Monday, August 31, 2009

Bill Moyers Journal:
Money-Driven Medicine

Best Bits:

DR. DONALD BERWICK: It is, I guess, politically correct, widely believed, that to say that American health care is the best in the world. It's not. There's a much more complicated story there. For some kinds of care my colleague Brent James calls it rescue care. Yes, we're the best in the world. If you need very complex cardiac surgery or very advanced chemotherapy for your cancer or some audacious intervention with organ transplantation, you're pretty lucky to be in America.

You'll get it faster and you'll probably get it better than in at least most other countries. Rescue care we're great. But most health care isn't that. Most health care is getting people with diabetes through their illness over years or controlling the pain of someone with arthritis or just answering a question for someone who is worried or preventing them from getting into trouble in the first place. And on those scores: Chronic disease care, community-based care, primary care, preventive care. No no, we're no where near the best. And it's reflected in our outcomes.

We're something like the… We're not the best health care system in the world in infant mortality rates. We're like number 23. There is an index that is used in rating health care systems, which is the rate of mortality that could have been prevented by health care. There are at least a dozen countries with lower rates of preventable mortalities than the United States and not one of those countries spends 60 percent of what we do on health care.


LARRY CHURCHILL: We're now treating medicine as if it were an industrial product. Through put. How many units of care can you deliver? The idea that you are going to see a patient on average for between 12 and 15 minutes, no matter what their condition or how many kinds of problems they have or how complicated their diagnoses or how much reassurance they might need is an idea that you can treat medicine like a production line product and you can turn out patients in the same way like we produce widgets. That's a commercialization and an industrialization of the relationship. So this is a system which is fundamentally broken in terms of the kind of conflicts it raises in the minds of physicians and, also, in the minds of the patients.


MAGGIE MAHAR: What's truly staggering is how much waste there is in our health care system. Up to one out of every three of the more than two trillion dollars that we spend is wasted on ineffective, often unproven procedures, overpriced drugs and devices that are no better than the drugs and devices that they're replacing. Unnecessary hospitalizations, unnecessary tests. Now this may seem like an overstatement. I mean, how can it be that 1/3 of the money is wasted? We actually have close to three decades of research done by doctors at Dartmouth University proving how much waste there is in the system. What the Dartmouth research ended up doing was looking at health care all across the country and what they discovered is that in some high treatment states, like New Jersey, Medicare was spending 20 percent more per patient than the average. And in other low treatment states, like Iowa, Medicare was spending 25 percent less than average. They tended to focus in on what happened to patients during their final two years of life.

So in that way you're comparing apples to apples, pretty sick patients, and they began looking at sick patients who had the same disease etcetera- Finding these enormous differences in what Medicare spent. Some people said, "Well maybe patients in New Jersey are simply more demanding than the stoic citizens of Iowa." But, in fact, very few people demand a chance to spend more days in the hospital during their final two years of life. Very few people cry out for a chance to die in an ICU or to have that fourth procedure or to be poked and prodded by eleven or twelve specialists during your final six months of life. In the states where Medicare spends more, these are the things that happen to people.

They're getting more aggressive, intensive, and expensive care. And here's the stunner: The outcomes are no better. Often they are worse on average in states like New Jersey or New York or California than they are in low treating states like Iowa or North Dakota.


DR. JAMES WEINSTEIN: My daughter's name is Brieanna. She had beautiful blue eyes, curly brown hair; your first child, the light of your life. 13 months later I get a call from our pediatrician saying, "Could you come over to the hospital?" And I walk into the pediatrics hospital and I ask my wife what's wrong and she says, "They won't tell me. They won't tell me." The doctor walks in with about, it seems like, 10 other people other people. Very intrusive. And said, "I think your daughter has leukemia and we need to treat her, immediately."

The protocol for a treatment was very intense chemotherapy. She would lose her hair quickly. She would be sick. She would develop sores in her mouth. She wouldn't be able to eat because of sores from the chemotherapy in her esophagus. She would have all kinds of rashes. Her blood counts would be almost zero so her risk of infection would be very high. We couldn't take her any place. She had to be protected. And it sounds, "Well, that's not so bad, we can do that for a week." But the protocol was for 3 years. She did pretty well for about, I think, 2 years and then the leukemia came back. And they said, "We need to re-induce her with the bad medicines again and we have to consider brain and spinal radiation.

So spinal taps every day for three weeks." I said, "I don't get it. I mean, you just told us if we followed this protocol, these are the results. We did everything you said and it is still not working. And now you want us to do something worse." "Well, you have no choice and if you don't do that we will sue you." I said, "What?" "If you don't do what we tell you, we'll sue you."


MAGGIE MAHAR: If you can believe it, Rashi Fein has survived 5 decades of the battle for health care reform. In 1953 he served on President Truman's commission on the health needs of America at a time when Truman was pushing for universal coverage. Then he worked with JFK when he fought unsuccessfully for Medicare, a battle that LBJ would later win. As a professor of medical economics at Harvard, Fein has never given up. He firmly believes that medicine should not be all about money. As he puts it, "We live in a society not just in an economy."


MAGGIE MAHAR: A physician takes an oath to put his patient's interests ahead of his own. A corporation is legally bound to put its shareholders' interests first. And this is part of the inherent conflict between health care as a business, part of our economy, and health care as a public good and part of our society. Health care has become a growth industry. That means higher health care bills. That means more and more middle class people cannot afford health care in this country.


BILL MOYERS: ...And remember that television ad Barack Obama made as a candidate for president?

BARACK OBAMA: The pharmaceutical industry wrote into the prescription drug plan that Medicare could not negotiate with drug companies. And you know what, the chairman of the committee who pushed the law through went to work for the pharmaceutical industry making $2 million a year. Imagine that. That's an example of the same old game-playing in Washington. I don't want to learn how to play the game better. I want to put an end to the game-playing.

BILL MOYERS: Now look at this recent story in the LOS ANGELES TIMES. Lo and behold, since the election, the pharmaceutical industry's $2 million dollars a year superstar lobbyist Billy Tauzin has morphed into President Obama's pal. Tauzin says the President has promised not to pressure the drug companies to negotiate with the government for lower drug prices and has agreed not to allow cheaper drugs to be imported from Canada or Europe - contrary to the position taken by candidate Obama…

Each of these stories illuminates the scarlet thread that runs through Maggie Mahar's book - the story of how today's market-driven medical system gives Wall Street investors life and death control over our health care, turning medicine into a profit machine instead of a social service to meet human need. That's the conflict at the heart of next month's showdown in Washington.


I don't really have a comment. Just see it or read it. Amazing stuff.