The American healthcare system, or nonsystem as Dr. Arthur Garson Jr. and Ryan Holeywell call it in Exposing The Twenty Medical Myths, is not only bad (life expectancy is 43rd in the world), it is framed in myths and falsehoods. The book shows in no uncertain terms how and why the stories we read are generally wrong, the complaints misguided, and the situation even worse than we think we know.
This is the 36th book on healthcare that I have reviewed, and I can quickly and easily say Exposing The Twenty Medical Myths is the most important book on American healthcare yet. It is focused, clear, organized, cogent, helpful and fair to all. It is carefully written at a lowest common denominator level, with no five dollar words, no hyphenated Latin and no attempt to hide the diagnosis from the patient.
Dr. Garson began as a pediatric cardiologist. He helped a little girl stabilize and survive, and watched her grow to adulthood, becoming personally close with the entire family. One day he took a call from the girl’s mother. The girl had dropped dead after running out of meds. She was 19, and Medicaid had cut her off because – she turned 19. This incident changed his outlook and Dr. Garson moved into the policy and management arenas.
We all think we know about waste in American healthcare, but Garson and Holeywell break out the sickening numbers. Of the one trillion dollars a year that are wasted, $192 billion go to overtreatment (unnecessary tests, procedures and treatments). They say doctors demonstrate an “entrepreneurial spirit”, piling up charges wherever possible. They are encouraged in this by the system, where doctors are self-employed contractors, paid by the piece (“fee for service”). It can also be defensive, as in avoiding malpractice suits and the accompanying insane insurance premiums. When doctors are salaried, overtreatment drops 9-33%. Remarkably, doctors want to get off this hamster wheel too. 69% would prefer a salary plus bonus for positive outcomes. The top hospitals use this adult system, but not insurers or government.
There are calls we aren’t making. Health issues from high cholesterol levels cost $10.8 billion a year to remedy. These costs could be greatly reduced if all people with heart disease took statins daily as prescribed. However, the statins would cost more than $28 billion a year, two and a half times as much. Similarly, the cost of regulating high blood pressure in the entire population is three or four times the cost of treating those adversely affected by it. The authors examine the tradeoffs and point out where not only the system, but we ourselves have been wrong in our arguments. Prevention is not automatically better.
There is incredible bureaucracy. With all the coding necessary to appease insurance companies and government programs for payment, 25% of expenditures go to administration, not care. The book points to Duke University Hospital, where the 900-bed facility employs 1300 full time bill coding specialists. With a single payer system, there would be an instant massive reduction in expenditures and pricing.
So-called corporate wellness programs not only don’t save companies money, they lose money on them. Pointless tests, misinterpreted results and the simple fact that young people won’t feel the bad effects of their abusive lifestyles until much later, mean the whole effort is a loss for the employer. Not to mention employee resentment at the intrusiveness of questionnaires and wristband personal trackers. Surveillance is not healthcare. And the accompanying threats are not welcomed.
Back on the Medicaid front, most recipients already work, but their employers offer no health insurance. So changing the laws to force Medicaid recipients to work in order to receive coverage is largely meaningless. 75% of the uninsured have at least one full time employed person in the family (but the employer offers no insurance). People 19-64 without health insurance die 40% more than those with health insurance.
The best way I can describe what’s going on in Exposing The Twenty Medical Myths is to simply list the chapters, something I have never done before in a review. But the titles are so descriptive and enticing they speak volumes by themselves:
1 Myth: US Health Care Is the Best in the World
2 Myth: In Many Ways, US Health Care Is Cheaper than Other Countries’
3 Myth: The United States Wastes One in Every Ten Medical-Care Dollars
4 Myth: Most Medical-Care Dollars Are Spent in the Last Six Months of Life
5 Myth: The United States Consistently Provides High-Quality Medical Care
6 Myth: Consumers Make the Best Decisions about Their Medical Care
7 Myth: Preventive Care Saves Money
8 Myth: The United States Will Not Ration Medical Care
9 Myth: The United States Faces a Dangerous Shortage of Doctors
10 Myth: The Current Malpractice System Protects Patients
11 Myth: In the United States There Is a Safety Net of Government Health Programs for the Poor
12 Myth: People Who Work Can Afford Health Insurance
13 Myth: The Uninsured Get Adequate Care in the Emergency Department
14 Myth: The Market Can Fix Health Care
15 Myth: Doctors and Hospitals Should Be Paid Separately for Each Service They Perform
16 Myth: The United States Will Never Be Able to Reduce the Cost of Medical Care
17 Myth: When It Comes Right Down to It, Americans Are Like Everyone Else
18 Myth: Previous Attempts at Health-Care Reform Have Taught Us Very Little
19 Myth: Americans Are So Divided That We Can’t Even Agree on Goals for Our Health Care
20 Myth: There Is No Health-Care System That Will Work for the United States
One of the core facts behind America’s spending is a misconception about what medical care can achieve. The authors say 40% of life expectancy comes down to personal behavior. Only 10% of life expectancy can be attributed to medical care. Between self-destructive tendencies and waste in the system, America pointlessly spends trillions annually.
There is a terrific, intelligent discussion of the medical food chain. As the doctor shortage worsens (and doctors collect in big cities), primary care doctors will take on more of the responsibilities of specialists. Nurse-practitioners will take on more of the functions of primary doctors, and technicians will perform more of the routine tests. This “task shifting” should make appointments easier to get and cheaper to perform. Patients themselves will take on more responsibilities through phone and computer apps and home versions of test equipment. Telemedicine will help make up for the lack of rural doctors. Artificial intelligence will help make more accurate decisions right over the phone with a consulting nurse. Finally, leaps into gene modification might begin to lessen the need for constant checkups and monitoring chronic diseases.
As for value received, value is defined as quality divided by cost. If the cost increases without improvements in care, the value decreases as the system heads into volume-based care instead of value-based. This brings up the only obvious omission I could find: shopping. Hospitals will not tell patients what a procedure costs. The truth is they make it up afterwards, jacking it as high as possible, knowing the insurers will knock it down. There is zero transparency for the patient, and looking for value is impossible in the USA.
Exposing The Twenty Medical Myths is a remarkable achievement. In just 210 pages, it captures the essence of the situation and explains it rationally and fairly, backed by facts, figures and direct experience managing the system. It is a sane analysis of an insane nonsystem where the quality of patients’ healthcare varies directly with the quality of their jobs. This is unique in the world and in no way desirable, fair or workable, but the edifice is so huge and convoluted, it pretty much has to continue. Insurers want to profit, government wants out, and patients are caught in the middle, paying more than 30% of their income for coverage at average figures. It’s all just wrong, and the stats show it definitely isn’t working.
But now you will at least know why.
Editor's note: This review has been published with the permission of David Wineberg. Like what you read? Subscribe to the SFRB's free daily email notice so you can be up-to-date on our latest articles. Scroll up this page to the sign-up field on your right.
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