Shift Happens

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer by Shannon Brownlee (Bloomsbury, 343 pages, $25.95)

Sick: The Untold Story of America's Health Care Crisis by Jonathan Cohn (HarperCollins, 302 pages, $25.95)

A Second Opinion: Rescuing America's Health Care by Arnold S. Relman (A Century Foundation book published by Public Affairs, 205 pages, $24.00)

The problem is that most of us are healthy most of the time. At least, that's the problem if you want to change the health-care system. In any given year the average American isn't likely to come face-to-face with the worst that system has to offer. And those who confront its limitations most often -- the chronically ill and the uninsured -- also happen to be among the most powerless groups in the electorate. Meanwhile, the economic burdens grow each year: Medical goods and services become ever more expensive, and employers and insurers shift more costs to patients.

It's not as if we haven't had a series of attempts at reform, but the pull of medicine for profit has distorted nearly all of them. Health maintenance organ-izations (HMOs) had noble origins in the mid-20th century as an innovative means of providing comprehensive and integrated coverage through nonprofit organizations such as the Group Health Cooperative of Puget Sound and Kaiser Permanente. In the mid-1970s, innovative primary-care residency programs developed (I trained in one of them) to turn out a new breed of doctors who would focus on appropriate and effective care in a new patient-centered world. Besides immersing us in the traditional arcana of acute hospital treatment, we also learned how to care for ambulatory patients as well. It seemed then as if the front-line practitioner -- the patient's ally, the steward of the system -- would move up from the bottom of the health-care hierarchy to assume a long-denied position of centrality and authority.

That noble vision lasted for just a few years. Corporate insurers took over, with a business model based on avoiding sick patients and limiting what was provided to those who did get covered -- turning the once-idealistic concept of the HMO into a reviled epithet. The old general practitioner, who had become a "primary care doctor," now became a "gatekeeper," as physicians were enlisted in insurance companies' attempts to reduce their medical loss ratios -- what the rest of us call taking care of sick people.

These new books examine this sordid transition from three perspectives. Shannon Brownlee's Overtreated provides a welcome antidote to the narrow view that simply finding enough money to buy health insurance for all the uninsured would solve our health-care crisis. She reminds us that entrepreneurial medicine often drives physicians and other providers to do too much to patients, which can be bad for their health as well as for everyone's wallet. Doctors order costly imaging studies like MRIs and CAT scans when a careful history and physical exam would do. They administer courses of toxic chemotherapy (which account for over half the revenues of many oncology practices) to dying cancer patients in the absence of evidence that it will help. They manage heart disease with invasive procedures when much simpler regimens would work as well.

As Brownlee points out, the culprit here is not just the for-profit free-for-all that American medicine has become. Patients often demand the fanciest technology for its own sake, and physicians sometimes prefer to provide the newest and most complex treatments because they want to do everything possible for their patients. But these desires alone cannot explain the irrational technological exuberance of U.S. health care. Physicians in other advanced nations want to be on the cutting edge, too, and patients everywhere want the best care available. What is distinctive about our system is that it provides economic incentives that encourage doing the most expensive thing all the time to everyone who can pay for it or have it paid for. In most settings, there is little pressure to consider costs, and much reason for physicians, patients, and other decision-makers to maximize expenditures. In the effort to prevent unnecessary expenses, we have introduced new layers of care deniers, who sometimes deny coverage even for appropriate services. And so the world's most expensive health-care system paradoxically provides a great deal of medical care that isn't needed, while people who lack coverage cannot get even the most basic services. Overtreated is a must-read for all those (and there are many) whose main concept of "fixing the health-care system" is buying Blue Shield or Medicare for everyone.

Sick, by Jonathan Cohn, focuses instead on those for whom the glass is less than half-empty, following nine patients in their often-bloody confrontations with American health care and health insurance. Near Boston, a middle-aged woman with heart disease dies when an emergency room goes "on divert" because of overcrowding, forcing her to another institution that can't provide the care she requires. In Florida, an office worker is denied medical insurance because she has diabetes. A California security guard has a stroke that might have been prevented if he had been able to afford treatment for his chronic illnesses.

These are more than depressing horror stories (or train wrecks, as physicians sometimes call such cases). After engaging the reader in these gut-wrenching personal histories, Cohn skillfully uses each well-researched vignette to illustrate just how health care in America so often goes off the rails. It is as if each case is subjected to a careful systems autopsy to demonstrate just how a lesion here, a deficiency there, an inbred vulnerability throughout, came together almost inevitably to generate these human disasters. He also backs his reporting with a solid presentation of otherwise esoteric health-policy data and theory.

