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Why U.S. health care is bad value for money

Why U.S. health care is bad value for money

By Jody Heymann and Douglas Barthold, Special to CNN

Editor’s note: Dr. Jody Heymann is dean of the UCLA Fielding School of Public Health, an elected member of the Institute of Medicine, and Distinguished Professor of Epidemiology, Medicine and Public Policy at UCLA. Douglas Barthold is an economics doctoral candidate in economics, and a doctoral fellow at McGill University's Institute for Health and Social Policy.

Worried about what your new mandated health insurance will cost next year? We should all be worried, but it has little to do with the Affordable Care Act. Over the past two decades, the United States has run near the top of the pack in a competition no country wants to win – spending the most while getting the least.

The American Journal of Public Health published the results of our study examining health systems of 27 high income countries over 17 years, and their efficiency at turning dollars into extended lives. The United States was near the bottom, ranking 22nd. Every hundred additional dollars spent in the United States was associated with a gain of less than half a month of life. In Germany, more than four months of increased life expectancy were associated with every additional hundred dollars spent.

Not everyone does equally poorly in the United States. Our new study has the U.S. ranking 18th when it comes to the efficiency of investments in reducing men’s deaths.  Worse yet, when it comes to reducing women’s deaths, the U.S. ranks 25th.

This is not an abstraction. In previous research, Ellen Nolte and Martin McKee found that in a mere five years, between the late 1990s and early 2000s, the U.S. dropped four positions in global death prevention rankings. How much does it matter? If preventable deaths in the U. S. looked like the average across France, Japan, and Australia, more than 100,000 fewer people under 75 would die each year.

How did we end up with one of the advanced economies’ most inefficient healthcare systems? How do we manage to have so many preventable deaths?

The short answer is that we are willing to spend almost anything as a country once you are dying – not to make you more comfortable or to ensure you have more meaningful time with your family, but rather in an effort to keep you alive a few extra days at a time when the dollars yield little advantage.

The problem is that, as a nation, we have not been willing to spend anything on preventing people from getting sick. And what really contributes to whether you’re likely to die prematurely is whether you get sick in the first place.

The U.S. spends $2.65 trillion per year on health care. The Affordable Care Act had earmarked less than 1/10th of 1 percent of this for prevention. The only thing both parties seemed to agree on was to eliminate that small amount of prevention dollars. The Republicans labeled it a slush fund, and the Obama administration, in the absence of other dollars for implementing the ACA, was all too ready to raid it. So the actual dollars spent on prevention in the ACA last year were less than half of the miniscule amount first allocated.

In fact, helping people get sick is institutionally embedded in some of the actions of Congress. Because the presidential primary is in Iowa, the country provides heavy subsidies to corn syrup, contributing dramatically to rates of diabetes, obesity, heart disease and stroke. The Congressional Budget Office typically assesses a cost to prevention programs in any new bill, but usually does not allow the bill to count the savings that occur – they are considered too far out into the future.  As a result, prevention is often left out by legislative staff, to improve the CBO score.

Yet there’s a great deal we know about what works. If in the workplace and at school you take a 10-minute recess every day to exercise, your body mass index will go down, as will your risk of diabetes and heart disease. It’s free. There’s no company or stakeholder that will make money off of it. But you’ll be healthier, there’ll be fewer premature deaths in the U.S., and our healthcare will cost less.

When healthy food and fitness options are available in our schools, the epidemic of childhood obesity and early onset diabetes can be reversed. In its absence, we will continue to see the tripling of diabetes costs we saw in a generation. Policies that kept smoking out of schools, workplaces, and public places saw a dramatic decline in smoking rates in the U.S., and in illness and deaths associated with smoking. When we set our mind to it as a nation, we know how to make prevention work.

So yes, we need a health insurance system that covers all Americans. And we should all worry whether it is affordable. But the only way to make it affordable, and to improve the health of Americans, is if we start to seriously invest in preventing people from getting sick in the first place.

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U.S. health care’s dangerous profit fixation

By Russell J. Andrews, Special to CNN

Editor’s note: Russell J. Andrews is a neurosurgeon who has been a U.S. Army flight surgeon, a clinician and researcher in both academia and private practice and a medical device developer with NASA. He is the author of ‘Too Big to Succeed: Profiteering in American Medicine.’ The views expressed are his own.

Medicine is big business in America. Nearly one fifth of our GDP is spent on health care – 50 percent more than any other developed country. Yet by many measures we are not getting value for money. Even nearby Cuba, which spends less than one-tenth as much as the U.S. per capita on health care, has outcomes that are as good or better: life expectancy is just as long, and the infant mortality rate is actually lower. Health care in the U.S. is on an unsustainable course, and costs cannot continue to increase while outcomes continue to deteriorate.

