Friday, January 25, 2008

Becoming a Wise Healthcare Consumer

First a disclaimer, I am a bit of an outlier when it comes to the use of physician and other health services. I firmly believe that, at least in the U.S., if we have good insurance, we are overmedicated and generally overtreated for many illnesses and pseudo-illnesses.

An excellent book on this subject is Overtreated by Shannon Brownlee. Ms. Brownlee presents an at times disturbing look at the U.S. health system. We spend more on health care per capita than any other country in the world, but our health care outcomes are worse than many other countries. Part of the problem is our large population (48 million) of uninsured. But, as Ms. Brownlee points out, for those with the resources to pay for care themselves or through their insurers, we are an overtreated population. Too much medical care, according to her, is making us sicker and poorer.

I have spent my entire career in the health care system as a researcher, administrator and consultant. I have worked closely with many of the health system stakeholders that Ms. Brownlee criticizes in her excellent book. I could find very little to dispute. She points out that the amount of care that we receive depends less on our health status than in does on where we live. She describes the work of Dr. Jack Wennberg of Dartmouth who over a 30 year career has vividly pointed out the differences in patterns of care in various parts of the country. In Vermont, for example, he found a wide disparaty between two cities in the percentage of children who had had their tonsils removed. The differences could not be explained by differences in health status. The populations of these two cities were economically homogenous. The difference turned out to be that in one of the cities there was a physician group that was very aggressive in removing tonsils. Over the years Dr. Wennberg has pointed out that variations in physican practice are dramatic as you move around the country.

Our health system has become a Medical Industrial Complex driven by several economic factors. One is Medicare. Hospitals and physicians have become expert at designing their services to maximize reimbursement from Medicare and the Carriers. Rates of reimburseement are high for cardiac procedures so Cardiology has become the biggest money maker for many hospitals. This has led to a dramatic increase in the number of Angiograms, Cardiac ByPass surgeries and Stent implantations. To make matters worse, there is evidence that many of these procedures are not only overused, but do not improve the long term health of the patients who receive these treatments and may even harm us. Ms. Brownlee points out in disturbing detail how our health care system has become focused on revenue generation and only secondarily on patient welfare. A prime example is the pharmaceutical industry, which, over the past 10 years or so has moved into direct-to-consumer marketing of prescription drugs. This has led to huge increases in the number of prescriptions that physicians write and, not surprisingly, shocking overuse of medications that not only do not improve health, but often contribute to deterioration of health.

This is not to take away from the wonderful improvements in medical technology that we have seen over the past few decades. Many people have benefitted from life-saving procedures, devices and medications. But the economics of healthcare lead to overuse of these services which not only contribute to fast growing national health care expenditures, but also poorer health for many patients.

To Brownlee's credit she finishes the book with a prescription for fixing our ailing health system. Political candidates wishing to reform health care would do well to read this book.

What does this mean to health consumers? It means that we have to educate ourselves, be willing to get second opinions from trusted sources and be sensitive to the fact that our physicians and hospitals may have profit-making motives that may trump their concern over our health and welfare. We need to be on guard all the time when encountering the business of healthcare delivery.

I will be writing much more about this topic in future posts. I am firmly convinced that understanding the serious flaws in our health system and educating ourselves as best we can about various treatment options when we need care makes us wiser consumers. Being a wise consumer of health care services is an important component of a healthy lifestyle.

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