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Medicine Education Government The Almighty Buck Politics

What US Health Care Needs 584

Medical doctor and writer Atul Gawande gave the commencement address recently at Stanford's School of Medicine. In it he lays out very precisely and in a nonpartisan way what is wrong with the institution of medical care in the US — why it is both so expensive and so ineffective at delivering quality care uniformly across the board. "Half a century ago, medicine was neither costly nor effective. Since then, however, science has... enumerated and identified... more than 13,600 diagnoses — 13,600 different ways our bodies can fail. And for each one we've discovered beneficial remedies... But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we're struggling. There is no industry in the world with 13,600 different service lines to deliver. ... And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it's the economic bailout plan. But take both away and you've made almost no difference. Our deficit problem — far and away — is the soaring and seemingly unstoppable cost of health care. ... Like politics, all medicine is local. Medicine requires the successful function of systems — of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively. ... This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do."
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What US Health Care Needs

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  • by adam ( 1231 ) * on Monday June 21, 2010 @02:17AM (#32637582)

    If I want to give my patients the best care possible ... This will take science. It will take art. It will take innovation. It will take ambition.

    ...it will also take the AMA not artificially restricting the number of new doctors. More than half of ostensibly qualified applicants every year are turned away. In the 1800s there were 400+ medical schools in the united states. By the early twentieth century there were less than eighty. The fewer doctors we have, the more each doctor is paid. The AMA carefully guards doctor salaries. This practice can be seen over and over (and resistance to influx of doctors willing to work for cheap) in country after country (the film Salud covers this well).

    Furthermore, we need to eliminate the debt load for student doctors. You can't expect doctors to work for lower salaries (as I propose above) when they are graduating with hundred of thousands in debt. Basically we need way more medical schools (or slots in existing schools) and we need to lower their cost in exchange for a willingness to work for less money. This has the benefit of more doctors and lower cost, as well as shifting the pool of applicants to those who want to be DOCTORS and not just those who want to make MONEY or play GOLF all the time (and so on).

    Cuba is a perfect example of this. They have better or equivalent health outcomes to the United States, yet they spend a fraction (read: less than 1/20th) as much per person on healthcare. They achieve these same outcomes using finnicky x-ray machines from the 1980s and out of date textbooks. They do this by having the greatest doctor-to-patient ratio of any nation, and by focusing on preventative medicine. But that's evil socialism. Insert dramatic music here. At any given time more than a third of Cuban doctors are voluntarily serving abroad (often in Africa) doing global health work. More than a third. What percentage of American doctors voluntarily serve in Africa? And they have a 98% retention rate, so any claim that this service is to "escape Cuba" is pretty well dispelled. (and just to go on the offensive for a sec, since I don't generally reply to those who reply to me, unless they actually make good points, since as you know /. has a typical signal-to-noise comment ratio... for those who want to doubt my claims above, calling them propaganda, etc, they are backed up by reputable sources. Paul Farmer, for instance, has written extensively about Cuba [and also happens to be the UN Envoy to Haiti and runs Harvard's School of Social Medicine at their Medical School, so he tends to be considered a reputable source] and almost never has a bad thing to say about their healthcare attitudes or outcomes. The list goes on.)

  • Re:Interesting... (Score:3, Informative)

    by xcut ( 1533357 ) on Monday June 21, 2010 @02:43AM (#32637720)
    It is true. Here's an article in the economist, which has good coverage of this: article [economist.com].

    Note: The proportion of GDP devoted to health care has grown from 5% in 1962 to 16% today. Rising health-care costs appear to have suppressed wages, as firms seek to make up for the expense. America spends 53% more per head than the next most profligate country and almost two-and-a-half times the rich-country average..

    There is a systemic problem in the US that is well document: that of wrong incentives in the system (over-testing by doctors because of bad payment models, lack of litigation protection, etc). Not easy to fix.

