Yves here. Maggie Mahar’s post focuses on a pet peeve of mine, namely, the way treatments and procedures are overprescribed in the US. She includes a favorite example, that of colonoscopies. The US is the only country in which doctors recommend colonoscopies for everyone over 50, as opposed to people in high-risk groups.
Another source of waste is the way insurers and the government allow Big Pharma to introduce minor reformulations of drugs as “new drugs” (“new drug applications” or NDAs in Food and Drug Administration-speak) and use those to extend patent lives and keep prices high. Given that the US already massively subsidizes the drug industry via NIH research, it’s unconscionable that the government does not push back, as is the norm in other countries, by negotiating prices and restricting access to pricier drugs unless a clear benefit is shown. By contrast, in Australia, the Therapeutic Goods Administration reads the research on various drugs, picks one or two in each category that it deems most effective (which often isn’t the newest) and uses the fact that it has concentrated its buying power to secure better prices.
However, I take issue with Mahar’s conclusion, that waste in Medicare means that Medicare for all should not serve as a way to get to single payer (even assuming that issue can be opened up again in the next decade). The US healthcare system is massively wasteful, and it will inherently be most wasteful in populations that consume more in the way of medical services than the country at large. The elderly is far and away the biggest cohort that fits this description. Moreover, my limited sample of older people dealing with doctors (elderly relatives and their friends) strongly indicates that they are very deferential toward doctors, and are thus not inclined to reject suggestions for aggressive (as in costly and possibly unnecessary) treatments.
Even worse, as we’ve written in older posts, when family members try to intervene on behalf of aged relatives who aren’t capable of making their own decisions, they are often threatened by the hospitals that if they don’t back off, they’ll be denied any decision-making role. I am not making this up. And Mahar clearly knows about this issue, since she wrote about it at length. From her must-read post in May:
But “in an era of advanced medical technology,” Katy Butler soon learned that, “having legal and moral rights was not the same thing as having power. . . . Those who knew my father best– Dr. Fales my mother and I –wanted to let him die naturally. Those who knew him least and least understood his suffering were eager to prolong his life, and had the know-how and power to do it.”
Katy Butler was advised that she “should not be rude or threaten a lawsuit. When family members become agitated or disruptive, “hospital bioethicists. . . may decide that the surrogates lack ‘decision-making capacity’ and the medical team may simply ignore them, or go to court and ask to have the troublemakers removed from the job. If that happened, my father’s medical proxy wouldn’t be worth the paper it is written on.”
Mind you, the Butlers’ plight might look to be a Medicare problem if (as one can probably assume) the procedure that led to a life-prolonging pacemaker being unnecessarily implanted happened happened while Katy’s father was on Medicare. But unnecessary procedures are a staple of the US medical industry, whether the patient has insurance or not.
Thus while Mahar is correct in her description of the problem, she mistakenly treats Medicare as a cause, as opposed to a symptom. My concern with Mahar’s recommendations is that they can and almost certainly will be used to support corporatization of medicine as a vehicle for creating the standardization that she desires, except with the objective of increasing profits, as opposed to improving care (see this post for a much more detailed discussion of how advanced this trend is and how Obamacare accelerates it).
By Maggie Mahar, a financial journalist who wrote for Barron’s, Time Inc., The New York Times and other publications. (Her first book, Bull: A History of the Boom and Bust 1982-2003 (Harper Collins, 2003) was recommended by Warren Buffet in Berkshire Hathaway’s annual report. For more on her books, click here. Originally published at Angry Bear
You write: “That claim that one-third of Medicare spending is wasted sounds pretty questionable to me.”
This is your opinion. If you had spent the last 20 years working as a medical researcher investigating unnecessary treatment, your opinion would be of great interest to all of us; but, I’m assuming you have not done so.
Thus, you might be interested in some facts . . .
Dr. Donald Berwick, who headed up Medicare and Medicaid during the 1st half of the Obama administration has said, repeatedly, that at least 1/3 of Medicare dollars ware wasted on unnecessary tests, procedures and drugs that provide no benefit for the patient. He is only one of dozens of health policy experts who have made the same statement. (Google “Health Affairs” the leading medical journal that focuses on health policy and “unnecessary treatments” Over the past 30 years, researchers at Dartmouth have provided stacks of evidence documenting unnecessary care in the U.S.
You also write: “I doubt that treatment protocols in the U.S. are all that different from other countries.”