Despite his excellent diagnostic acumen, Cohn does less well with therapeutic recommendations. A short final chapter on policy options confuses government-provided health insurance with direct government provision of medical services, an error that still bedevils much progressive debate about where to go next (Britain is not Canada). But as a compelling, authoritative analysis of what's wrong, how we got there, and what our system is doing to our fellow citizens, Cohn's eminently readable book will draw even the most jaded observer into a useful state of coherent fury. Think Arrowsmith meets SiCKO meets The New England Journal of Medicine.

The editor emeritus of that journal, Arnold Relman, has produced a book that is likely the most concise and best analysis of the American health-care debacle now available. A distinguished academic and clinician with extensive experience in several aspects of medicine and broad interdisciplinary acumen, Relman gets right to the point in A Second Opinion. He describes how we ended up commercializing nearly all of medicine, the harm caused by that shift, and how to fix it. Most current policy proposals deal with finance but say little about the organization of medical care. Relman puts the organizational issues back in the center, insisting that we need nonprofit groups of practitioners working in integrated systems, efficiently sharing information, and coordinating resources for the benefit of the patient. Such systems would be more likely to provide high-quality care in an affordable manner instead of gaming the system to maximize reimbursements and stinting on unprofitable services.

This theme, presented so cogently in A Second Opinion, is the missing element in most popular discussions of health reform. The main problem we face is not how to buy more health insurance for the uninsured. It's about how to organize health care so that it works better and doesn't cost at least 50 percent more per capita in the United States than in the rest of the industrialized world, especially because we get only average medical outcomes for the additional expenditure. As Relman and others suggest, restructuring care to provide evidence-based, patient-centered, comprehensive services through nonprofit integrated delivery systems is the key to an effective and affordable system.

Relman, who coined the term "medical-industrial complex" in a seminal 1980 New England Journal article, has spent nearly his whole medical life (which dates back to 1946) in the part of the system generously called nonprofit. As a result, he is particularly acute in pointing out that even some of our most esteemed academic and community institutions have learned to emulate their corporate brothers in adopting business strategies that evoke Halliburton more than Hippocrates.

Three chapters of A Second Opinion are particularly welcome. In one, Relman demolishes the currently trendy consumer-driven health-care movement and its much hyped individual health savings accounts. Under the guise of patient empowerment, this vicious little idea further erodes what is left of the medical safety net by encouraging the healthy to spend as little as possible on health insurance and to pocket the difference. He points out a fact that marketplace aficionados usually don't understand: Expecting consumers to drive up quality and push down costs by making smarter medical-care purchasing decisions reveals a dismal understanding of the (often absent) information that would be needed to guide such choices, and also makes the fatal assumption (perhaps literally) that consumers can evaluate a surgical procedure or a medication as if it were analogous to a new car that they might test drive around the block.

Relman also addresses The Canada Syndrome head-on by discussing just what works well and what (face it) works badly in the much-debated system to our north. He points out the folly of shutting down discussions about universal coverage with condescending references to all those long waiting lines in Toronto and Montreal. Yes, there is more waiting in Canada for some elective procedures than well-insured patients have to endure in the United States -- but not for acute care, emergency care, or primary care. And in the United States, a wait can be infinitely long if you don't have coverage. Relman's analysis reminds us that our health-policy goal needn't be the system that Canada, or Great Britain, or even France has. All we have to do is try and develop a much better version of American health care.

The book's final chapter, "An Open Letter to My Colleagues in the Medical Profession," is a doctor-to-doctor chalk talk that's well worth the attention of non-physicians as well. The system isn't working for us or for our patients, Relman reminds us. Some of us are getting very rich, but most of us are being nibbled to death by restrictions on what we can do for our patients, and inundated with mindless billing forms and administrative garbage. We find our professional lives increasingly distorted by commercial pressures that distract us from the compassion and scientific rigor that initially drew us into this calling. Relman calls on his professional brethren to lead the fight for a kind of universal coverage that is centered on clinicians serving patients.

Although his appeal to physicians is not directed in the same way toward patients, Relman might have made a similar case to them. You wanted lower costs, he might say, you wanted to keep all your options open, you wanted government out of the picture. Here is where we've ended up in 2007. Is this really what you wanted?

As these books remind us, the American health-care system may finally be imploding from the weight of its unsustainable cost, intolerable inequity, and (on average) mediocre outcomes. As a disclaimer, I've been expecting that since about 1970. But shift happens. What may really drive change now is the increasingly common strategy of insurers, employers, and government to transfer more and more costs of care onto the shoulders of patients through higher co-payments and deductibles, or termination of coverage altogether. This trend may kick-start a new movement for reform much as the draft galvanized opposition to the Vietnam War in the 1960s. Most people aren't propelled into action over abstract issues of distributive justice or rational policy. But when you lose your health insurance because your company ends its coverage, or your spouse can't afford the medicines her doctor prescribed, or your kid can't get a necessary surgical procedure, arcane policy choices jump to life, as they did for the patients in Cohn's book. With these books, an aroused citizenry (remember them?) will have three good manuals to carry into battle.

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