Q&a -- Shannon Brownlee

More Money, Less Health

An acclaimed journalist says $700 billion in excessive spending on drugs and

high-tech health care actually makes millions of Americans sicker

January 27, 2008|By David Kohn | David Kohn,Sun Reporter

By now you surely know the U.S. health care system is massively messed up. But the question is why.

A few years ago, health journalist Shannon Brownlee was going through some global health statistics. She noticed that even as U.S. health care costs were rising steadily, Americans were not getting healthier. How to explain this apparent paradox?

Brownlee became fascinated and began to collect data in search of answers. The result is Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, her analysis of how American health care has failed. The book has received good reviews and was praised by one prominent economics columnist as the best business book of 2007.

Brownlee, who worked for many years as a correspondent for U.S. News & World Report, says that U.S. doctors and hospitals offer more care -- specifically, more expensive, and unproven, care -- than necessary, inflating costs and sometimes even endangering patients. She argues that between 20 percent and 30 percent of health care spending is wasted on useless treatments and hospitalizations.

Last week, Brownlee, who lives in Annapolis with her husband and 12-year-old son, talked to The Sun about the perils of doing too much, and what might cure this ailment.

What's the key problem with our health care system?

Most physicians think of themselves as businessmen and -women. It's all based on the way we reimburse doctors and hospitals. Most payments to doctors and hospitals are called fee-for-service. In other words, they get paid for doing something, either having an office visit, giving you a test, putting you in the hospital, a consult in the hospital. This fee-for-service system basically rewards doctors and hospitals to do more rather than to do better. That's the central problem, I think, is the payment system. It's providing all these perverse incentives to do more.

Are doctors too greedy?

I don't see doctors as any greedier than any other group of people. Physicians are working within a system. And like a fish doesn't know it's in water, a lot of doctors don't know their own system. They don't understand how the medical industry works. They're dong the best they can within their own world, not realizing the larger forces that are upon them.

How big is the U.S. health care industry?

This is a $2.1 trillion industry. It's one of the biggest industries on the planet. You've got this enormous industry, a gigantic machine. And it is not producing the health it should, given the amount of money we've spent.

So what's a good example of overtreatment?

There's a good example now in the news, of this cholesterol drug Vytorin. Vytorin is an anti-cholesterol medicine that is actually made up of two separate drugs. One of these drugs is Zocor, which is an old-line statin anti-cholesterol drug. And the other one is a drug called Zetia. And the two together are supposed to work as a 1-2 punch against cholesterol.

There are a couple of problems here. One, the evidence that giving people who have never had a heart attack, who don't have outright heart disease, but only have risk factors for heart disease -- there's only a teensy, weensy, beensy little bit of evidence that maybe it might help some people. The vast majority of the evidence doesn't support the idea of giving statins to everybody on the planet.

Right now we're giving all kinds of people these drugs to prevent first heart attacks. There's lot of evidence that if you've already had a heart attack, taking a statin will lower your risk of having a second heart attack. But the vast majority of people taking these drugs have never had a heart attack. So this looks like a clear case of overtreatment. And now the new evidence says that Zetia may in fact possibly increase your risk of having a heart attack -- and millions of people have been prescribed this drug.

Why is this happening?

This is happening because the pharmaceutical industry and its allies in academic medicine have been very good at persuading physicians and their patients that the statin drugs are the be-all or end-all, that they really are reducing risk.

One way to think about it is this phrase "indication creep," which I really love. An indication is a diagnosis of a disease, for which you have some treatment. So the indication here would be heart attack, or risk of heart attack. Statin studies have looked at people who are at very high risk of having another heart attack. ... You study these people and you find you can really reduce their risk of heart attack. OK, it's probably a good idea to prescribe these drugs to people who have heart attacks.

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