Unitarian Universalist Fellowship
of North Bay, Napa, California
April 4, 2004
Thomas B. Newman, MD, MPH
Good morning.
This morning I'm going to talk about healthcare in America. I'll start with a few stories and provide some statistics that illustrate some of the symptoms of our sick health care system. Then I'll offer some ideas on what is wrong—some diagnoses—and end with what can be done about it—a possible treatment plan.
Because a lot of my time is spent teaching and doing research I don't have as many horror stories to tell as many doctors out in practice. Instead of those sorts of horror stories, I want to just tell about some experiences I have had that made me think, and that I hope will make you think, too.
The first story is about a little girl named Alice. One thing I do about fours weeks a year is act as the attending physician for children in the hospital at UCSF with general pediatrics problems. The last time I did that I took care of a six-year-old girl named Alice, who was having trouble breathing because of her asthma. I wanted to talk to her primary care provider to let her know that Alice had been admitted. So, as is my custom, I took a stack of charts over to the phone, so I could write some notes in case I got put on hold while waiting to talk to the doctor. In fact, I got through all of the charts, and I was still on hold. This was mildly traumatic for me, because then I had to sit there with nothing else to do but wait. Anyway, I eventually spoke to the doctor, who said she hadn't seen Alice for a while, but agreed with what we were doing.
When I next saw Alice's mother, I asked if she had had any trouble getting through to her pediatrician. She became very sad, and said apologetically, "Doctor, it's very hard for me to make an appointment for Alice to see her doctor, because my breaks at work are only 15 minutes."
Think about this story. Is something wrong here?
The second story is an academic medicine story. Recently an old friend invited me to lunch with one of his other colleagues, a professor in the school of pharmacy, who was studying adverse reactions to cancer chemotherapy drugs. She told us about a gene she was studying, associated with slower metabolism of a particular drug and hence higher blood levels and more toxicity. About 1 in 300 children with leukemia has the low-activity variant of this gene, and if they get a regular dose of chemotherapy with a drug called 6-MP, they can have serious, even life-threatening, toxicity. So if every child needing 6-MP could be tested ahead of time, some serious adverse reactions to the drug could be avoided.
The trouble is, although a test for this gene is now commercially available, it is very expensive and it is not reimbursed by Medi-Cal. Therefore, our laboratory, which has to send the test out to a commercial laboratory, will not do so unless the patient or their representative first puts up the cash to cover the cost of the test.
We'll come back to this story later, but meanwhile, I want you just to think about it. What is wrong with this picture, and what can be done about it?
Finally, one last story, about social action committee e-mail. I'm in a few Pacific Central District Social Action Committee Groups on Yahoo, so I get e-mail about issues that other Social Action Chairs are concerned about. A while back I got a message from one of the other Social Action chairs about length of hospital stay following mastectomy for breast cancer. I got a similar e-mail more recently from a cousin in Southern California.
The e-mail highlights the fact that many women are discharged from the hospital the day after a mastectomy, and urges people to support legislation requiring insurance companies to pay for at least a 48-hour hospital stay for women following that procedure.
This issue resonated with me, because not that long before, my sister had been sent home the day following her mastectomy. She had called me in tears a day or two later, overwhelmed just trying to figure out how to get dressed and undressed with all of the drains that had been left in place.
Again, I'll come back to this. Meanwhile, think about the problem illustrated here and the proposed solution.
Let me move from stories to some data. There are an awful lot of sobering statistics I could share, but that works better with slides and references, so I’ll just pick a few.
You probably know that the USA is the only industrialized country that does not provide basic health care to its citizens. In fact, the current number of US citizens without health insurance is about 45 million, with millions more uninsured for at least part of the year, and most of us vulnerable—only a layoff and a serious illness away from disaster.
Here's an interesting and sad statistic: 46% of all personal bankruptcies involve a medical reason or a large medical debt. The group at particular risk is people in their fifties or early sixties—not eligible for Medicare yet, but vulnerable to layoffs and serious illness. Maybe there's hope that as we baby boomers reach that age, we'll try to do something about it.
You may also know that the US spends more than any other country on health care. In fact, we spend about 40% more per person than Switzerland, the second highest spending country, and more than twice the average of other industrialized countries. This amounts to more than $4000 per person per year. What you may not know is just how poor the value we are getting for the money is. When you look at measures of health, we are dead last of the top-ten spending countries. In fact, whether it’s measured as infant mortality, life expectancy, or years of life lost, the US is far below other countries that spend much less. We ranked 37th in a 2000 WHO study of 219 countries.
So what is wrong? What's the diagnosis?
