As Reinhardt’s larger body of work makes clear, we cannot separate high prices from the structural failings of our dysfunctional and regressive health care financing system. Reinhardt’s new book gives a cogent synthesis of all the reasons why “it’s the prices, stupid”—not the quantity of care we receive—that drives our high health spending.
Yet that community care rarely materialized. When Medicine Got it Wrong shows how these families launched one of the fastest growing grassroots movements the nation had seen to date, ushering in an era of dramatic advances in understanding, treatment and brain research. Medicine now knows that recovery is possible, and happens for the vast majority who receive treatment.
For as Reinhardt’s larger body of work makes clear, we cannot separate high prices from the structural failings of our dysfunctional and regressive health care financing system. Indeed, until we transform who pays for health care, cost containment—and more importantly, health care justice—will remain a distant mirage. More important than confronting the question of who paid for health care, Gawande argued, was reforming a reckless and inefficient entrepreneurial ethos on the part of medical providers that led to excessive provision of services. His observations squared with decades of research from a group of scholars at Dartmouth.
These ideas did not originate with Gawande, but his reporting helped to popularize a broader ethos within the health care community. And those ideas were taken seriously.
Still, as Rosenthal’s and Cooper’s prescriptions illustrate, the new price consensus has failed to jumpstart thoroughgoing change, and it may now threaten to cloud the reform debate rather than clarify it. For all the lucidity Reinhardt’s price hypothesis has brought to our understanding of the political economy of U.S. health care, it is constantly at risk of being oversimplified—distorted into an internal problem of markets and divorced from the concern for equity at the heart of Reinhardt’s work. In this increasingly common interpretation of the price hypothesis, privatized payers are simply taken for granted, so the costs attributable to privatization itself—ethical as well as economic, as the subtitle of Priced Out puts it—are simply rendered invisible. Reinhardt, by contrast, recognized the harms of a fragmented and privatized financing system; no doubt that partly explains why he recommended a single-payer system to the Taiwanese (even if he was pessimistic—for political reasons—about the prospects of such reform at home).
In the early days of my having the disease I could find good doctors like Anthony Komaroff if well enough to travel and had the money but over the decades these died or retired and there were years of having no knowledgeable medical care and it left me unable to work and support myself. As far as the above info (in quotes) is concerned; the reason you can’t find the relevant symptoms and/signals is because you are constantly using the wrong criteria in patient selection, wrong criteria in physical clinical diagnosis and the wrong criteria in research. You can’t keep mixing people with Encephalomyelitis in with Fatigue and expect to find the problem. This has been going on for 35 yrs and it will continue to go on for another 35 years unless you seriously start diagnosing and sorting patients correctly. Fortunately, many physicians and biomedical scientists around the world became interested in this illness, and over 9,000 scientific studies have been published in the past 35 years.
Gawande embraced ACOs as a central solution to the many McAllens throughout the land. In doing so, as health care analyst Kip Sullivan has written, Gawande “channeled” the Dartmouth researchers; both influenced Obama’s director of Office of Management and Budget Peter Orszag, and indeed the president himself. ACOs came to have a key place in the ACA.
The fourth thing wrong is the way patients are treated by society as a whole. Nobody believes how incapacitated we can become or the range and severity of symptoms triggered by exceeding the “energy envelope”. Physicians refuse to understand that patients can be reduced to living in dark rooms, unable to eat, talk, or even leave their beds unaided. Millions of patients are not simply told that there’s nothing wrong with us, for years and decades. We’re often mistreated by medical professionals, locked up in psychiatric wards, we lose our jobs, abandoned by friends & family due to our illness, we’re often accused of faking, etc.
It is a good thing that the new price hypothesis has displaced the old quantity assumption. This change has been propelled not just by the new price-hunting health journalism and research such as Cooper’s, but also by the failure of policy after policy that was engineered to control spending by reducing use. High-deductible plans, for their part, may indeed deter the use of needed health care (for instance, they keep women from obtaining breast cancer treatment), but their proliferation has done little to stem rising private health insurance premiums. The large reported savings from “hot-spotting” “superutilizers” that Gawande described in Camden have not been replicated in larger studies. Workplace wellness programs are not merely despised by workers, but, increasingly, appear to be a total sham when it comes to lowering costs.