  • Re:Interesting... (Score:4, Informative)

    by evilviper ( 135110 ) on Monday June 21, 2010 @02:45AM (#32637726) Journal

    It's called Medicare. It's a large percentage of federal spending right now, and it's projected to exceed 100% of all federal spending by about 2020, baring any changes.

    If you don't know this, it's simply because you aren't informed at all. Experts have been sounding the alarm bells for at least a decade, loudly and repeatedly. It seemed to be the top topic just a handful of years ago, when ballooning medical costs were the largest problem facing the general public, just a while before the economy started to fail completely, and more immediate concerns became paramount.

    Obama, Clinton, and McCain talked about it all through their presidential primaries and campaigns, in no uncertain terms. It was a major issues discussed endlessly in the house and senate for about a year as Obama tried to push health care reform through. I have no idea how you could be ignorant of this fact, if you pay attention to national/world events at all.

    http://blogs.abcnews.com/theworldnewser/2009/12/president-obama-federal-government-will-go-bankrupt-if-health-care-costs-are-not-reigned-in.html [abcnews.com]

  • Re:Interesting... (Score:5, Informative)

    by nametaken ( 610866 ) * on Monday June 21, 2010 @02:58AM (#32637788)

    Of course I've heard all the clamor over Medicare. Medicare represents $491 billion. DOD's annual budget alone is something like $1 trillion. I believe we've spent over a $1 trillion on the wars in Afghanistan and Iraq. Iirc the bailout ran into many trillions of $'s (certainly correct me if I'm wrong, some more inflammatory sources seem to put it at $24 trillion). Not to say that Medicare isn't a serious problem, but this doesn't seem to answer this question of our war and bailout costs being a fraction of what medicare costs us. No?

    Sounds like the earlier posters overall estimation of all healthcare costs as a percentage of GDP was more likely what he was talking about.

  • Let's ask the AMA (Score:5, Informative)

    by adam ( 1231 ) * on Monday June 21, 2010 @03:00AM (#32637798)
    Don't listen to me, just listen to the AMA instead; they're happy to admit their mistake (although they won't overtly admit the motivation behind it). Basically in the 1980s they wrongly predicted in 10-20yrs we'd have a surplus of hundreds of thousands of doctors and the market would crash (yeah, wouldn't that be horrible, to have too many doctors? I mean, horrible if you want to drive a Lexus and you're a doctor, I suppose...). Of course they got it wrong ("accidentally," I am sure) and overshot in the other direction and now we have a huge shortage. "Whoops." Unfortunate byproduct: ridiculous salaries (mostly for specialists). Not so unfortunate if you're a dermatologist, though.

    Some quotes from the AMA themselves [ama-assn.org]:

    "Not a single allopathic medical school opened its doors during the 1980s and 1990s ... The surge in new medical schools is taking place as the Assn. of American Medical Colleges predicts a shortage of at least 125,000 physicians by 2025 ... But some experts on work-force issues say new schools are not enough. They say that without more federal funding for residency slots or changes in the doctor payment system, the schools are unlikely to avert an overall work-force shortage or address the undersupply of primary care physicians and general surgeons ... 1 in 3 active physicians is 55 or older."

    I think we can agree that it's unreasonable to have 99.999% of the applicants on one side of the line or the other, but beyond that? What about taking only the best 10%, or only the best 90%, would one of those be OK with you?

    How about 98% rejection rate? From the AMA article above: "Many private medical schools have 5,000 or more applicants for a class of 100 students."

    Again, I hope it comes across, I know something about this issue. I said "ostensibly qualified" and "more than half" in my OP because I didn't want to get into a big debate about the exact percentage of people who apply and are grossly underqualified and rejected versus the legit applicants who are rejected, but basically the former is not happening, since you need to take the MCATs (not easy) and complete the equivalent of a degree in Molecular Biology simply to even apply to med-school (and currently to be competitive you need hundreds of hours of volunteer work, professional medical experience such as EMT work, and even then it is often a crapshoot, I know many qualified applicants who have been rejected more than one year in a row).

