American Healthcare Is an American Sickness

Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

Medicine has always been both a business and a profession. Chaucer wrote about it; so did George Bernard Shaw. Balance has always been the key.

By 1985, the balance began to tip toward business—a development I chronicled in JAMA in 1990 with the visual metaphor "medicine's rocking horse."[1] This editorial got me into a bunch of trouble with the Illinois State Medical Society, among others. But I was right. Twenty-seven years later, it has never rocked back, and this imbalance has created the god-awful mess with which we are now burdened.

What could rescue us and set this toppling horse straight? Back in 2012, I blamed "the MBA" in total.[2] [Editor's Note: "MBA" refers to "master's in business administration," which Dr Lundberg used as shorthand for the use of business models in healthcare.] But, I was wrong. MBAs are simply tools used by the medical money culture.

So many books have been written about this issue. How many books will it take? Here are nine that I recommend.

  1. Money-Driven Medicine, by Maggie Mahar[3];

  2. How We Do Harm, by Otis Brawley[4];

  3. Overdiagnosed, by H. Gilbert Welch[5];

  4. Epidemic of Care, by George Halvorson and George Isham[6];

  5. Too Much Medicine, by Dennis Gottfried[7];

  6. Stabbed in the Back, by Nortin Hadler[8];

  7. Hope or Hype, by Richard Deyo and Donald Patrick[9]; another

  8. Money Driven Medicine, by David Cundiff[10]; and my book,

  9. Severed Trust: Why American Medicine Hasn't Been Fixed.[11]

In aggregate, these books did not make a dent. The system just roared on.

Could super-journalist Dr Elisabeth Rosenthal's brand-new book, An American Sickness,[12] be the one that finally makes the difference? Could it activate Malcolm Gladwell's "tipping point"?[13]

Take a look at Rosenthal's list of 10 economic "rules" that are guaranteed to make money, but not to improve outcomes:

  1. More treatment is always better. Default to the most expensive option.

  2. A lifetime of treatment is better than a cure.

  3. Amenities and marketing matter more than good care.

  4. As technologies age, prices can rise rather than fall.

  5. There is no free choice. Patients are stuck. And they're stuck buying American.

  6. More competitors vying for business doesn't mean better prices; it can drive prices up, not down.

  7. Economies of scale don't translate to lower prices. With their market power, big providers can simply demand more.

  8. There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.

  9. There are no standards for billing. There's money to be made in billing for anything and everything.

  10. Prices will rise to whatever the market will bear.

And I add number 11: Always seek consultation; each consult can bill, add more specialized procedures, and refer back.

To her credit, author Rosenthal has provided a ton of actions that consumer patients can take to defend themselves. That is great for individuals. Do it. But even with social media and crowdsourcing, it would probably require something like 100,000,000 Americans taking these actions, in concert, to actually make a dent in this entrenched money-driven establishment. I hope it works, but I doubt it.

In his first inaugural address, Ronald Reagan famously said, "Government is not the solution to our problem; government is the problem." For some things, he was right. Applied to American healthcare in 2017, however, Reagan's dictum is dead wrong. Government is the only force strong enough to put the American healthcare system on a necessary budget. It will be done, sooner or later. Why not now?

That is my opinion. I am Dr George Lundberg, At Large at Medscape.


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