Overtreated

Here’s a book for my “to read” list. Shannon Brownlee’s Overtreated, a book receiving positive reviews like this one from Publisher’s Weekly:

Medical journalist Brownlee acknowledges that state-of-the-art medicine can improve care and save lives. But technology and drugs are misused and overused, she argues, citing a 2003 study of one million Medicare recipients, published in the Annals of Internal Medicine, which showed that patients in hospitals that spent the most were 2% to 6% more likely to die than patients in hospitals that spent the least. Additionally, she says, billions per year are spent on unnecessary tests and drugs and on specialists who are rewarded more for some procedures than for more appropriate ones. The solution, Brownlee writes, already exists: the Veterans Health Administration outperforms the rest of the American health care system on multiple measures of quality. The main obstacle to replicating this model nationwide, according to the author, is a powerful cartel of organizations, from hospitals to drug companies, that stand to lose in such a system

I think her diagnosis makes sense to most people; it does seem like there is a lot of unnecessary treatment and given that health care providers are on a fee for service system—its not surprising.

But that’s where agreement will end. Few people are proposing her solution—even Kucinich isn’t proposing a VA system for all, and physicians on salary.

Republicans think this problem can be addressed by empowering consumers. The reason there is overtreatment, they say, is because insurance companies pay for services; consumers never see the bill. Turn loose the American consumer on the health care industry. That will drive down overtreatment and costs.

As an abstract argument, this approach has some merit, but there are some problems in the details. One, is the demand for medical services really like the demand for big screen TVs and cars? It’s entirely likely that I would want a 60″ plasma tv without needing it, but how likely is it that I will want physical therapy or surgery or nursing home care–without needing it? For many consumer goods the requirement that I choose what to buy with my own money is a useful drag on overconsumption, but it doesn’t matter how much money I have, I’m not going to buy a root canal unless I have to.

Two, think for a moment about the implications of consumers being responsible for driving down costs and overtreatment. Consumers (aka patients) would need to assume that the sellers (aka hospitals, doctors) are trying to sell them too many things at the highest price possible. Therefore patients would need to question all treatment proposals and—not being trained in medicine—at a minimum, get an independent opinion. Patients would also need to shop for better deals and dicker with physicians and hospitals for lower prices. Arranging for surgery would be like buying a used car. You’d have to be ready to walk off the lot at least once during negotiations, or risk being hosed by the dealer.

Regardless of whether it would work or not, do you really want to walk into a hospital or clinic in the same defensive and suspicious frame of mind that you walk onto a car lot? This is the GOP proposal to fix healthcare.

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