  • by JumperCable ( 673155 ) on Monday June 21, 2010 @03:11AM (#32637844)

    No. That isn't until 2012.

  • by Hognoxious ( 631665 ) on Monday June 21, 2010 @03:18AM (#32637870) Homepage Journal

    war spending != defense spending.

    There aren't many nuclear submarines deployed in Afghanistan.

  • Yeah, so if you want to have teeth as lovely as late 20th century brits, follow their lead!

    There's a formula for good teeth. It goes something like this:

    Calcium + Phosphate + Vitamin D + (misc other vitamins minerals) -> normal teeth

    If a child's diet doesn't have enough nutrients, bone structures will not develop properly. Good teeth come from good nutrition and sunlight (Vitamin D), NOT nationality.

    See Gerard Judd's work [healingtee...urally.com], Dr. Weston A Price's work, [westonaprice.org] etc

  • Mod Troll. (Score:5, Informative)

    by adam ( 1231 ) * on Monday June 21, 2010 @03:25AM (#32637902)

    Cuba has a dog and pony show.

    ...and you know this how, exactly?

    I already warned you in my original post not to trot this shit out, because I'm not some idiot who happens to have seen a Michael Moore film and now thinks Cuba is a utopia. Instead I'll choose to believe the guy who runs Harvard Medical School's Social Medicine program (see: end of my original post), Jim Kim MD (former Prof of Medicine and Chair of Global Health for Harvard Medical School, now president of Dartmouth), and the World Health Organization, amongst many other credible sources.

    Because I am busy and you make no effort to substantiate your claims, I'm just going to paste a chunk from Tracy Kidder's (Pulitzer Prize winner) biography of Dr Farmer, where Farmer talks to Kidder about dispelling myths about Cuba (and then after that some of Farmer's own writings)...

    "For me to admire Cuban medicine is a given," Farmer said. It was a poor country, and made that way at least in part by the United States' long embargo, yet when the Soviet Union had dissolved and Cuba had lost both its patron and most of its foreign trade, the regime had listened to the warnings of its epidemiologists and had actually increased expenditures on public health. By American standards Cuban doctors lacked equipment, and even by Cuban standards they were poorly paid, but they were generally well-trained, and Cuba had more of them per capita than any other country in the world-more than twice as many as the United States. Everyone, it appeared, had access to their services, and to procedures like open heart surgery. Indeed, according to a study by WHO, Cuba had the world's most equitably distributed medicine. Moreover, Cuba seemed to have mostly abandoned its campaign to change the world by exporting troops. Now they were sending doctors instead, to dozens of poor countries. About five hundred Cuban doctors worked gratis in Haiti now-not very effectively, because they lacked equipment, but even as a gesture it meant a lot to Farmer.

    One time he got in an argument about Cuba with some friends of his, fellow Harvard professors, who said that the Scandinavian countries offered the best examples of how to provide both excellent public health and political freedom. Farmer said they were talking about managing wealth. He was talking about managing poverty. Haiti was a bad example of how to do that. Cuba was a good one.

    He had studied the world's ideologies. The Marxist analysis, which liberation theology borrowed, seemed to him undeniably accurate. How could anyone say that no war among socioeconomic classes existed, or that suffering wasn't a "social creation," especially now, when humanity had developed a grand array of tools to alleviate suffering. And he was more interested in denouncing the faults of the capitalist world than in cataloging the failures of socialism. "We should all be criticizing the excesses of the powerful, if we can demonstrate so readily that these excesses hurt the poor and vulnerable." But years ago he'd concluded that Marxism wouldn't answer the questions posed by the suffering he encountered in Haiti. And he had quarrels with the Marxists he'd read: "What I don't like about Marxist literature is what I don't like about academic pursuits-and isn't that what Marxism is, now? In general, the arrogance, the petty infighting, the dishonesty, the desire for self-promotion, the orthodoxy. I can't stand the orthodoxy, and I'll bet that's one reason that science did not flourish in the former Soviet Union."

