The Great Health Care Bailout

Jan. 14, 2009— -- "Bailout" conjures up an act of desperation to keep a sinking boat afloat. For our financial system, we're all wondering if "bailout" is plugging holes in the hull or just throwing good money after bad.

In "reforming" our sinking health care system, we need assurance up front that we're not paying for a similar bailout in disguise.

There is no argument that the United States supports the most irrational health care system on the planet. By 2006 we were spending almost $7,000 per capita. That's about twice what was spent in Australia, Canada, Germany, The Netherlands, New Zealand, Switzerland, or the United Kingdom, and it is more than twice that spent in Japan.

However, by any measure of health, all these countries are buying much more bang for the buck. The American health care system is more than irrational; it's an indefensible travesty.

There is no argument as to the inadequacies of the organization of the American health care system. It is inefficient, uneven in quality, inequitable in distribution and overpriced. Most of this has become painfully obvious to all of us, except maybe the overpricing. For example, for comparable drugs, the price per pill in the U.S. is 50 percent higher than in EU countries.

Furthermore, the U.S. system is inefficient, uneven, inequitable and overpriced despite the fact that we are pouring money into its administration. By 2006 we were spending about $450 per capita to administer our system; no other country came close. France got away with $250 per capita, Canada $150 per capita, and Denmark, Finland and South Korea were under $100 per capita.

There is no argument that the administration and administrative structure of the American health care system need to be brought to heel. The rallying cry of the leading health care reformists is to render delivery of health care efficient, equitable, and higher in quality -- and to do so before the current system leaves us even less well and less well off. Single payer, standardization of care, electronic medical records, pay for performance, and a tweaking of the pricing structure are in our future.

Debate of Health Care Reform

There is no argument that such reforming is long overdue.

However, there is a compelling argument that such reforming is doomed to render us even less healthy and much more rapidly bankrupt.

Certainly, more Americans would have ready access to coronary artery bypasses and stents, to arthroscopic surgery, to pills to lower their blood sugar or cholesterol or mild hypertension, to spine surgery, end-of-life intensive care, and so much more. The trouble is that these and many other high ticket items, which account for the majority of the direct cost of health care, either don't advantage patients at all or do so minimally. That is not a matter of opinion; it is the inescapable conclusion derived from the relevant science.

Health care reform that takes efficiency, equitability of distribution, and quality of performance as its primary goal might reduce the cost per case, a savings blunted by an increase in case load because of the more equitable distribution. It will succor the system and all its stakeholders and rescue those who fear a contraction in the market as the ranks of the uninsured and underinsured swell. But it will do nothing for the health of Americans.

Rational reform is not possible until we, as a nation, learn to demand effectiveness from medical treatment. If it doesn't work, Americans should not want it at any price. If more than 50 patients with a particular condition need to be treated to afford one beneficial outcome, Americans shouldn't opt for it.

That's not rationing; that's because an individual who does not have the medical or surgical intervention may be just as likely to enjoy such an infrequent meaningful benefit as an individual who does.

(In fact, I'd stake the cut-off at one benefited in 20 treated, but that's a matter of philosophy that needs a transparent discussion.)

We have the talent, the methodology, the ethic to place effectiveness at the top of our reform agenda.

Then we can rationally turn our attention to efficiency, equitable distribution, and quality of performance. The cost per capita of a health care system that takes effectiveness as essential, regardless of the suppositions, is a fraction (less than a third) of what we spend today. More importantly, physicians will be serving patients instead of being constrained by a system that is ethically bankrupt, and patients will be truly and well served.

And all that misspent money can be redirected to the major public health crisis in America, the macroeconomic crisis that deprives the growing numbers of unemployed, downsized, disaffected, disallowed and disavowed Americans the promise of a long and fulfilling life.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at theUniversity of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," and "The Last Well Person."