The Sorry State of Health of US Medicine

As the debate about healthcare in the United States rages, several articles in the March 2011 issue of The American Journal of Medicine strive to add reasoned arguments and empirical research findings to the dialog.

The issue leads off with the editorial, “The 800-Pound Gorilla in the Healthcare Living Room,” by Journal Editor-in-Chief Joseph Alpert, MD, professor of medicine at the Arizona College of Medicine in Tucson. As a practicing physician and medical educator, Alpert has first-hand experience with the current environment of medical treatment. In his view, “the most important deficit in our new healthcare legislation was the failure to address the 800-pound gorilla sitting squarely in the middle of the US healthcare system: the need for tort reform.”

He contrasts his own training at Harvard Medical School, where the rule for good patient care was “Don’t order any test or intervention (medical or surgical) that has little or no chance of improving the patient’s quality or length of life” against the current rule: “Order a huge array of tests, including radiographic imaging, to rule out every conceivable clinical condition including very unlikely diagnostic entities.”

Without meaningful reform to stem the tide of defensive medicine with its staggering volumes of unnecessary diagnostic testing, he believes that all attempts at controlling health care costs in the US will be doomed to failure.

In “On the Critical List: The US Institution of Medicine” authors Salinder Supri, PhD, of Änderung Consulting, and Karen Malone, University of Medicine and Dentistry of New Jersey, examine the US institution of medicine. They characterize it not as a single, comprehensive and cohesive system of health care, but instead, as a myriad of large and powerful organizations including insurance companies, health maintenance organizations (HMOs), corporate for-profit hospital chains, and pharmaceutical companies.

The authors lay out the “rules of the game” as played by these interconnected entities. Insurance companies have set the rule “restrict choice and coverage” by using an elaborate system of co-payments and deductibles, exclusion clauses, and loopholes.

HMOs have set the rule “manage care” to limit the number of treatments patients receive, the days spent in hospital, and their choice of provider. The pharmaceutical industry has set the rule “charge as much as we want, because insurance will pay.” This rule has resulted in prescription drug prices that are nearly 60% higher than in Canada, and nearly 100% higher than in Europe, and has led to patients being prescribed sometimes unnecessary, often useless, and even potentially dangerous drugs.

Finally, corporate hospital chains have set the rule “test as much as we want, because insurance will pay.” Under this rule, they extend the patient’s range of tests and procedures, even when excessive or unnecessary.

According to the authors, “The sum of the ‘rules of the game’ devised by these organizations has resulted in a fragmented, haphazard, and broken system of health care. Reform is long overdue, and … this requires us to understand these rules, who is setting them, and how these rules are being used to exploit the system of medicine. Only then can we begin to heal our ailing health care system.”

In “Medical Bankruptcy in Massachusetts: Has Health Reform Made a Difference?” investigators David U. Himmelstein, MD, and Steffie Woolhandler, MD, of the City University of New York School of Public Health, and Deborah Thorne, PhD, of Ohio University, surveyed bankruptcy filers in Massachusetts in 2009, comparing them with similar subjects from 2007.

They report that during this time period the share of all Massachusetts bankruptcies with a medical cause went from 59.3% to 52.9%, a statistically non-significant decrease of 6.4 percentage points. Because there was a sharp rise in total bankruptcies during that period, the actual number of medical bankruptcy filings in the state rose from 7,504 in 2007 to 10,093 in 2009.