And yet, it turns out that this entire edifice of reform was built on sand. Quite simply, as a nation, we actually do not use too much health care; if anything, we use fewer services than people in other high-income countries. While “overutilization” may indeed be a major problem in some areas (and who wants an unnecessary slice from a scalpel?), it cannot, simply as a matter of basic accounting, explain our total off-the-charts spending. In particular, it cannot account for the fact that we spend more than $10,000 per capita on health care—approximately double that of Canada—nor for the nearly six-fold rise in inflation-adjusted healthcare spending from 1970 to 2017, according to estimates from the Kaiser Family Foundation.
More important than the question of who paid for health care, Gawande argued, was reforming an entrepreneurial ethos that led to overuse of medicine. The situation isn't hopeless. Geneticists have mostly mended their ways, tightening statistical criteria, but other fields still need to clean house, Ioannidis says. Surgical practices, for instance, have not been tested to nearly the extent that medications have.
For more than a decade, nearly all health care cost control strategies were directed at reducing the quantity of medical services we use. Statistical flukes also plague epidemiology, in which researchers look for links between health and the environment, including how people behave and what they eat. A study might ask whether coffee raises the risk of joint pain, or headaches, or gallbladder disease, or hundreds of other ills. "When you do thousands of tests, statistics says you'll have some false winners," says Ioannidis. Drug companies make a mint on such dicey statistics.
The key to this new research is the ability to see through a methodological blind spot in some of the earlier work. Since Medicare rates are administratively set by the government, most of the variability in Medicare spending reflects differences in utilization rates rather than in prices—but this says nothing about spending by private insurers, where prices are determined by the market. In a paper published this year in the Quarterly Journal of Economics, Cooper and colleagues reported that service prices paid by private insurance companies to hospitals varied greatly by region (and even within hospitals), and that hospital industry consolidation was an important driver of higher prices. It is worth noting that in absolute terms, rates paid by private insurers are substantially higher than those paid by Medicare (at least nowadays), and that while Medicare spending accounts for about a fifth of total spending, private insurers account for about a third.
When Medicine Got it Wrong is the groundbreaking story of loving parents who rocked the halls of psychiatry, changing how we understand schizophrenia. In the 1970s, a small group of parents rebelled against then-popular psychiatric theories blaming schizophrenia on bad parenting. Their activism helped revolutionize treatment forever and their stories reveal the origins of the tragic state of mental health care today.
Kliff has written about being influenced by Reinhardt’s work, noting that he “shaped what I decide to report on. It is why I tackle projects that try to bring more transparency to American health care pricing, and the reason I think it's important to tell the stories of the medical bills my readers send me.” Along similar lines, Elisabeth Rosenthal wrote a series featuring outrageous medical bills, “Paying Till It Hurts,” while at the New York Times, and today she publishes a regular “Bill of the Month” feature as editor-in-chief of Kaiser Health News.
More and more scholars who scrutinize health research are now making that claim. It isn't just an individual study here and there that's flawed, they charge. Instead, the very framework of medical investigation may be off-kilter, leading time and again to findings that are at best unproved and at worst dangerously wrong. The result is a system that leads patients and physicians astray—spurring often costly regimens that won't help and may even harm you. It's associated with charm, manipulation, callousness and the ability to tell the difference between right and wrong but having little care for the rules in practice.
He grew up in an office-sized “tool shed” within a factory that he shared with his mother, grandmother, and four siblings, he recalled in a 1992 interview with the Journal of the American Medical Association. They lacked running water, and stole fuel and food when they needed it.
Clinics and emergency rooms are unable to provide for even the most basic needs of patients, such as a quite place to lay down while waiting our turn for care. By the same token, it is our financing system that has accommodated, and indeed rewarded, hospitals that transform into capitalistic, consolidating, revenue-maximizing behemoths—because those institutions can then extract higher prices from payers through greater leverage of their own. It is the way we pay for health care in the United States that has led to an arms race of administrative bloat, as insurers and providers fight over payments with legions of bureaucrats and billers. And it is our financing system that has allowed some hospital systems to flourish and expand facilities of ever-increasing technological prowess and splendor, but that forces others—the unprofitable ones—to wither, and sometimes die.
"I wouldn't be surprised if a large proportion of surgical practice is based on thin air, and [claims for effectiveness] would evaporate if we studied them closely," Ioannidis says. That would also save billions of dollars. George Lundberg, former editor of The Journal of the American Medical Association, estimates that strictly applying criteria like Ioannidis pushes would save $700 billion to $1 trillion a year in U.S. health-care spending.
