On health care, paying Cadillac prices for a Pinto

April 14, 2000|By Barbara Starfield

MANY AMERICANS lament the high cost of U.S. health care, but console themselves with the thought that, well, it's expensive because it's the best care available in the world. It sounds good, but it's not true.

At least, not when you look at the results. How do the outcomes of our health-care system stack up against our Western, industrialized counterparts in Canada and Europe? In a recent Johns Hopkins study that measured death rates and other indicators of health, the United States finished nearly last -- 12th out of the 13 countries studied.

Some of our excess deaths are likely a result of our high-tech orientation. In the report study, "To Err Is Human," the Institute of Medicine estimates that between 44,000 and 98,000 Americans die each year as a direct result of medical errors.

Those numbers, while alarming, do not take into account hospital deaths from medical intervention not clearly associated with medical error. Several studies, taken together, indicate that 225,000 Americans die each year as a result of medical intervention, the largest component (106,000) a result of "non-error adverse" side effects of medications.

Thus, medical interventions cause 10 times the number of homicides in the United States each year and trail only cancer and heart disease as the leading killers of Americans.

Not only are we paying more for health care but a lot of what we buy directly leads to adverse affects for patients.

Why? Money has a lot to do with it.

Doctors who do procedures and tests earn more than those who don't; drug companies make more money if more drugs are prescribed; medical instrumentation companies, the makers of the latest testing devices, want more tests done, not less.

We're doing too much of the high-cost specialized medical interventions at the same time that more than 40 million Americans are denied access to health insurance. And many of the rest are deprived of an opportunity to build a strong relationship with a doctor of their choice, someone who would coordinate all their care, because of managed care and the way our health insurance system works.

Another common misunderstanding about health care is the notion that in other countries -- for instance, in England or Canada -- patients have free health care, but must wait months and months to see a doctor.

That is true only for elective surgery. Otherwise, patients see their primary care physician quickly and often, leading to a system of health that focuses more on prevention and early care and less on drastic medical interventions that run the risk of errors and adverse effects.

True primary care has never taken root in the United States, despite the idea of the old family doctor making house calls.

The leading medical schools, including Harvard and Johns Hopkins, do not have training for family physicians, who are the mainstay of primary-care practice in most of the other wealthy countries.

Our health care system is rooted in specialists and, as some have said, specialists are doctors who look for zebras rather than horses because that is what they are trained to do. To make sure that a patient is not a zebra, specialists do a lot of unnecessary testing.

Critics often cite Americans' own bad behaviors as explanation for our poor health, when compared with other countries. But the truth is our smoking and heavy drinking rates are among the lowest of those in countries with better health.

The United States spends $1.1 trillion a year on health care, nearly $4,000 per person, according to 1997 figures (the latest available). By comparison, Switzerland, Canada and the United Kingdom spend $2,547, $2,995 and $1,347 per person, respectively.

For the money we spend on health care, we really should be the healthiest people in the world, but we're not. There's a lot that can be done to change this, but it won't happen over night.

People must first recognize this as a problem, which is no small task. Not when, at every turn, Americans are being told they ought to try the latest MRI or have the newest drug.

The next thing that needs to happen is for doctors to be more accountable for what they do. For every test done, every procedure performed and every drug prescribed, data ought to be gathered and analyzed, with this in mind: Did the patient get better? Were there side effects? These data are easy to collect and examine and this process ought to be part of every practice.

Finally, we have to persuade more people to become primary care physicians, and we have to train them better -- if we ever expect to get what we pay for in health care.

Barbara Starfield, a physician and health services researcher, is university distinguished professor at the Johns Hopkins Schools of Public Health and Medicine.

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