Well, of course this is a huge topic, and there's plenty of blame to go around. I just want to focus on one fundamental structural problem with how we do healthcare in the US, and then spend the rest of the time talking about how we think about healthcare.
The fundamental structural problem in the US is that we have private, employment-based health insurance. This is unkind, unfair, wasteful, and creates the wrong incentives.
It's unkind because if you are not employed, or are one of millions unlucky enough to be employed in a job that does not provide health insurance, you are out of luck. What a divisive, unkind message it is to say that only people with "good" jobs are entitled to health insurance and then only as long as they are working.
Of course if they can afford it, people whose jobs do not provide insurance may be able to buy it on their own. But here is where the system is triply unfair! It is unfair that they have to buy the insurance themselves. It’s doubly unfair that they will probably have to pay a higher premium, because they are not part of a large group. And it is triply unfair because poorer people who don't itemize deductions will have to pay taxes on the premium, while people like me and many of you, whose health insurance is provided by their employer do not.
Employment-based insurance is wasteful. One thing that not only wastes a lot of money, but also compromises good patient care is the discontinuity that occurs when someone changes jobs, or their employer changes insurance companies, or their insurance company changes medical groups. In each case, the patient may have to find a new doctor, who must then start all over again trying to get to know the patient. When I had my own patients, I saw this first hand when patients I'd known for years would bring me a list of providers covered by their new insurance company, and ask for a recommendation for a new pediatrician. This is particularly sad, because one of the main rewards of primary care is the relationship you establish with patients over time. When no matter how good a job you do, patients end up switching, it's demoralizing.
Of course the biggest waste is that by not providing uninsured people with good access to outpatient care, we end up spending more to take care of problems that could have been prevented with timely care.
Finally, employer-based insurance creates the wrong incentives. Insurance companies can make more money by spending less on health care. This is not necessarily entirely bad, as there is still much over-diagnosis and over-treatment in the US. But instead of focusing attention on expensive, unnecessary, and often unwanted care, insurers can make much more money if only they can improve their case mix—finding ways to get well people into and sick people out of their health plan.
OK, that's the structural problem -- spotty, private, employment-based health insurance. What else is wrong? George Annas, a health policy writer for the New England Journal of Medicine wrote a particularly thoughtful piece in 1995, following the demise of the Clinton health plan. One of his points was that we in America face daunting cultural obstacles to health care reform. Here's an excerpt:
We live in a country founded on the proposition that we are all endowed by our creator with certain inalienable rights, especially the rights to life, liberty, and the pursuit of happiness. Any government-sponsored health care plan must take into account the assumption made by Americans that these rights support entitlement to whatever makes them happy.
Perhaps equally important, we live in a wasteful, technology-driven, individualistic, and death-denying culture.
I just want to repeat those four characteristics because they ring so true to me: "We live in a wasteful, technology-driven, individualistic, and death-denying culture."
The main thesis of George Annas's piece is that we have been using dysfunctional metaphors in medicine. Annas stresses how important metaphors are in helping us frame and make sense of the world. He points out that we have traditionally used a military metaphor for medicine, but that it is gradually being replaced by a market metaphor, and neither one works.
Let's begin with the military metaphor. Examples of a military metaphor abound in medicine. Diseases attack the body, we muster our defenses to fight them off. Physicians seeing patients are "in the trenches" and "on the front lines." We call our equipment for fighting disease our armamentarium, and treatments are conventional or heroic.
Annas argues that the military metaphor is dysfunctional. A war justifies massive expenditure of resources to achieve dominance; the only goal is winning. It leads us to ignore costs, side effects, and feelings. The patient's body becomes a battlefield. Hospitals and doctors engage in costly medical arms races. Military thinking is hierarchical, dominated by men, and intolerant of ambiguity, uncertainty, and autonomy. Bravery, sacrifice and dramatic rescues are valued over sympathy, kindness and letting go.
As many of you have experienced first-hand, the military metaphor is still alive and well and fighting battles in medicine. But it is losing ground to another metaphor: the metaphor of the market.
In the market metaphor, medicine is a business, patients are customers, and health care is a product that is bought and sold like any other. We strive for efficiency, we have advertising and competition, and we embrace maximization of profit as the primary goal. Back in the bad old days of the UCSF-Stanford merger, the managers referred to the services we provide, like kidney transplants and intensive care, as our "product lines."
But the market metaphor has some problems.
Obviously, a big one is that the poor and uninsured are left out. Of course, in our society, the poor are left out of all kinds of things that they can't afford—theaters, restaurants, cars, as well as more basic things like apartments and houses.
