'Perverse' Incentives Examined in New Health Care Documentary

Aug. 12, 2009— -- This year, August recess for members of Congress comes with a hefty (home)work load. As the Sept. 15 due date set by President Obama for health care reform approaches, the raging debate has both Democratic and Republican lawmakers encountering town hall meetings that often turn into free-for-alls.

On Tuesday, Obama travelled to Portsmouth, N.H., for the first of three health care town meetings, using the presidential bully pulpit to counter criticism of the health care reform proposals.

"There's been a long and vigorous debate about this, and that's how it should be. I hope we will talk with each other and not over each other," Obama told the crowd of 1,800 listeners.

Amidst the finger pointing and the shouting comes a quiet new documentary that offers another diagnosis of what's ailing the country's health care system. The documentary is called "Money Driven Medicine."

Reporter and author Maggie Mahar, who wrote the book that inspired the film, says the root of the problem is that the health care system has become profit driven. In an interview with "Nightline" anchor Terry Moran, Mahar said, "What I learned, knowing Wall Street pretty well, is that our health care system was profit driven. Those people who made money on the health care system were really in charge.

'They Pay What They're Told'

"They could charge whatever they wanted to," she said. "If you have cancer, and you're told the cancer drug is $10 million, even if you had to pay out of pocket, you probably would mortgage your house to do it. This isn't about skin in the game; this is about people who are really sick. Eighty percent of our health care dollars are spent when people are really sick. They don't have a lot of choices as consumers to shop around or to demand a lower price. They pay what they're told they have to pay, whatever the market will bear."

Veteran filmmaker Alex Gibney, who directed "Money Driven Medicine," wanted to hear the stories of doctors on the frontline who understood the issues. "We went out and photographed a lot of doctors and, indeed, doctors who had opted out of the system to become spokespeople for a new idea, to say, 'You know what? Our system is not the best in the world,'" said Gibney.

"It's the best in the world at some small things, what they call 'rescue care,' these high-octane, very technologically proficient procedures. But we're terrible compared to other industrialized, democratic nations in primary care or preventive care. So, you know, they were saying, 'It's broken, we gotta fix it.'"

Health Care Quality Versus Quantity

According to these doctors, it's the treatments, test, surgeries and pills that get paid for, not healthy results. That in turn creates what Gibney calls "supply driven demand, meaning, the more supply you create, the more people demand. And the way it works is this: If you have five big MRI machines in your hospital, next thing you know, there are pressures on the doctors in the hospital -- 'Well, you know, how about another MRI, let's take a look at that.'

"And next thing you know, the MRI machines are being used around the clock," added Gibney. "But you don't always need an MRI -- a good orthopedist can kind of feel your knee or look at an X-ray, which is cheaper, and figure out what's going on much more simply."

"The financial incentives are perverse. We pay doctors for doing more. What we should be doing is paying them for the quality, for better outcomes, for effective care. Instead, we're paying them for quantity," Mahar further explained.

Gibney has tackled tough, complex subjects before. His film "Taxi to the Dark Side" was about the torture and murder of an innocent Afghan cab driver by American interrogators. It won an Academy Award for best documentary in 2008.

Sharper Focus on Health Care

One of Gibney's other movies was "Enron: The Smartest Guys in the Room," which told the story of the greed and criminality that brought down the giant energy trading company.

Now, Gibney has focused his lens on health care. What makes "Money Driven Medicine" compelling is how the film listens -- to patients and, even more, to doctors.

Dr. Andrey Espinoza, an interventional cardiologist, shared his views in the documentary. "What I miss most is the ability to sit in a room and talk with a patient for an hour. You see somebody for 15 minutes, 15 minutes is a long time these days. Basically, you get on the assembly line," he said.

And that assembly line is driven, the film argues, by a profit incentive that pays for simply doing things to people rather than making sure they are well. And, as the movie shows, more and more doctors are branching out -- becoming part owners of the hospitals and testing centers they send patients to -- a potentially sharp conflict of interest.

Doctors Driven by Pressure, Not Greed

But Mahar thinks that most doctors aren't susceptible to the naked greed depicted in Gibney's Enron film; in the health care system that has developed in the United States, it's more insidious. "Most doctors are doing the best they can for their patient. But you've got all these other pressures, the drug makers, the device makers, trying to sell them the most expensive drug and device. You've got a hospital that wants them to do as many tests and procedures as possible because that's how the hospital stays in the black."

So, what's the fix?

Though Gibney and Mahar do not take a specific stand on the contentious issues in the health care debate, the emotional stories the movie tells -- a doctor whose daughter is stricken with leukemia, a woman whose husband is terribly burned -- point to one big idea.

"The more that patients are involved with their own health care, by mandate, or because they're working with good doctors, they actually make really good, informed decisions that are more frugal than the decisions made by insurance companies," said Gibney.

"I think if we actually take health care and put it back in the hands of the patients and the doctors, instead of the insurance companies and the manufacturers, we're going to be a lot better off," he added.