Critical Condition: How Health Care in America Became Big Business & Bad MedicineBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7482.99 (Published 06 January 2005) Cite this as: BMJ 2005;330:99
These authors may have won a couple of the highly respected Pulitzer prizes, but their journalistic style owes more to the newspaper proprietor the prize is named for. Towards the end of the 19th century Joseph Pulitzer's New York World engaged in cut-throat competition with William Randolph Hearst's New York Journal, each trying to outdo the other in sensationalism, emotional exploitation of news, and what became known as “yellow journalism.”
Critical Condition, with its litany of horror anecdotes, hyperbole, and frequent distortions, is more in that mode. “Everywhere there is unease,” the authors write, while contributing to it themselves by citing numerous examples of the US healthcare system failing individual patients. Take, for example, the retired seam-stress whose gallstones were diagnosed but whom the hospital refused to treat because she was uninsured. Retired? If she was over 65 she would have been covered by Medicare; if in poverty, by Medicaid.
US drug companies spend some $3bn a year advertising their prescription products directly to the consumers
And yes, it's a national disgrace that an estimated 45 million Americans are uninsured. Even so, health policy panellists at the recent conference of the American Society for Bioethics and Humanities noted that about half of these people are uninsured for a full 12 months and that ensuring a basic level of insurance for all of them would add an estimated 4% to the total US healthcare bill, now estimated to be $1.6 trillion. Barlett and Steele trot out the—surely hyperbolic—statements that this figure will soon be in the multitrillions and that more than 100 million Americans are underinsured. Moreover, they note, Americans live an average of two years less than Canadians; but they fail to mention that this has less to do with health care than with such social issues as crime and ghettoisation. And when the late premier of Quebec, Robert Bourassa, developed cancer, he fled to the United States for treatment. The authors do note, though, that the United States stands 29th in a World Health Organization league table of health criteria, somewhere “between Portugal and Slovenia,” yet few if any Americans seem to be seeking care in Slovenia or any of the other 28 nations listed.
Market driven care is exactly what Americans want, if it can be made to work
The authors claim that there are “thousands” of health insurance plans, but there are in fact 1300. They allege that overprescribing of drugs “on a titanic” scale is turning the United States “into the world's pill capital,” yet the French consume more pills per person. It's true, though, that US drug companies spend some $3bn a year advertising their prescription products directly to consumers and that this adds hugely to the cost of health care. As a speaker at this year's meeting of the American Medical Publishers Association put it: “A few years ago, you'd be lucky if you could find a dozen men suffering from ‘erectile dys-function.’ Now it's become a multimillion dollar industry.” But when the authors state that drug companies pay doctors to attend dinners “and talk about the curative powers of their latest drugs” they're behind the times. Those companies are no longer allowed to bribe medical practitioners, and studies show that “physician access”—or lack of it—is a subject that keeps drug company executives awake at night.
Citing “financial carnage” even where efficiencies have been achieved, the authors remain sceptical. For instance, they say that between 1980 and 2001 US hospitals lost 29% of their beds. Yes they did—mainly as a result of decades of duplication and waste. They note that managed care was supposed to reduce costs. It did—from annual escalations of 18% a year to about 4%. The fact that these are rising again has mainly to do with an ageing population, increasingly sophisticated and expensive technology, and inflated malpractice awards. They deplore the “faceless bureaucrats” in call centres in “nondescript buildings” who are making healthcare decisions. Yet this, surely, is a form of evidence based medicine and even a counterweight to what Michael Millenson, in Demanding Medical Excellence, says were an estimated two million unnecessary medical and surgical procedures performed each year before managed care.
In their chapter entitled “The Remedy” the authors make the leap of comparing the American healthcare system to the D Day landings if the Allied forces had all been operating as individuals rather than as a coordinated whole. Essentially, their remedy for the system is an independent, single payer agency much like the Federal Reserve that, they argue, would “instantly correct everything that's wrong with market driven health care.” It would guarantee all Americans basic care, pay all costs to treat catastrophic illness, allow patients to choose their own doctors, allocate money for preventive care, control costs, and scale back overdiagnosis and treatment. People could supplement their basic coverage through private insurance.
The trouble is that market driven care, as Regina Herzlinger puts it in her best selling book of that title, is exactly what Americans want, if it can be made to work by what she calls “activist consumers, entrepreneurial managers, and innovative technologies that are mapping out the new market-driven healthcare system that these forces are creating.”
And surely competition is vital to bring that about. Describing the noted guru of managed care Alain Enthoven as “the person generally credited with spawning the idea that competition would be the salvation of American healthcare” and as “a technocrat with a coldly analytical belief in the power of computers to solve problems” Barlett and Steele surely over-reach and misconstrue the American ethos of individual, rather than collective, enterprise.
Cold analysis is needed for a clear eyed approach to reforming American health care. You won't find much of it here.
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