Kip Sullivan responds to Bob LeBow:
Today's message from Kip Sullivan, which follows in the next e-mail, you may be inclined to delete since it appears to be another long response in the current Reinhardt-Sager-LeBow-Sullivan series, and most of you are too busy for this. Please bear with us on this one. Sullivan describes one of the most important policy issues facing us today as we struggle with the issues of expanding coverage while containing costs. A major emphasis is being placed on controlling costs by creating patient-consumer cost-sensitivity, or "empowering" the patient-consumer in the health care marketplace. In reading Sullivan's comments, I would suggest ignoring the challenge to LeBow in order to concentrate on the important policy behind his comments.
Don
Bob,
I disagree with your variation on Uwe's criticism of "the American people." Your version is that the American people are to blame for the world's most expensive health care system because we want too many health services. You rested this rather controversial statement on the comment of a single patient that America's health care system is expensive because Americans "expect the world."
I make three points in this response:
(1) If we really must speculate on whether overuse of the US health care system is worse than underuse, the evidence should cause us to lean toward the conclusion that underuse is a worse problem.
(2) Your argument that "Americans expect the world," even qualified as it was by your statement that our insane longing for medical services is abetted by corporate advertising, assists the right-wing in its quest to maintain a market-based system in the US.
(3) Your argument that drug company advertising is contributing to the high cost of health care is correct, but drug advertising is a minor issue compared to the other causes of the health crisis.
We do have some evidence that a few services are overused (e.g., bypass surgery and hysterectomies, and antibiotics), but we also have substantial evidence that the system is greatly underused. I'm thinking here primarily of the uninsured and the underinsured. I'm also thinking of evidence, including the Surgeon General's recent report, indicating great underuse of mental health services. The seemingly intractable problem of low-quality nursing home care could also qualify as an example of underuse. I could list other evidence of underuse.
I won't commit the mirror-image sin I'm accusing you of, that is, I won't go out on a limb and say underuse of the US health care system is far worse than overuse. But I will say that existing evidence does not warrant the statement that "Americans want the world" and that this insane wanting is causing the US health care crisis. You can say it if you like, but you should note you're engaged in pure speculation.
I believe the opinion of the patient you quoted is not based on her personal experience but is rather the product of the propaganda machine of the gigantic right wing in the health care debate -- the health insurance industry, the AMA, big pharma, the Jackson Hole Group, hangers-on in academia, the Republican party, and a substantial number of Democrats who wish they were Republicans. This unholy alliance has drowned out competing explanations of the US health care crisis, to wit, that administrative costs and prices are excessive. This alliance claims that the health care system is expensive because patients want services they don't need and because greedy doctors are eager to acquiesce to the demands of their dumb and/or gullible patients.
If the US is going to be forced to retain a market-based health insurance system, it is essential that the public be fooled into thinking that the primary cause of high costs is the consumption of an excessive volume of drugs and medical services, not the price of those drugs and medical services. If the public and law-makers can be fooled into thinking that the problem is primarily high volume rather than high price, they are more likely to be influenced by advocates of HMOs, MSAs, and defined-contribution schemes (e.g., Bush's Medicare voucher plan). As long as the "volume is the problem" mantra reigns supreme, HMO advocates get to claim that someone has to do the dirty work of wiping out all those unnecessary services, and better to have HMOs do that than some government bureaucrat. And MSA and defined-contribution advocates get to claim that unnecessary services will be wiped out by "consumers" thinking twice about whether they actually need this or that service because now they have "first dollar exposure," not "first dollar coverage."
But if the public and law-makers understand that over-utilization of the health care system is minimal or atypical and perhaps more than offset by gross underuse, market advocates have a much tougher row to hoe. If overuse is atypical, HMO advocates have to admit their professed raison d'etre doesn't exist, and MSA advocates have to give up pretending that MSAs will save money by cutting services and will instead have to peddle the implausible fantasy that MSAs will save money because patients will now be motivated to bargain with drug companies, hospital chains, and clinics for lower prices. The notion that the US health care system will enjoy substantial savings from patients driving hard bargains with drug companies, hospital chains, and clinics is too ludicrous for words.
Finally, I would like to offer the unfashionable view that the great brouhaha about drug advertising is a tempest in a teapot. Yes, drug advertising appears to be causing too many Americans to demand expensive drugs when less expensive drugs or no drugs at all would do. But total US health care costs in general, and drug costs in particular, were double those of the rest of the First World before the FDA gave the drug industry permission to do direct-to-consumer advertising, and they're double now. The relative contribution that drug advertising makes to total health inflation is small, and the relative contribution it makes to the enormous disparity between US and rest-of-the-world health costs is very small compared to other factors, to wit, no drug price controls, no controls on provider expenditures, and a multiple-payer system with all its administrative costs.
The next time you hear a patient spouting HMO and right-wing theories of the health care crisis, I urge you to inform her she's repeating speculative agitprop, not well established fact.
I leave town for a month in a few hours, so I won't be able to respond to any brickbats or kudos. I wish everyone a cool remainder of the summer.
Kip Sullivan
Excerpt from a message dated 8/11/01:
< There is much truth in what Uwe says, about the American public wanting a health care system that has double-digit inflation. I have been querying my patients with a simple question about why they think the U.S. doesn't have universal coverage. I've gotten an interesting array of answers so far, but one young woman today responded with a variation on Uwe's response. She said that people were just expecting the world. But I think Uwe's theory is only partially true. I think the American people have been programmed to "expect the world" by some interest groups that will profit from the expectation.>>