Healthcare's Medical Gluttony

Seems to me we always have a few big breaking healthcare stories early in the year.  I remember last year when Mary Meeker released her stunning report – USA, Inc.  For the first time, it gave us a detailed view into the health of our country – as if it were a Corporation using balance sheet accounting.  That report is truly outstanding.  If you haven’t read it – I can’t recommend it highly enough.  In some ways I think it’s “table stakes” for any intelligent discussion around the health (and healthcare) of our Country. In that report are two charts that graphically illustrate the size of our healthcare spending (as reported through 2009) – and then the results of our healthcare system.  This was the first one:

From Mary Meeker’s Report – USA, Inc.

Lot’s of takeaways from this.  Including the sheer size ($2.5 trillion in 2009) – and at least one financial opinion that we don’t have a debt problem in this country – we have a healthcare problem.   In this graph, Mary Meeker’s focus was more on the hyper-growth of Medicare/Medicaid – which basically went from 0% to 35% in about 45 years.  It doesn’t take a proverbial Village to see this chart and that statistic as unsustainable.  The companion chart was one that compared our healthcare results (as measured by Life Expectancy) to other countries using per capita cost per year.  This too was eye-popping:

OECD Data for 2009

For those of us that have been tracking this over the years – no real surprises – these numbers don’t just arrive in a year.  It takes a sustained effort to deliver this kind of appalling value – for this kind of money. Shocking? Clearly. Surprising?  Not so much.   No, the real, perhaps only question is – what’s causing this – and how do we really stop it? Of course this debate has raged for years – and is still ongoing. Lots of good politicking, teeth gnashing, jaw boning, turf protecting and food fighting. Hey – there’s lots of blame to pass around.

Finally, in March of 2010 – President Obama signed into law the Patient Protection and Affordable Care Act – or PPACA for short.  We were told this was THE fix – or the best we could reasonably get.  We were told that healthcare insurance was to blame.  Profits were obscene and they had been denying coverage for “pre-existing” conditions.  Insurance companies were inefficient accounting bureaucrats – that delivered no value. We were told that our system of “fee-for-service” was a system of sheer volume over value. We were told that 50 million uninsured was a major cause of higher insurance costs for everyone.  All true – and all partially to blame.  But were any of those really core, systemic issues – or were they, are they conveniently around the edges?

Dr. Otis Webb Brawley – CMO of the American Cancer Society

Now, for the first time, a leading healthcare clinician – the Chief Medical Officer of the American Cancer Society – Dr. Otis Webb Brawley is breaking ranks – literally and figuratively.  His new book is squarely aimed at the Hippocratic oath and aptly titled – How We Do Harm: A Doctor Breaks Ranks About Being Sick In America. I haven’t read it (yet) – but even the Editorial Reviews are noteworthy:

  • “My friend and colleague Otis Brawley has written a raw and honest portrayal of our health care system. There are certain to be special interest organizations and medical groups that take issue with Dr.Brawley’s conclusions, but few can argue with the scientific rigor he has demonstrated in writing this book. Otis is the go- to oncologist I send so many patients to see, because he is not only a great doctor, but also a compassionate man. As we discuss the transformation of health care in this country, put Dr. Brawley’s book at the top of your list.”  Sanjay Gupta, Associate Chief of Neurosurgery Grady Memorial Hospital, Chief Medical Correspondent, CNN
  • “Otis Brawley is one of America’s truly outstanding physician scientists.  In How We Do Harm,  he challenges all of us– physicians, patients, and communities– to recommit ourselves to the pledge to ‘do no harm.’”  David Satcher, Former Surgeon General of the United States, Director, Satcher Health Leadership Institute, Morehouse School of Medicine
  • “Sweeping, honest and brave . . . How We Do Harm dazzles with a wealth of  scientific insight, but its genius lies in the author’s recounting of individual patient stories that illuminate the dark underbelly of medicine’s missteps. Brawley does not shrink from revealing medicine’s warts, but this book  offers much more. It is a  triumph of humanity and clarity in which oncology becomes a Rorschach for the practice of American medicine. You will finish this arresting book reluctantly, with a new appreciation of what American medicine could be.” Harriet A .Washington, author of Deadly Monopolies: The Shocking Corporate Takeover of Life Itself and the Consequences for Your Health and Our Medical Future and Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present

CNN provided coverage on the book’s release here – and had these direct quotes by Dr. Brawley:

  • “There is often selective reading of the science, especially by those trained in a specialty wanting to advocate for it.”
  • “Medical gluttony, the inappropriate use and overuse of medical treatment, is not just adding unnecessary cost to health care. It can actually be harmful to the individual.”
  • “Health care providers and the public often overlook the emotional and financial conflicts of interest of health care professionals.”

The CNN article also recounted the story of a woman, Helen, who was diagnosed with early stage breast cancer.  As was fairly common in the early 1990′s – surgery was followed by high doses of chemotherapy – and a bone marrow transplant.  Quoting Dr. Brawley:

“The therapy Helen received was expensive and commonly given to women with breast cancer in the early 1990s. During this time, numerous women sued insurance companies who did not want to pay for the therapy and nearly a dozen states passed laws saying insurance companies had to pay for it.”

“There was one really good reason why the health insurers did not want to pay for high dose chemotherapy and bone marrow transplant for breast cancer:  No study had ever been done to prove it beneficial.

“Even without evidence, some patients and their doctors had faith that it worked. The procedure was common because some doctors taught that the transplant was beneficial to patients. Truth be told, it was very beneficial to the doctors and hospitals offering it.”

“By 1999, well after Helen had recovered, three well-designed clinical trials were completed. They showed that bone marrow transplant and high dose chemotherapy, a treatment now common for nearly a decade and a half, was not better than the standard therapy and there were indications it was more harmful.”

Again, I haven’t read the book – it’s just releasing today – but all of this does suggest at least one more very large and systemic failing in our healthcare system.  It also adds a new clinical term that I had not heard before.  Medical gluttony.  Simply put, the healthcare system we have rewards expensive specialty care over primary preventative care.  In order to reduce expensive specialty care – you have to add primary preventative care.  I can’t help but agree with Dr. Brawley’s final prescription:  ”The cold hard reality is America does not need to reform health care, we need to transform health care.”

By Dan Munro- Forbes.com contributor