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Q&A; -- SHANNON BROWNLEE

The Baltimore Sun

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.

Then what happens is the manufacturer seeks to expand its market, and so the indication creeps outward, from people who have clearly benefited to more and more people for whom the evidence is much more shaky. We really don't have the evidence to say that giving statins to people who've never had a heart attack is going to reduce the risk of a heart attack. But they're given these drugs anyway because doctors think it's true and patients think it's true. You write a lot about how competition between hospitals often doesn't really serve patients' needs. How does that work?

The supply of medical resources tends to determine what happens to you in hospital more than how sick you are and what you need. ... The central thing driving supply of in-the-hospital care is the competitive environment in which the hospital finds itself.

Hospitals have two sets of customers. They have patients, obviously, but their more important customers are physicians, because physicians are generally not employed by the hospital. They have what are called admitting privileges. What hospitals want to do is to get physicians to come practice in their hospital and bring in paying patients.

Hospitals are constantly competing for doctors who bring in the highest-paying patients. That means cardiologists, neurologists, orthopedic surgeons. They want to attract these specialists.

One of the ways you attract specialists is by having gizmos. So one way you can recruit cardiologists is by buying GE's newest CT scanner, which can take a picture of the heart in a matter of five seconds and create this 3-D picture of the coronary artery. ... It is a very nice image and it will undoubtedly save some lives. But what will probably also happen is it will get overused. It will produce overtreatment. Hospitals are trying to cater to doctors by purchasing the technology that doctors think is cutting-edge. Once they invest in it, the hospital wants it to be used.

In the book, you talk about geographic variation -- how does that work?

Geographic variation means that there are huge differences in the amount of care and the kind of care that patients get depending on where they live and which hospital they go to.

If you live in Salt Lake City and you have a heart attack, you cost Medicare $4,000. If you live in Los Angeles and you have a heart attack, you cost Medicare $8,000. The difference is due to the fact that you get more care in Los Angeles. But the problem is you're not getting better care in Los Angeles. This is how we know that up to one-third of health care expenditure goes for unnecessary care. This isn't me saying this -- this work was first done by researchers at Dartmouth, and it's been shown over and over.

Talk a little about the presidential candidates' health care ideas.

We are obsessed with covering for everyone. That's a very important issue. It's the right thing to do, but it's not the only thing. The other thing is to figure out how to improve quality and control costs. But the candidates are not talking about costs. ... The reason they're not talking about cost is that Americans are really afraid that the next word after "costs" will be "rationing."

Candidates don't want to scare the voters. They're also not talking about cost because one man's waste is another man's revenue stream. The presidential candidates know that if they start talking about health care costs they will raise the ire of many powerful interest groups -- the drug industry, the device industry, the hospital industry, the specialty groups; there are lots of people who will lose if we start to control costs.

I think there is hope, but someone is going to have to be brave and start saying the word "C-O-S-T." There's so much waste. We can control costs without rationing. We're spending on the order of $700 billion on unnecessary care. That's like having a $700 billion piggy bank sitting there -- and if somebody could figure out how to break it open, we could cover everybody and have plenty of money left over. And absolutely provide all the baby boomers with all the care they'll need as they get older. But if we don't do something about costs and unnecessary care, I think we're bankrupting ourselves.

What do we do about this problem?

The first thing that has to happen is we get rid of fee-for-service. We have to stop paying doctors and hospitals on the basis of each separate thing they do. We need to pay them to take care of populations of patients. And we also need to pay the hospital and the doctor together.

Now that turns out to be a really inflammatory statement, because right now hospitals and doctors are at each other's throats. The specialists and the hospitals are fighting over who gets to keep the money. We have to break this logjam.

Second, we need a Manhattan Project for evidence. Only half of what doctors do is backed up by real, solid evidence. That is crazy. That is absolutely crazy. We think of medicine as being scientific but in fact it is not, half the time. And I think that even that estimate, that half of medicine is backed up by evidence, is probably being overly generous.

The problem is we have basically handed over control of medical research to the pharmaceutical companies. The drug companies pay for about 80 percent of clinical trials. We've basically said, "OK, we'll let the drug industry take care of it." Well, the drug industry is not interested in studying the stuff that needs to be studied. Their first responsibility is to stockholders. Their first responsibility is to sell more drugs. ...

As a nation, we need to fund the research to find out what works and what doesn't in medicine, and we need to pay for it publicly. That will help guide physicians more clearly about what they should be doing.

david.kohn@baltsun.com

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