But healthcare is different. It doesn't follow the laws of supply and demand. It is possible for consumers to make choices about most products they buy, balancing cost and quality. But this choice is not generally available for healthcare. All of it is expensive, and it is not realistic to expect people to weigh cost and quality when they are sick and the information needed is unavailable.
Furthermore, unlike the situation with most consumer products, failure to provide access to basic healthcare can end up costing society more. When a poor person does not buy an inexpensive car this year, it doesn't make it more likely that society will be forced to buy him an expensive one next year. But failure to provide timely access to outpatient care can cause little problems to turn into bigger, much more expensive problems. Society still ends up footing the bill, but now there's a bankruptcy and needless suffering of the patient and family.
Finally, as the ideology of medicine is replaced by the ideology of the marketplace, it is harder for patients to trust their physicians. As Annas puts it, trust is replaced by "caveat emptor" -- let the buyer beware. This problem is exacerbated by the discontinuity I mentioned earlier, when patients have to leave a physician they trust because of insurance or employment changes. This lack of continuity and erosion of trust is traumatic to patients, demoralizing to physicians, and also leads to increased costs, due to more defensive medicine.
The virtues of the market are sung by people like economist Milton Friedman, who wrote:
Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their shareholders as possible.
This is not the ethical environment in which I wish to practice medicine.
I've talked about the diagnosis—our employment-based health care system, with private, largely for-profit insurance companies, our particular cultural characteristics, and our dysfunctional military and market metaphors. What can we do about it? What is the treatment?
Well, the most important thing is that we need to join the rest of the civilized world and get a single-payer health care system that covers everyone. There are many possible forms this could take and just about any of them would be better than the unkind, unfair, wasteful system we have now.
However, even a single-payer system won't address the problems raised by the stories I told at the beginning.
We need to address head-on some of our maladaptive cultural characteristics that have gotten us into and kept us in the mess we are in. To do this, I think what really has to happen is that we need to change the way we think about healthcare.
Annas suggests that an ecological metaphor should replace our military and market metaphors for medicine.
Ecologists stress interconnectedness, sustainability, conservation, quality of life, and limitations of resources. If applied to health care, ecological thinking might help us to accept limits on the lengths of our lives and on the expenditure of resources to prolong them. We might even learn to accept death as natural and inevitable. We might think more about populations than about individuals and more about underlying causes rather than about immediate symptoms. We might want to confront some of our wastefulness, individualism, and obsession with technology.
Let's return to the first story I told, of the girl Alice whose mother had trouble getting through to her doctor to make an appointment. If we are in the military mindset, the sorts of solutions we might imagine includes requiring people to answer the phone within a reasonable period of time. (Alternatively, we might choose to continue to ignore phone access, making a strategic decision to pour resources into new treatments and technologies to help people once their breathing difficulty is more severe.)
The market metaphor would encourage us to suggest to this mother that she find another provider, who provides better telephone servivce, or find another job, that provides longer breaks.
But the ecological metaphor, in which we try to appreciate limited resources and interconnections, might lead us in a different direction. For example, we might think, the next time we are ordering an MRI scan on someone who probably doesn't need it, "The price of this scan is enough to pay for a full time person to answer the telephone for two weeks." (And I just want to add, I really do think this way!)
Or we might wonder why this girl has asthma in the first place, and why the number of children dying from asthma has tripled in the US in the last 25 years. Most importantly, we might try to see this problem as an example of a bigger problem, which is figuring out how best to allocate limited resources in a way that optimizes health.
This brings us to my second story, about the professor who helped develop a test to predict adverse reactions to 6-MP, that the lab wouldn't send out without cash in advance. What was wrong with that picture? The military metaphor might lead us to push for more resources, so we could afford to order the test on everyone who might benefit from it. Or we could pour money into technological improvements in the test that might bring the price down. The market approach would be to let the patients decide whether this is something they want to spend their money on. If they want it and can't afford it, that's the way it goes—they should get a better job or work harder.
But if we think ecologically, and recognize that resources are limited, we might have a different approach. We'd need to think about how Medi-Cal makes the decisions it makes about what to cover, and how they can do a better job. But we'd also need to look at how we got into this situation. What sorts of problems are faculties in our medical schools addressing, and will the solutions to the problems leave us better off?
Now I have nothing but respect for the professor that did the research that made this test possible. But the trouble is, this is exactly the type of research predominantly being done now in medical schools (and also in many private companies) all over the country. And we are developing all kinds of similar new tests and treatments that offer a small marginal benefit in relation to their costs.
