Friday, May 27, 2011

Why US Health Care Isn't More Cost-Effective: Industry's Role

Health economists Victor R. Fuchs and Arnold Milstein provide a useful synopsis of the barriers to cost-effective health care in the US in this week's New England Journal of Medicine:

I want briefly to summarize their list, then look more closely at the role of industry marketing.

Drs. Fuchs and Milstein begin by noting how out of line health care costs are in the US compared to comparable wealthy nations, without any discernible health advantage in exchange; and also how much money is now spent on ineffective interventions (they estimate at least $640B annually, more than enough to pay for all conceivable costs associated with extending insurance coverage to all Americans who now lack it). So why are we not able to save that money and redirect it to more useful purposes? Fuchs and Milstein's Enemies List:

  • Private insurers: adopting common sense savings like standardized administrative rules and benefit packages could threaten profits

  • Employers: jealous of any expanded government role

  • Public: misinformed and easily scared off by misinformation

  • Media: Guess who misinforms the public and who has more interest in scare headlines than truthful reporting

  • Legislators: Often seeking campaign contributions from industries that profit from current inefficiencies

  • Hospital administrators: Fear that unilateral cost cutting will simply drive physicians and patients to rival hospitals and hurt revenue

  • Physicians: Don't want to give up money; fear standardization and giving up clinical autonomy that seems to go along with serious cost control

  • Academic health centers: assume that they cannot cut costs and still effectively teach and do research; thus forgo important opportunities to teach tomorrow's physicians a cost-effective approach

  • Industry: Often has the most to lose as system inefficiencies spell profits for them
Now, at first glance, it seems that industry enters into this mix in two places: by opposing efficiencies that cut into their sales, and by lobbying legislators. But a careful review of the whole list shows other opportunities for commercial marketing of drugs and devices to contribute to the present impasse. For example, why are the media so prone to spread hype and misinformation among the public about health issues? Could their heavy reliance on industry advertising (how many ads in the typical hour of TV end with "ask your doctor...") tilt their news and editorial policies? Why is the public so opposed to cost containment that ultimately is in the public interest--could this have anything to do with the way industry generously bankrolls patient-advocacy groups?

Fuchs and Milstein's concluding point should be no surprise to any readers of this blog who have followed my efforts to refocus attention on the ethical demands of professionalism in medicine: "There is not much physicians can do directly to change the behavior of ... other stakeholders, but physicians are the most influential element in health care. The public's trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care. Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this ethical imperative?"

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