The Ills of Money-Driven Medicine

A couple of weeks ago, nine medical specialty societies released a list of 45 medical tests and procedures they believed are significantly overused. On the heels of this announcement was a conference on “Avoiding Avoidable Care” attended by about 150 experts, mostly physicians. I attended.

We spent two days discussing the reasons for and ethics of unnecessary medical care in the U.S. Instead of blaming others (such as patients or malpractice lawyers), the doctors at this conference mostly agreed that “If you’re looking for an explanation for medical care overuse — too many tests, procedures and prescriptions — follow the money.”

The amount of overuse was estimated to be around 30 percent of all medical care. We spend $2.7 trillion annually on medical care in the U.S. Thirty percent of a big number is still a big number, about $800 billion in this case. In our industrialized health care system, moving “product” is important, whether or not it is really necessary.

The World Health Organization reported earlier this month that the U.S. ranks poorly in our rate of premature births. Our rate of prematurity has risen around 30 percent since 1981. We are now on a par with Turkey, Kenya, Thailand and Honduras at about 12 percent. Canada, Australia and Europe all fare significantly better with rates around 7 percent.

The high U.S. rate is attributed to a variety of factors. Lack of prenatal care tied to poor health insurance coverage is prominent among them. Many of these premature births could be prevented, and have been in many other countries, through better primary care and inexpensive public health measures. Many in Congress are now trying to eliminate such programs — to save money.

The BDN recently reported that 750 people showed up last month in Machias for free dental care offered by volunteers. The lack of dental care in rural Washington County was attributed largely to economic barriers made worse by poor economic times, such as lack of dental insurance, and to diets filled with cheap “soda, sweets and junk food.”

But don’t worry, your health care dollars are at work in other ways. Documents released earlier this month by the Minnesota attorney general detailed the increasingly desperate tactics employed by hospitals as unpaid debts mount. They are attempting to collect money owed by patients seeking emergency care, sometimes by threatening denial of services. Accretive Health, the company employed by the hospitals to collect the bills, reported a $29.2 million profit last year. Accretive Health saw its stock decline 19 percent after the papers were released.

The real tragedy in these stories is that the dysfunction in each is mostly avoidable. They are all the result of applying the principles of business and the techniques of industrialization to health care, where they don’t belong.

During the past several decades, clinical decision-making, from lab tests to pharmaceutical prescribing to procedures (including some highly invasive ones), have become subject to “market forces.” Most Maine doctors are now employed by large corporations that hold them to “productivity (profit) targets,” achieved mainly by ordering tests and procedures, in order to meet “business objectives.”

The result has been an explosion of health care services and costs for those who can pay. We as a nation now spend twice as much as other countries that provide health care for all their people, and with better results, at about half the cost.

Ballooning health care costs are crowding out public health and prevention measures, education, infrastructure and public safety. They have contributed in a major way to job-lock, stagnation of wages and declining health insurance protection (think MaineCare) for all but the most well-off.

While the federal health reform law was a remarkable political accomplishment and makes some important but limited progress, it will fall far short of getting the job done.

Real reform has to occur in three phases. First, replace our employment-based, for-profit health insurance system with a single nonprofit, publicly financed system — everyone in, nobody out. Second, remove economic incentives from clinical decision-making. Third, establish firm and effective budgetary limits on all aspects of health care that apply fairly to everybody. Finally, return the culture of health care to one of maintaining health and healing illness, and away from money-driven medicine.

Given the gridlock in Congress, I don’t expect to see such changes coming from Washington. But we in Maine can do it ourselves. All it takes is the will.