million up to the same standards as the 255 million and many want EVERYONE to come under the same system, all in a quest for equality. Well I would love to see everyone receive the same quality of health care but see NO WAY to do it given financial considerations both in America and world wide.
Maybe we “should” do it, but we must first answer the question of “can” we do it. In my view the answer is a resounding NO.
And most important there is no fundamental LEGAL requirement or even mandate for the federal government to attempt to do so. Check the Constitution and show me where national health care is a federal responsibility, clearly and plainly stated. It is not there in my view, even by some “penumbra” imbedded somewhere therein.
Every “scheme” to improve health care for the 45 million that involves government results in lowering the access and qualtiy of health care for the other 255 Million, by and large. Throw all the statistics you like at me but in the end a socialized health care system lowers both access and quality of care for many in order to bring a few under the tent of such care, at least on a broad basis. Is that “fair” I ask to the vast majority in America.
On the other hand as the government “tinkers” more and more with providing health care for “slices” of Americans (like Medicare) the cost of care goes up, way up for everyone over time. If we keep this up the 255 Million will receive less and less and we will stalemate on how to pay for improving the status of the 45 million. More or less that is what is happening with Obamacare. Look at the rising cost of private insurance now after ACA has been around for a year or so. Listen to Steve Wynn explain HIS health care costs as an employee of thousands of people trying his best to keep up with rising costs.
HIs solution and he of course is a free market capitalist but still a caring man from what I have seen is for government to “get out of the way”. Sounds like a call for more limited governement a la the Tea Party which gets every liberal panty on the block in a big wad for sure.
I do believe this one point however and to a degree I think Jim does as well. Until consumers of health care get more “skin in the cost game” (have to pay out of their own pockets for such care) costs will continue to escalate and go through the roof eventually for the 255 million, resulting in even less for the 45 million left “behind”.
In a nutshell I know of no way to control costs effectively other than to “let the market forces do so”. And of course that drives big government advocates crazy. If you can come up with a better way I will listen for sure, however.
Anson
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Anson,
I hasten to confirm my opinion that any reform of our present medical care system must involve making patients care about costs by having to pay something. But, my embrace of the government option is recognition that I don’t think that can happen.
I have the sense, reading your lengthy comment, Anson, that you feel the principal cost driver of the present system is the 45 million uninsured. While I agree that is an important component, I do not believe it is even the biggest cost driver. The main one that I see is thirst for growth and profit by the Medical Industrial Complex and the politically-driven inability of government to intervene in cost-driven healthcare decisions. I laid this out in two posts, Ice Bergs and Ice Cubes and Just Gimme The Latest and Greatest, Doc. Please, let’s not lose sight of the fact that the present system is driven by profit and growth, as in donvphilly’s example below. That’s the reason why I think things will only get worse unless we change.
Jim
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Anson,
“the best health care system in the world”. With 45 million people left out and the health care insurures making record profits. You’ve got to be kidding!
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don,
You just remade my point by yet again focusing on 45 million to the detriment of the 255 million that LIKE their health care system. Or might I say USED to like it until government yet again started tinkering thus driving the cost of health care, particularly health care insurance out of site.
All the yak, yak about private insurance and profits is a smoke screen and you know it. Insurance cost go up when the services costs go up and government ignores the cost of health care services but concentrates on bringing more people under the ten. Which drives up costs, again.
Any “kind” human, which I consider myself one, will be more than happy to bring as many as possible under the tent of equal treatment in a variety of areas. But when it is done by government the cost and efficency skyrocet UP (compare your health care insurance premiums today to say 2000). Why? Because the military industrial complex like Medical “Community” or whatever Jim calls it charges far more today than in 2000 for fixing hang nails to major heart surgery and all in between.
And history, repeatedly, shows us that when government really gets into cost controls big time (we call it socialism and communism) things go to hell in a hand basket over time. I only point to the Soviet Union of old, Greece today and not too long in the future, Europe unless they de-socialize their governments which some are now trying to do.
And guess what, at the urgings of folks of your evident persuasion, Don, we are following right down the same path as Europe. We call that a social democracy I believe. But call it what you like, economics, just like Mother Nature, could care less the name or intent. They are both brutally unaware of the “human” effect resulting from their individual set of laws that create tornados among other things and depressions or worse in other areas.
Anson
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Science author Sharon Begley featured prominently in my post and she also writes on the subject of medicine, and its cost, for Scientific American magazine. In the November 11, 2011 issue, I found the below letter to the editor which I now offer to those who followed the discussion. (Emphasis is mine).
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