Companies and universities whose researchers discover these tests can patent particular segments of the human genome in order to sell the test. And you can imagine how they can market the test to doctors and directly to patients, and how a health plan that does not cover the test could be sued if a patient develops a potentially preventable adverse reaction.
If we think ecologically, we realize that part of the problem has been our tremendous focus on research leading to the development of marketable products.
The NIH, which funds this type of research, has a budget of $27 billion. The Agency for Health Research and Quality funds research into issues like cost effectiveness, and how to use the knowledge created by the NIH to improve health. The AHRQ has a budget of $300 million—almost 100-fold less. So if you are in academic medicine trying to decide what to study, it's easy—you follow Willie Sutton's rule, and go where the money is.
If we thought ecologically, we might also begin to realize that we already have many more such products for health than we can possibly afford, and that more of our research dollars and faculty brain-power should be focused on how to best allocate the limited resources we have, rather than searching for ever more ways to spend. Our thinking would embrace notions of sustainability, limited resources, and equity.
This is not a new issue.
Senator Abraham Ribicoff said, "If contemporary medical marvels are priced out of the range of the average American, our brilliant conquest of so many illnesses will prove to be a hollow victory."
Notice the military metaphor? That was in 1964!
Finally, let’s come back to the bill requiring insurers to cover a 48-hour hospital stay after mastectomy. There are a lot of good people supporting this bill. And my own experiences lead me to want to support it.
Nonetheless, I do not support this mastectomy bill. This type of bill is what is known as "body part legislation"—almost by definition a piecemeal approach to the problem.
I oppose body-part legislation on general principles. The trouble with this type of legislation is not the unworthiness of the individual body parts, but that the solution doesn't address the underlying problem. The Band-Aid on a gaping wound metaphor doesn't fit, because it doesn't capture the problem that in order to be applied to one wound the Band-Aid needs to be yanked off another.
I don't think Congress is the place to debate things like the optimum length of stay after particular surgical procedures. I'd rather our lawmakers (and patient advocates) work on broader issues, and come up with solutions that will also benefit less empowered patients.
(I have to admit my opposition to this bill softened a bit after talking with my sister. She pointed out that, given other things that Congress has been doing, it might be better for them to spend as much time as possible debating length of hospital stay for specific surgical procedures.)
Let's look at our metaphors again. The doctors doing the mastectomies are battling cancer and the people supporting the bill are battling against powerful insurance companies. They need a victory to sustain the troops.
But wait a minute! The insurance companies are not really the bad guys here. The problem is that we need a system for allocating health resources where they will do the most good. And if we think ecologically, we might want to look at why we are doing so many mastectomies in the first place? Is it because we are doing too many mammograms, in spite of the lack of evidence that they save lives?
I couldn't resist throwing that in, but you'll have to have me back if you want to hear more about mammography. For now, it's time to wrap up.
As I said at the beginning, our healthcare system is sick. We pay enough to have a single payer system that covers everybody; instead we have a system that is unkind, unfair, and wasteful.
What can we do? I think the first step is for all of us to begin thinking about health in a healthier way. We used to think of the environment predominantly as something to be dominated, bought and sold. Now many of us think ecologically, and recognize how shortsighted and self-defeating that view was. We are beginning to realize that our actions as a country and as individuals have consequences not just for ourselves, but for other people and other species around the world. We need to move some of that same type of thinking to health care —both for ourselves and for others less fortunate.
Amen.
Further information:
Annas GJ. Reframing the debate on health care reform by replacing our
metaphors.
N Engl J Med. 1995 Mar 16;332(11):744-7.
For more information on single-payer healthcare, see or Healthcare
For All
http://www.healthcareforall.org/index.html
3707 5th Avenue # 303
San Diego, CA 9210
(888) 442-4255
or the Physicians for a National Health Program web site:
Further information about mammography:
The main take-home messages on mammography are 1) the only source of reliable information about its benefits and risks is randomized trials and 2) when randomized trials are pooled, excluding flawed trials, there is little evidence that mammography saves lives.
For a short article about the controversy in Nature, see http://www.nature.com/nsu/011025/011025-5.html.
The controversial review is Olsen, O. & Gotzsche, P.C. Cochrane review on screening for breast cancer with mammography. Lancet 358, 1340-1342, (2001). A summary and commentary is available at http://www.epicentro.iss.it/lavagna/mammo/reslet.pdf. I'm sympathetic to these authors, but think one of their criticisms of the New York study (for unequal post-randomization exclusions) is off base. So my position now (2004) is that mammography may save some lives, but probably not very many and we could probably save more lives spending the money other ways.
The full text of the review is available at http://image.thelancet.com/lancet/extra/fullreport.pdf.