It is a common misperception that the U. S. has the best health care in the world, another example of “American exceptionalism.” By constant repetition over many years, this myth has become a meme, a part of our language without regard to its merit. It is assumed by many that our rapid adoption of high technology and high spending on health care must bring us the best health care. However, as Drs. Elliott Fisher and Gilbert Welch of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School pointed out early on, there are diminishing returns to many of these technological “advances”. (1)
Lewis Thomas, a leading analyst of medical progress, saw this coming as early as 1975 when he described these three useful ways of looking at medical technologies:
- Nontechnology—non-curative care for patients with advanced diseases whose natural history cannot be changed (e.g. intractable cancer, advanced cirrhosis).
- Halfway technology—also care that is non-curative but may delay death (e.g. liver or heart transplants).
- High technology—curative treatment or effective prevention techniques (e.g. polio vaccination). (2)
Unfortunately, most of our technological advances are of the halfway non-curative type. Since they are often overused at great expense, this presents society a challenging task to manage their adoption in a cost-effective way.
How More Technology Does NOT Bring Us Better Health Care
These are some of the factors that undermine the quality of care in our profit-driven corporatized health care system:
- Medicalization of preventive and therapeutic services, which are then promoted by direct to consumer advertising. Examples abound, including widespread use of full-body CT scans as a screening procedure without approval by either the FDA or the American College of Radiology (3), and MRIs in completely asymptomatic patients finding “abnormalities”—one study found that one-half of young adults were found to have lumbar disc bulge without any back pain. (4)
- Early adoption of technologies without adequate testing. Adverse events in robotic surgery give us one example. Between 2007 and 2013, more than 1.74 million robotic procedures were performed in the U. S., most commonly in gynecology and urology, with 144 deaths (1.4 percent), 1,391 patient injuries (13.1 percent) and more than 8,000 device malfunctions (75.9 percent). (5)
- Corporate-friendly regulators. As one example, a large part of the budget of the FDA comes from user fees from the pharmaceutical and medical device industries, which are constantly pushing the FDA for earlier, accelerated approvals of their products. As a result, many products and procedures have to be withdrawn from the market as their harms become obvious, with these decisions often delayed by their manufacturers (e.g. withdrawal of morcellators for the treatment of uterine fibroids). (6)
Although many technological advances have been of great benefit to individual patients and society, such as replacement of hips and knees, coronary bypass surgery, and cataract surgery with prescription intra-ocular lens replacement, there are downsides to the rapid adoption of new technologies as well.
Despite our emphasis on technology, comparative studies of eleven health care systems around the world show how poorly we rank in terms of access and quality of care. (Table1) (7)
Can Health Care Technologies Be Managed in the Public Interest?
We have to ask why we haven’t been more effective over the years in evaluating and regulating the adoption and use of medical technologies. The answer, not surprisingly, is the economic and political power of corporate stakeholders in our market-based system. Two national organizations were established by Congress in the 1970s—the Office of Technology Assessment (OTA) in 1975 and the National Center for Health Care Technology (NCHCT) in 1978. Both were later abolished after a strong backlash from vested interests, especially the medical device industry and several professional medical societies. (8-10)
The FDA, as our major regulator for evaluation and approval of new health care technologies, has long been handcuffed by political forces preventing comparative evaluations of competing technologies based on required evidence for positive long-term outcomes. It has been underfunded, lacks sufficient authority, and is dependent on the industries it attempts to regulate through recurrent authorizations of user fees—a fox in the henhouse situation. There are many conflicts of interest among reviewers on its panels, and it is not permitted to use cost-effectiveness in its approval process. Health care industries collectively spent $489 million on lobbying in 2014, about one-half of which was spent by the drug industry in its ongoing effort to gain more rapid FDA approval based on weaker evidence. (11) As just one example, the FDA allowed expanded marketing of off-label cancer drugs in 2009 despite the lack of clinical evidence of their effectiveness. (12)
These problems can be fixed when we come to understand their adverse impacts on patients, families and taxpayers, develop the political will to confront the power of corporate interests in the status quo, and enact legislation for universal access through single-payer national health insurance, together with a stronger science-based regulatory system free from lobbying and political interference.
John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans
Fisher, ES, Welch, HG. Avoiding the unintended consequences of growth in medical care: How might more be worse? JAMA 281: 446-453, 1999.
Thomas, L. The Lives of a Cell: Notes from a Biology Watcher. New York. Bantam Books, 1975.
Brenner, DJ, Hall, EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 357: 2277-2285, 2007.
Jensen, MC, Brant-Zaawadzki, MN, Obuchowski, N et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 331: 669-673, 1994.
Alemzadeh, H, Iyer, RK, Kalbarczyk, Z et al. Adverse events in robotic surgery; a retrospective study of 14 years of FDA data. Cornell University Library, July 21, 2015.
Thompson, D. FDA warns against procedure for uterine fibroids, hysterectomy. CBS News, April 18, 2014.
U. S. health system ranks last among eleven countries on measures of access, equity, quality, efficiency and healthy lives. New York. The Commonwealth Fund, June 16, 2014.
Perry, S. The brief life of the National Center for Health Care Technology. N Engl J Med 307: 1095-1100, 1982.
Mervis, J. Technology assessment faces ax. Science 266: 1636, 1994.
Leary, RL. Congress’s science agency prepares to close its doors. New York Times, September 24, 1995.
Demko, P. Healthcare’s hired hands: When the stakes rise in Washington, healthcare interests seek well-connected lobbying firms. Modern Healthcare, October 6, 2014.
Abelson, R, Pollack, A. Medicare widens drugs it accepts for cancer care: More off-label uses. New York Times, January 27, 2009.