Why Is Fixing American Health Care So Difficult?

Meanwhile, the health care provider industry is currently awash with new ideas about improving the quality and cost-effectiveness of the care it delivers. It is well-known within academic health care circles that somewhere between one-third and two-thirds of all care delivered is inefficient and unnecessary.

A huge body of research conducted at Dartmouth under John Wennberg shows conclusively that patients with similar conditions receive significantly different treatment depending on which area of the country they live in and which doctors they see. Even worse, it appears that the more that gets done to patients, the worse are their outcomes. But, of course, no physician or hospital believes that it is the one providing the inefficient or unnecessary care -- it's those other guys who are at fault.

Meanwhile, the medical industrial complex continues to invent more and more high-tech procedures, devices and pharmaceuticals -- all of which come at a higher and higher cost. And why not, as the people who write the checks keep paying.

There have been rapid positive advances in many areas of medical care as a consequence of all this new technology, such as dramatic improvements in the treatment of heart disease, but there has been essentially no systematic analysis of which new interventions are good value for the money. So, for instance, the introduction of drug-eluting stents in the last decade has seen the creation of a multibillion-dollar market for the devices' manufacturers, and even more for the associated procedures.

There has been essentially no assessment of whether this money was better spent than if we had just continued to do coronary-artery bypass grafts for the more advanced cases of heart disease. Recent evidence from teams at Stanford and Duke suggests that the answer might be no, as patients tend to need the CABG eventually anyway.

This is, in fact, the typical pattern of how the health care industry works. It does something new, and employers, taxpayers and, increasingly, consumers, pick up the tab in a fairly unquestioning way. At the margins, employers stop offering insurance and poorer consumers go without, but because health care is such an emotionally important part of most people's lives, it's very hard for consumers and their employers to say "no."

Consequently, even though people drop out, more and more money goes into the system, which increasingly entrenches the interests of those who benefit -- those providing services and the insurers who take a big cut off the top.

Attempts by providers to improve the cost-effectiveness, quality and safety of the care being delivered are done more from a sense of moral obligation than from self-interest. Intermountain Healthcare in Utah, which has probably made greater strides than any other organization in the nation to improve the quality of care it delivers, found that when it reduced the number of hospital-acquired infections among its patients, its profits went down. This story has been well-known in health care for several years, yet only very baby steps have been taken by some of the most sophisticated employers -- and, as yet, barely any by the Medicare program -- to change the "do more, get more" incentives under which America's health care providers operate.

Is There an End Game?

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