Again, this is your opinion. Unfortunately, you are wrong.
In other countries, doctors and hospitals tend to follow evidence-based guidelines. In the U.S. a great many doctors object to the idea of someone telling them how to practice medicine (Even though “someone” is “science”). They value their autonomy and prefer to do things the way they have always done them. Of course, this is not true of all doctors. But even when you look at protocols at our academic medical centers, you find that the way they treat similar patients varies widely.
Here , I’m not talking about how much they charge for a procedure (which also varies widely) but how many tests they order, how often they prescribe spine surgery for someone suffering from low-back pain, how often they tell a woman she needs a C-Section . . .
One big problem is that our doctors and hospitals are paid “fee – for service;” in other words, the more they do, the more they are paid.
As Dartmouth’s Dr. Eliot Fisher points out: “U.S. patients are not hospitalized more often than patients in other countries; but in the U.S., a lot more happens to you while you’re there.”
In addition, traditionally our medical schools have trained doctors to practice very aggressive medicine. The resident who orders a battery of tests is praised. Students are told “Don’t just sit there (and think). Do Something!”. Traditionally, our medical culture has been a very macho culture and it is just beginning to change.
Finally, Americans tend to think that “more is always better”. Larger servings in a restaurant, bigger cars, bigger homes, etc. And when it comes to healthcare, patients in the U.S. tend to think that “more care is better care.” They are wrong. Every medical product and service carries some risk. If it provides no or little benefit, the patient is exposed to risk without benefit.
When medical protocols in the U.S. are compared to how medicine is practiced in other countries, researchers have found: —- Much unnecessary spine surgery. The rate of back surgery in the U.S. is five times higher than in the UK. Studies have shown little difference in long-term outcomes for patients who undergo back surgery compared to those who select non-surgical treatment.
The U.S. does more testing than other countries. For instance, the number of MRI and CT tests for every 1,000 people in 2010 was double the average in other OECD countries. Comparatively, there were also more tonsillectomies, caesarean sections and knee replacements. Regardless of how much more nearly every procedure, scan and drug costs; it’s nothing compared to how out-of-whack the medical heroics thrown at Americans in the last stages of life The Cost of Health Care: A Country-by-Country Comparison
Colonoscopies are prescribed and performed more frequently than medical guidelines recommend and are given preference over less invasive tests that screen for colon cancer. Those less invasive tests are not only routinely performed in other countries, they’ve also been proven to be just as effective by the U.S. Preventative Services Task Force.
“We’ve defaulted to by far the most expensive option, without much if any data to support it,” said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.
In the U.S. many more patients die in ICU’s getting futile care. This is a painful, lonely way to die. In other countries, more patients are treated in hospices or allowed to go home where nurses and even doctors visit them.
Half of all heart surgeries (using stents) do no good. We know which half! But stent-makers and other providers have turned this into a big business.
– Our drug companies enjoy 20% profit margins.
– Our device-makers boast 16% profit margins.
We are over-medicated (particularly older people), and undergo too many surgeries that involve very expensive devices. Medicare covers virtually everything (even drugs that have been shown to be dangerous–until they are taken off the market). If it does not cover all of the newest treatments and products lobbyists would howl– and Congress makes sure that heads roll.
This is one reason why we don’t want to give everyone 40 to 65 a chance to enroll in Medicare. No one could afford it. (This idea was considered in the late 1990s. Do you have any idea how much 40-65 year olds would have to pay for our extraordinarily inefficient and wasteful Medicare system? On top of that and like people over 65, they would have to pay hefty sums for MediGap to Medicare advantage — private insurance plans that cover all of the things that Medicare doesn’t.
Medicare is now beginning to cut back, and over time it will refuse to pays for unnecessary surgeries (heart surgeries, unproven prostate cancer surgeries, and some hip and knee replacements, unless the patient has tried physical therapy first–and losing weight, if possible. (Some people just can’t lose weight, even under a doctor’s supervision.)
Medicare will also stop covering every new drug that comes on market, setting up a formulary and only paying for drugs that are effective — and cost-effective. The same will be true of devices.
Then — and only then — we might talk about letting people 40-65 sign up for Medicare, though in many cases, research on quality of care suggests that they would be better off with the best of our non-profit insurers: Kaiser, Geisinger, etc.
Medicare is a highly politicized bureaucracy and inevitably, Congress dictates what it can and can’t do. Medical guidelines should be set by medical researchers and doctors who have no financial interest in the outcome.