As a result, decreasing arbitrary variations in private insurers’ payments for care, rather than reducing the quantity of services Americans use, might be the more effective path to reducing health care spending. Like Reinhardt’s “It’s the Prices, Stupid,” this paper turned the conventional wisdom on its head. The authors acknowledged in a footnote that they “drew inspiration” from Reinhardt and dedicated the paper to his memory. Other journalists have since taken a similar tack. For instance, Sarah Kliff, formerly of Vox and now at the New York Times, has assiduously collected a database of more than 2000 (often outlandish) emergency room bills from patients—along the way, getting more than $100,000 in medical bills cancelled merely by dragging them into public view.
The Institute of Medicine has concluded that the condition, now called myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) “is a serious, chronic, complex systemic disease that often can profoundly affect the lives of patients.” It affects up to 2.5 million people in the United States, and generates direct and indirect expenses of approximately $17 to $24 billion annually. That system leaves millions uninsured and underinsured—by current counts upwards of 87 million are inadequately insured. It is premised on the notion that private insurers can control costs by forming restrictive provider networks—increasing their market leverage but reducing patients’ choice of providers—but this scheme invariably results in out-of-network bills of the ruinous sort Kliff and others describe. Obama’s signature health law also incentivized “workplace wellness programs,” financial sticks and carrots that employers wield to prod their workers into healthier lifestyles and, so the theory goes, reduce their health care needs (and, consequently, use). Most significantly, there has been the growth of “Accountable Care Organizations” (a coinage of one of the Dartmouth researchers), financial arrangements in which hospitals stand to lose money when their patients use more health care, as in Health Maintenance Organizations (HMOs).
ACOs, meanwhile—the holy grail of cost containment, according to some—have been shown to produce little to no cost savings. None of this is surprising, of course, once we acknowledge that the very premise upon which these policies were based—that overuse is the problem—was dead wrong.
Most communities, however, still wrestle with mental health care policies based on debunked theories from the 1960's and '70's - pushing many with severe mental illness directly into homelessness or incarceration. Reinhardt helped reorient the health care reform discussion from quantity to price, which was a step in the right direction. Yet high prices should be seen less as the underlying disease than a symptom of the true malady, our uniquely privatized and fragmented financing system. That is what Canada did in the late 1960s and early 1970s when it built its single-payer system along the lines of the system set up in Saskatchewan when Reinhardt was living there, and it explains why that was the precise moment when its health care cost curve first began to diverge from that of the United States. It also explains why the rate of growth of spending in Taiwan actually slowed after implementing its single-payer system, even when the economic theory of “moral hazard”—that insurance increases use—suggests it might have exploded.
For more than a decade, nearly all health care cost control strategies were directed at reducing the quantity of medical services we use. Employers, for instance, have raised insurance deductibles year after year in order to deter “excess” care use among their employees. Similarly, the ACA included a “Cadillac Tax” designed to penalize overly generous healthcare plans that, again, ostensibly lead to overutilization.
At the same time, following in Reinhardt’s footsteps, new lines of academic research have confirmed the “price problem” exposed by this new wave of price-hunting narrative journalism. Past studies, including much of the recent Dartmouth work (and Gawande’s shoe-leather reporting in Texas), focused on variations in use by the Medicare population, mainly because this data is easy to obtain. But when Yale health economist Zack Cooper and three colleagues recently analyzed a new giant data set from three of the five largest private insurance companies, they found something very different. By exposing the financial and even physiological damage inflicted by medical bills, this reporting has done a tremendous public service, sometimes even directly helping the victims to bargain down or even void their bills.
This is Ioannidis's moment. As medical costs hamper the economy and impede deficit-reduction efforts, policymakers and businesses are desperate to cut them without sacrificing sick people. One no-brainer solution is to use and pay for only treatments that work. But if Ioannidis is right, most biomedical studies are wrong. But what if wrong answers aren't the exception but the rule?
Published on Apr 6, 2010When Medicine Got it Wrong is the groundbreaking story of loving parents who rocked the halls of psychiatry, changing how we understand schizophrenia. In the 1970s, a small group of parents rebelled against then-popular psychiatric theories blaming schizophrenia on bad parenting. Their activism helped revolutionize treatment forever and their stories reveal the origins of the tragic state of mental health care today.
By testing an approved drug for other uses, they get hits by chance, "and doctors use that as the basis to prescribe the drug for this new use. I think that's wrong." Even when a claim is disproved, it hangs around like a deadbeat renter you can't evict. Years after the claim that vitamin E prevents heart disease had been overturned, half the scientific papers mentioning it cast it as true, Ioannidis found in 2007. Rating is available when the video has been rented. This feature is not available right now. Please try again later.