    He distrusted all ideologies, including his own, at least a little. "It's an ology, after all," he had written to me about liberation theology. "And all ologies fail us at some point. At a point, I suspect, not very far from where the Haitian poor live out their dangerous lives." 'Where might it fail? He told me, "If one pushes this ology to its logical conclusion, then God is to be found in the struggle against injustice. But if the odds are so p

  • Re:Interesting... (Score:5, Informative)

    by Galvatron ( 115029 ) on Monday June 21, 2010 @04:27AM (#32638210)

    Where the heck are you getting your numbers? $24 trillion would be something like 1.6 times the total US GDP, how would it even be physically possible to spend that much?

    Per the official US Budget DoD section, the total amount including supplemental spending hasn't exceeded $666 million. (see here: http://www.gpoaccess.gov/usbudget/fy10/pdf/budget/defense.pdf [gpoaccess.gov])

    Wikipedia's got a pie chart showing general expenditures for 2009, demonstrating that total defense spending was 23% of the budget, whereas Medicare and Medicaid are barely less at 19% of the budget (here: http://en.wikipedia.org/wiki/File:U.S._Federal_Spending_-_FY_2007.png [wikipedia.org])

    But the big problem, as noted, is not today's spending, but what happens in the future. Wikipedia's got a great graph for that, too: http://en.wikipedia.org/wiki/File:Medicare_%26_Social_Security_Deficits_Chart.png [wikipedia.org]

  • by Anonymous Coward on Monday June 21, 2010 @04:36AM (#32638244)

    The US medical culture is often about "doing everything possible" (more often when you are both white and non-poor), and our infant mortality stat is measured differently, but this difference is marginal at best.

    The difference is basically as he said, we try to save babies that are below 1KG in weight, and half of those die, and we count that. Other countries don't. BUT! The total number of births below 1.5KG is only 1.3% so this does not significantly affect the stat. The number I am citing is from his OWN LINK where he is arguing this point elsewhere in the thread.

    I don't think the post above needs to be modded troll, but it's important for people to understand the difference in infant mortality measurement is marginal, and the US is the outlier in how we record these deaths.

  • CITE WITHIN (Score:1, Informative)

    by Anonymous Coward on Monday June 21, 2010 @04:55AM (#32638320)

    ACing because I don't need ego-stroke or karma for reposting, but since you want the cite:

    Erwin Ackerknecht's A short history of medicine, page 224. This is on Google Books if you doubt me. Quote:

    "There were no less than four-hundred medical schools in the US in the nineteenth century. [skipping less than a sentence] ... and it was not until 1930 that the number had been reduced to seventy-six well-qualified institutions."

    Incidentally I agree with the rest of your post, and many of the 400 were certainly diploma mills or quackeries. My point is that we have expanded as a nation, aged as a population, and reduced the number and proportion of doctors we create. Bad idea if your foremost goal is public health.

  • by RightSaidFred99 ( 874576 ) on Monday June 21, 2010 @04:57AM (#32638326)

    Nonsense. You're focusing on a small part of the overall discrepancy. That plus about 10 other factors are why the US is artificially high in infant mortality, especially in regards to quality of health care available.

    OK, how about this one [findarticles.com] then? That got enough facts and numbers for you?

    What would be interesting would be survival rates for all births by country. Every single child than emits from between a woman's legs would be counted, every thousand. And from that thousand the number that live to 5 years old.

    Care to wager how the US would do against other nations in that comparison? My guess is it wouldn't be 45th. Or 19th. Or 5th. More like top 3.

