EDITORIAL

Inside Health Care: Crisis of Faith?

By Rick Flinders, MD

I’ve never begun an editorial in these pages with more misgiving. This won’t be a “feel good” piece. The profession I’ve served and loved for over 30 years has provided me livelihood, fulfillment and inspiration. With rare exception, my colleagues have been diligent and dedicated professionals, committed to caring for the patients we mutually serve. To my colleagues, I say it is still a pleasure and privilege to work with you all. But we work inside a lousy system. In fact, it is no system at all. So if I seem critical, please understand that my complaint here is a lover’s quarrel.

Medicine is a mess. We spend $2.2 trillion a year for health care in the United States, and it’s not as good as we thought. “Best health care in the world” now refers to isolated islands of medical excellence in a sea of mediocrity. By the best health metrics our outcomes rank 37th in the world. Among the 13 industrial economies of the world we rank last. We can transplant organs and keep people alive through the terminal stages of chronic illness, but we can’t immunize many of our children, guarantee adequate care to all our pregnant women, or provide basic care and preventive services for the estimated 45 million people in our population who are uninsured.

Not a pretty picture. Few want it this way, but the problem is complex, and it touches every level of values around which societies organize. Health care has been described by one bioethicist as “the largest social reform issue in the U.S. since the abolition of slavery.”

For starters, health-care dollars comprise nearly a fifth of our domestic economy. President Eisenhower left office in 1960 with his famous warning of a vast “military-industrial complex.” When Dr. Arnold Relman retired as editor of the New England Journal of Medicine in 1983, he warned: “Beware the medical-industrial complex.” The financial juggernaut of the Big Three—pharmaceuticals, private insurance, and the medical technology marketplace—drives the current practice of medicine with an undue influence that has distorted our science, distracted us from the reason we practice medicine, and threatens a stranglehold on any meaningful reform. If you doubt this influence, consider our Congress, where drug lobbyists outnumber legislators two to one.

Congress is where the 2003 story of Medicare’s “drug benefit” unfolded. Medicare Part D, which provides prescription drugs for the elderly at drug-company prices, was written by drug lobbyists. The bill forbids Medicare from negotiating the price it pays for drugs. As Billy Tozan, the Louisiana congressman who steered the bill through the House, boasted, “Not one word was written by Congress.” Just six weeks after pushing the bill through Congress, Tozan took a $2-million-a-year position as president and CEO of PhRMA, the lobbying conglomerate of 12 major drug companies, including Abbott, Lilly, Bayer, Pfizer and Merck.

Tozan is not alone. Fifteen other representatives who voted the bill into law are now lobbyists for the drug industry. Thomas Scully, Medicare’s top administrator at that time, now represents a half-dozen drug firms through a contract he negotiated while the bill was being debated. When his chief actuary, Richard Foster, found the cost-analysis to be almost twice the original estimate, Scully threatened to fire him if he disclosed the information before the congressional vote.

The result of Part D is a pharmaceutical windfall that requires Medicare to pay up to 10 times the price charged to others for the same drug. For example, Medicare pays $1,485 for a year’s worth of Zocor, while the VA—which negotiates its price—pays $127. We’re talking $800 billion over 10 years, up to 60% of which is a “gouge.” Since the passage of Part D in 2003, the drug industry has raised its prices to Medicare by 30%. Who “benefited” the most?

The influence of drug companies extends well beyond Congress. Seventy percent of academic drug trials are sponsored by the drug industry, and the industry determines what gets published—and what doesn’t. For example, Merck (the same company that brought us Vioxx) has now disclosed data that their lipid-lowering drug, Zetia, has no benefit in cardiovascular outcomes, despite reducing levels of LDL. They knew this two years ago and sat on the data, while they generated more than $4 billion each year in sales.

I’m not saying that drug companies are evil. I think, like any capitalist enterprise, they’re trying to make a buck. And I believe they’re honestly trying, along the way, to even help some people. But I no longer trust their judgment, or what we see of their data. I can no longer trust that their judgment of what’s best for my patients is not compromised by what’s best for their profits, conscious or otherwise. Would you buy a used car from Merck? And if not, why would you trust their judgment of what’s best for your patient?

Unlike the pharmaceutical industry, which actually produces drugs that work, the insurance industry produces nothing. This Byzantine bureaucracy of 1,300 different companies, dealing over 27,000 different health plans, charges us a 15-30% “administrative fee” depending on whether the company is investor-owned or “not-for-profit.” Compare this fee to Medicare’s administrative cost of 3%. Most single-payer systems, worldwide, operate at under 10% administrative costs. Annually, the difference in the United States would mean an additional $300 billion for actual health services.

Recently, Blue Cross of California placed its member physicians in yet another new role, sending them copies of their patients’ insurance applications and asking their help in canceling policies of patients who fail to disclose “material medical history” or other pre-existing conditions. Physician as informant: who are we working for?

Finally, there is the cost of technology. It is hard to deny the modern daily miracles, but I would ask that the words technology and appropriate be merged in medicine into one: approtechnology. Last year 62 million CAT scans were ordered in the United States. By September there will be more MRI scanners in Sonoma County than acute psychiatric beds. Most Medicare dollars are spent in the last 30 days of life.

I recently saw a 14-year-old gymnast who received plain films, CT and MRI of his sore knee before ever getting a history or physical exam. He turned out to have Osgood-Schlatter disease, a common condition among teenagers that can be diagnosed with your thumb on the tibial tuberosity. Let’s be reasonable. We should use our clinical skills first and only apply our technologies when they should be done, not just because they can be done.

Our medical heritage, passed on from the professors who taught us, by lecture and example, is that the practice of medicine, at its purest, is guided by science and driven by compassion. Money matters. But it has distorted the methodology of our science and has distracted us from the motive of our practice. As a professional, all I ask to know is what’s best for my patient. I’ve been a good soldier who’s preached the gospel of evidence-based medicine for 30 years. And now I learn that the evidence may be tainted.
Forty years ago, while I began studying for a career in medicine, a popular American songwriter declared, “I ain’t gonna work on Maggie’s Farm no more.” Maggie’s Farm was the perfect, modern metaphor for the classic relationship of serf to landlord. The laborer pours passion and sweat into his work, only to learn he’s really working for someone else. The oath we took when we became physicians binds us as privileged servants to our patients, not to Pfizer, Blue Shield or General Electric. We need to assure ourselves—and the generation of young men and women now entering medicine—that we still work for the patient, not for some new-age corporate rendition of “Maggie’s Pharm.”