This crisis has been blamed on greedy malpractice lawyers, drug companies, health care insurance companies and doctors who over treat patients by practicing defensive or wasteful medicine – unnecessary tests are ordered and unneeded operations are performed. And there is something to all of these. Doctors have failed to address this health care crisis, so other groups offer solutions – notably economists and political commentators. Not surprisingly these proposals represent the expected economic or political views, namely: “Which reform will rein in burgeoning health care costs?” and “Which reform will be politically acceptable?”

Medical students since ancient Greek times have sworn to uphold the Hippocratic Oath. Yet nowhere in the Hippocratic Oath is money, financing or making a profit mentioned.  Medicine is a unique relationship between two people, one born of a person’s need for the skills of another person to live and be healthy. Even more than the teacher or the religious leader, the physician bears a responsibility that transcends financial gain. That responsibility to uphold the Hippocratic Oath has been lost in present-day American medicine.

Runaway costs and deteriorating patient outcomes are symptoms, not causes, of the present health care crisis. There are two primary factors at play: (1) the exchange of the unique long-term doctor-patient relationship (where the doctor assumes personal responsibility for the patient receiving the best care possible) for impersonal “corporate medicine;” (2) the morphing of American medicine from a function of humanitarian society into a revenue stream for health care professionals, drug and medical device companies, hospitals, and insurance companies. In essence, we have transformed health care in the U.S. into an industry whose goal is to be profitable, and the health of the patient is not really in the equation. Imagine if such a transformation from a societal good into a profit-making industry occurred in public safety (police and fire), clean air and water or basic education?

True, many incoming medical students have humanitarian motivations (an M.B.A. or a law degree is a quicker route to financial success than medicine). However, corporate America begins invading the physician’s professional “genome” early in training. Academic medical centers are as challenged as community hospitals in making financial ends meet: the faculty member who does not maintain the revenue stream is likely to be let go. The same is true for a physician in private practice – remaining economically viable is a full-time job (leaving less and less time for actual patient care) as for-profit insurance companies work ever harder to reduce their expenses.

The family doctor who follows you over time and place (“from womb to tomb,” and in both the office and the hospital) is being replaced by compartmentalized corporate medicine.  In-hospital care is assumed by a team of hospital-based physicians (“hospitalists”). Hospitalized patients may see three or more different hospitalists in a 24-hour period – and still others if they remain hospitalized over a weekend. Indeed, one hospitalist group has impersonalized this to the point where the patient’s doctor is whoever happens to hold the “hospitalist pager” at the moment.

It is sobering how the for-profit “virus” has “infected” health care in the U.S. medical students learn that physicians must forego “the joy of healing those who seek their care” to survive in the profit-driven medical environment. Direct to consumer (patient) advertising – at present largely limited to prescription drugs, although ads for surgical procedures are appearing – clouds the physician’s ability to prescribe what is truly best for the patient. Physicians are forced to prescribe treatment plans that place the financial health of the system (including the doctor’s own “financial health”) ahead of the physical health of the patient.

Medical research and drug and device development also aren’t immune to the profit motive. Many examples exist of millions of dollars wasted in the development of drugs or devices that in the long run were doomed to fail. Competition in medical drug and device research is not like competition in the cellphone or automobile industries. Consumers quickly determine which cellphones are best for them. Health care consumers (i.e. patients) cannot determine if a novel (expensive) drug will be beneficial for them, nor can they predict if their artificial hip or lumbar spine fusion will provide many years of improved quality of life. There are “lemon laws” if your new car fails to perform – but there is no trade-in available for a “failed back.” And again, the profits are privatized up front (to the physicians, the hospitals and the drug and device manufacturers), while the losses are socialized later on (disability payments and the other societal costs of a person who cannot work).

Fortunately, there are signs of health care reform that put patient before profit. The PCMH (patient-centered medical home) places the physician-patient relationship at the forefront of a team providing full-service medical and social service care. The EPMA (European Association of Predictive, Preventive and Personalized Medicine) brings together medical societies, medical research institutes and university hospitals and medical corporations from around the world to address, comprehensively, medical challenges such as diabetes, cardiovascular disease and neurological disorders.  Unlike the U.S., European countries provide basic universal health care for their citizens and are not controlled by for-profit insurers and hospitals.

Yet ultimately, the only way true health care reform will happen here is if the voting public in the U.S. rejects the unsustainable course of for-profit medicine. We must lobby our elected representatives in Congress and locally, demanding change. The public must exercise their democratic duty to make their views known – through emails, letters and the ballot box. We don’t just owe it to ourselves to do something – our lives depend on us doing so.

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