  • by Mashiki ( 184564 ) <mashikiNO@SPAMgmail.com> on Monday June 21, 2010 @05:45AM (#32638548) Homepage

    Too bad the Dem's in the US want this brilliant idea to micromanage every single freaking point of the healthcare system. Sorry but systems like socialized insurance in Canada, are wholly incompatible with the Dem view of how it should be done. Only the feds know the right way to do it. To point out the obvious, in Canada, the feds do nothing to the healthcare system unless it's run federally aka reservations and government(RCMP/Mil/etc). It's all in the hands of the provinces.

    The republicans have the right idea in the US. Federally mandated control of the healthcare system is flawed.

  • Re:Where's the Link? (Score:3, Informative)

    by Anonymusing ( 1450747 ) on Monday June 21, 2010 @05:53AM (#32638588)
    I don't see a link either, but the speech appears to be up at the New Yorker [newyorker.com] (as is his commencement speech to University of Chicago's med school last year [newyorker.com]).
  • by Anonymous Coward on Monday June 21, 2010 @07:04AM (#32638860)

    Your suggestions tells poor people who happen to have a handicap or chronic condition to get stuffed.

    You sir fail at humanity. Congrats, you can now enroll in US politics.

    Sometimes, life just sucks. And guess what? Your government CAN'T fix that.

    Welcome to the real world.

  • by commodore64_love ( 1445365 ) on Monday June 21, 2010 @07:44AM (#32639062) Journal

    >>>Cuba is a perfect example of this. They have better or equivalent health outcomes to the United States, yet they spend a fraction

    False. The second part is true but the first is false, because Cuba's government hospitals often don't treat people at all. Since those persons are left to die, they never become part of the system and don't appear in the statistic. Plus given the type of government (totalitarian) it wouldn't surprise me to learn unfavorable stats are removed by the government. (See the scene in 1984 where negative news is expunged and rewritten into positive news.)

  • by Eunuchswear ( 210685 ) on Monday June 21, 2010 @09:24AM (#32639840) Journal

    Sometimes, life just sucks. And guess what? Your government CAN'T fix that.

    In an discussion of US health care problems the first step is to admit that the problem has been solved, in many different ways, in many places.

    So don't:

    1. Claim it can't be solved.
    2. Propose a solution without pointing to a working example
    3. Claim a proposed solution can't work if the same system is being used elsewhere.
  • Sure, but... (Score:2, Informative)

    by OneAhead ( 1495535 ) on Monday June 21, 2010 @09:36AM (#32639980)

    The original article is the commencement speech at Stanford’s School of Medicine. It gives a bird's eye philosophical perspective on the state of the medical profession. As such, I like it.
    What I don't like are the people here trying to derive a political message from it. Health care in the US is so much [ngm.com]less cost-efficient than the other industrialized countries [peltiertech.com], countries that have equivalent or better health care and that face the same challenges. This discussion sounds like looking for excuses not to fix the broken health care system.

  • by antifoidulus ( 807088 ) on Monday June 21, 2010 @10:12AM (#32640402) Homepage Journal
    wrong answer [webmd.com], try again!

    Infant mortality rates: the US ranks an embarassing 33rd according to the UN, 46th according to the CIA [webmd.com]

    US also ranks pretty shittily in heart attack rates too [nationmaster.com]

    Do I really need to go on pointing out what a farce the supposed "superior" US healthcare system is?
  • by fprintf ( 82740 ) on Monday June 21, 2010 @10:45AM (#32640950) Journal

    You can. http://www.google.com/search?source=ig&hl=en&rlz=&q=individual+HSA+plans&aq=f&aqi=g1g-m2&aql=&oq=&gs_rfai=CtG-tNnofTJixIIfAzQTJ9aHfDQAAAKoEBU_Q2Rjm [google.com]

    Specifically, note in the Wikipedia article http://en.wikipedia.org/wiki/Health_savings_account [wikipedia.org] that 1.1 Million people have purchased into their own HSA accounts.

