by Bruce Goldman
The U.S. health care system, although it’s the costliest in the world, doesn’t even deliver the goods when it comes to delivering health. That’s the conventional wisdom. But is it true?
At least a few well-researched studies by credentialed and respected experts suggest we might want to pause to consider whether, in the mad dash now underway to fix our ailing health care system, we could inadvertently end up breaking parts of it that work very well.
Money down the drain?
Let’s start with a claim we’ve been hearing a lot lately, summarized as follows: High-tech treatments and procedures (MRI and CT imaging, sweeping use of pricey meds, etc.) cost a fortune, yet produce no substantial treatment gains and carry little preventive payoff.
Here’s a study, by University of Pennsylvania scholars, showing that five-year survival rates in the U.S. for cancer and heart disease are the world’s highest, due not only to earlier detection but also to more-aggressive treatment of these conditions once they’re caught.
And then there’s a National Bureau of Economic Research analysis whose author looked state by state and found that the more a state was characterized by high usage of sophisticated diagnostic imaging, the greater the longevity within that state. According to the study, this was a causal relationship, not an artifact (such as richer states having healthier people and more high-tech equipment).
No doubt there’s a whole lot of prescribing and imaging going on in these United States, and some of that — maybe a lot of it — is wasteful. But there are reasonable ways of dealing with this short of a complete overhaul. Why not ban self-referral (i.e., to a diagnostic facility, by a physician who owns a piece of said facility). How about reforming American tort laws, whose financial costs to the health care system far exceed the direct-litigation expenses because medical practitioners prescribe diagnostics and drugs out of fear of malpractice suits, and because specialists’ sky-high malpractice insurance premiums are passed on to patients.
Life in the U.S.A.: Short, nasty, and brutish?
Finally, what about the claim that “U.S. life expectancy falls short of that in other advanced countries, no doubt as a result of our broken healthcare system”? After all, there’s no primary endpoint like death, is there?
Health economists Robert Ohsfeldt of Texas A&M and John Schneider of Health Economics Consulting Group dispute the widely held assumption that Americans’ substandard life expectancy reflects the poor health care served up in this country. They found that, once you factor accidents and homicides out of the picture, U.S. longevity is unsurpassed. As reprehensible as our high murder rates are, they can’t be construed as an indictment of the American health care system, can they? (And if they can, what in the bills now worming their way through Congress would change this?)
Also dragging on America’s calculated overall life expectancy is what all acknowledge to be a relatively high infant-mortality rate. The presumption is that this high rate probably stems from an abundance of preterm births attributable, in turn, to mothers deprived of prenatal care. That’s a plausible claim — but one confounded a bit by a recent March of Dimes white paper, which flags high and increasing rates of preterm births in the United States — and in Canada, and in Sweden, and in Denmark, countries seldom accused of neglecting pregnant moms.
An alternative hypothesis is that high premie rates could reflect older would-be parents’ rising resort, in economically advanced countries, to fertility-assistance techniques. And America’s infamous high reported infant-mortality rate is to no small extent the product of the heroic efforts now routinely made (certainly in the United States, as any neonatologist specialist can attest) to rescue premies that, in past days, would have been logged not as dead infants but as stillbirths.
Expensive? No question. Inefficient? Maybe. But, just maybe, those bucketloads of bucks we collectively throw at our medical problems aren’t going entirely down the drain.
Bruce Goldman covers immunology and infectious disease, neurosciences, cell biology and biochemistry on Scope at the Stanford University School of Medicine.
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