What Are the "Top 3" Changes Needed to Improve US Healthcare?

Robert M. Centor, MD; Pennie Marchetti, MD; R.W. Donnell, MD; Roy M. Poses, MD

Disclosures

November 13, 2006

In This Article

Pennie Marchetti, MD

Asking a doctor to recommend 3 things to improve American medicine is a little like granting him 3 magical wishes. There are so many possibilities, it's hard to choose. My own choices come from the perspective of a solo family physician whose patients come from diverse backgrounds and whose insurance coverage runs the gamut from self pay to the most generous employer-provided insurance imaginable.

From that perspective, I would have to say that my first wish would be to introduce more patient responsibility into healthcare decisions. We once had a system in which the doctor was held accountable first and foremost to his patients, but that system is long gone. In the 1990s, we made the switch to a system in which doctors were accountable first and foremost to insurance companies. But very few people trust big business, especially big insurance business, so the system quickly devolved -- with the help of political pressure -- into one in which doctors were accountable to no one.

A good example of this lack of accountability was the use of bone marrow transplants for advanced breast cancer. Despite little to no evidence of benefit, insurance companies were pressured to pay for it or risk demonization and loss of customers.[1] Where has that gotten us today? To a point where we routinely recommend tests and treatments of marginal benefit but substantial cost. We spend billions on cholesterol drugs and billions more on lab tests to monitor them to reduce the rate of heart disease by 2% to 3%. We are about to spend $225 per infant on immunizations against rotavirus[2] to prevent 13 deaths a year, an equation which the US government itself admits is not cost-effective.[3] Who knew we were so altruistic?

Well, we aren't. We just don't realize what it costs. It's the insurance company's money, or the government's money. We are like the spend-thrift wife of the rich man who thinks mistakenly that the source of her money will never run dry. It's always so much easier to spend someone else's money. But, of course, in this case we do pay the price. We pay it in higher insurance premiums and higher taxes, or the loss of other government services, like education or defense. If we had to be held accountable for the cost of our recommendations and the magnitude of their corresponding benefits, we'd curb our enthusiasm. And the best way to be held accountable is for both the patient and the doctor to have an incentive to discuss the issue. The only way that that is going to happen is if the patient has to bear some of the cost. Who among us would not chose the Mercedes over the Ford if someone else was footing the bill?

My second wish would be to stop direct-to-consumer advertising. The lack of accountability in American medicine left a breach into which the pharmaceutical industry was happy to leap. Is there any other industry that has the advantage of advertising its wares to consumers who don't have to pay for the product themselves? With no incentive to comparison shop, it's no wonder that the drugs most heavily advertised to consumers are also the most popular selling drugs.[4] In 2000, direct-to-consumer advertising was responsible for an additional $2.6 billion in drug spending.[5] This is a price we all end up paying.

My third and final wish would be to relieve the coming demographic crunch. In 5 years, the first wave of baby boomers will reach 65. Doctors will be among them. The coming years will see declining numbers of doctors just when they will be needed most. Who is going to manage the rising tide of diabetes, hypertension, coronary artery disease, arthritis, and the other myriad diseases of aging? We should ask ourselves now, not later, if it's worth the time and money to collect labs every 3 to 6 months, to pile drug upon drug, in pursuit of a medical ideal that's more suitable to a young person than someone with 10 or 15 years of life remaining. Should we continue screening colonoscopies for the low risk? Should we dialyze the elderly? What about liver and kidney transplants?

The reality is that our resources -- in terms of time, manpower, and money -- are limited, and unless we do some hard thinking about the limits of those resources and of the benefits of what we do, things will only get worse.

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