    HSA (individual owned) and HRA (employer owned) savings accounts allow you to save money up to certain IRS limits per year. In the case of the HSA, this is your money and is not owned by the employer. That means you can take it with you if you go to a new employer, or if you lose your job etc. This is pre-tax money that is yours to use on most IRS 213(d) expenses. This money does not expire at the end of the year (you are thinking Flexible Spending Account, which is different).

  • by Behrooz ( 302401 ) on Monday June 21, 2010 @12:32PM (#32642642)

    And those people end up paying more in the long run? I don't have a problem with that. Unless of course you ask me to foot the bill for their lack of maintenance.
    ...which is the point. Providing a reasonable standard of health care to all individuals in a society provides huge benefits to the functioning, productivity, and quality of life of the society as a whole, and as a society we're going to face significant costs for 'lack of maintenance' or 'bad luck' or any other given issue that leads to serious health difficulties for an individual who lacks the means to pay. The assumption that we can reduce the costs to society as a whole by letting individuals get substandard care is false even from a purely economic perspective, backed up by a great deal of epidemiological and social science research.

    So, ideally, we need a rational healthcare system which decouples healthcare decisions from monetary incentives and relies on healthcare providers to make reasonable decisions about treatment that maximize the overall benefit to society.

    This was effectively SOP for the health care industry in the USA until relatively recently. I have half a dozen MDs in my family near/past retirement age, and they have stated that the expectation in the field of medicine was that between 10% and 30% of patients would simply be unable to pay for treatment, and that providing a reasonable standard of treatment for them regardless was simply the cost of doing business.

    Coming out of medical school today with hundreds of thousands of dollars in debt and with the range/cost of treatments skyrocketing, medical students today don't have this option. This has also contributed to a legion of other perverse economic incentives, such as clinics which make money from the tests they recommend, and the transitive nature of health care coverage has given insurance companies solid financial reasons to deny coverage to the greatest degree possible, so the greatest amount of the cost is distributed elsewhere. The prime motivator for the increase in health care costs isn't the cost of the treatments available, it's coupling treatment decisions with monetary incentives that are inherent in the structure of our current system.

    Health care can best be envisioned as a public utility. It's in our own interest to structure it in a way that provides the best quality of care available at a price we can pay.

    So, SOMEONE has to determine which treatments are actually beneficial and cost-effective for patients. The best group to do this is medical professionals who get a steady paycheck and are judged on the quality of the health outcomes of their patients.

    This means SOMEONE has to provide the steady paycheck, as well as provide metrics on the quality of work done, enforce professional standards, and generally keep a lid on things. Any structure capable of doing that society-wide is going to end up being functionally equivalent to a government. Attempting to do it on a smaller scale leads to massive structural inefficiencies as other health-care entities that are running for profit do their best to chuck 'unprofitable' patients/treatments out of their coverage areas and 'cherry-pick' profitable individuals.

    Any plan that significantly disagrees with these core ideas is likely to be based on political posturing or willful ignorance... which is precisely the problem we're running into.

  • by Anonymous Coward on Monday June 21, 2010 @01:05PM (#32643082)

    For example public transportation systems that work well elsewhere don't work as well here. We simply have too many people living in low population density areas.

    Wrong. The Canadian population is even more thinly spread (a larger country than the USA with 1/10th the population) yet every city and/or province has public transport.

      In all areas for public transportation to be convenient enough for people to use, there must be many stops. However, each stop cost money, and in low population density areas it may not be possible to recoup the costs if you have many stops, so they have fewer if there is a public transportation system in place at all. That explains a fair bit of the lack of good public transit in the US.

    The lack of a decent public transport system in the US, at least in the major cities, is thanks to the auto manufacturers who bought up city bus services in the late 40s/early 50s and then closed them down.

    In "Who framed Roger Rabbit" Bob Hoskins is asked why he doesn't have a car (in LA),

    "Why would I own a car in the city with the best public transport system in the world?"

    Did that line never strike you as odd?

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