Americans have traditionally equated more health care with better health, and viewed technological savvy as the ultimate measure of a medical system. As the L.A. experience suggests, those assumptions need rethinking. If the purpose of health care is to create a healthy population, then the challenge facing policymakers is not simply to fund more treatments for more people. The challenge is to gauge the impact of different kinds of care, and to embrace the ones that do the most good. No one denies that high-tech procedures have a role to play. But there is a growing awareness that we’ve placed too much stock in them. By all indications, we could have a less technological healthcare system and still have a healthier society.
As the nation’s health budget explodes, technological fixes are coming under closer scrutiny. Researchers are studying the costs and benefits of various interventions from fetal monitoring to heart surgery–and discovering that we could safely forgo millions of procedures a year. At the same time, employers, insurers and many physicians are recognizing that low-tech, community-oriented measures could temper the demand for costly treatments, by reducing the burden of disease From measles to AIDS, lung cancer and heart disease, an astounding 70 percent of the ills treated by U.S. doctors are preventable. The increasingly urgent question is whether we can learn to prevent them.
America’s high-tech medical system has achieved wondrous feats during the past four decades. Vaccines and antibiotics have helped control infectious disease. New drug treatments have brought relief from depression and high blood pressure and doubled the survival rate for children with leukemia. Surgical advances have helped alleviate everything from burns and trauma to bowel obstructions and congenital heart defects. And new instruments have enabled doctors to perform various procedures, from breast biopsies to gallbladder removals, more humanely. Yet these wonders have had surprisingly modest effects on the population as a whole. The greatest advances in public health have stemmed not from new techniques for treating illness but from social changes that helped people avoid it.
Consider infectious disease. Life expectancy in America has jumped dramatically since l900 (from 47 to 75 years), thanks mainly to a decline in deaths from contagion. But as the sociologists John and Sonja McKinlay have shown, 90 percent of the progress occurred during the first half of the century, before the modem medical system took shape. Four out of nine leading scourges (TB, typhoid, measles and scarlet fever) were already well under control by the time vaccines or treatments came into wide use. And the death rates for four others (flu, pneumonia, whooping cough and diphtheria) declined at basically the same rates before and after technology delivered a fix. Despite the major exception of polio–which plummeted after vaccines came into use in the mid’ 50s–the McKinlays calculate that less than 4 percent of the decline in mortality between 1900 and 1973 resulted from medical measures. The real breakthroughs, scholars now agree, were better housing, hygiene and nutrition.
Medical treatment has had similarly modest effects on the latterday scourges of cancer and heart disease. Americans of any given age are as likely to die of cancer today as they were in 1971, when the Nixon administration declared war on the disease. The United States now spends some $2 billion a year on cancer research and an additional $35 billion on treatment. The effort has helped improve the survival rates for several malignancies, including lymphoma, melanoma and childhood leukemia. But the only big successes have come from prevention. Stomach cancer, a leading killer in the 1930s, has declined dramatically since the home refrigerator came along, reducing people’s reliance on cured and smoked foods. And the death rate from uterine cancer is now less than half what it was in the early ’50s, when Pap smears started detecting it at readily treated stages. Unfortunately, those triumphs have been overshadowed by an epidemic of lung cancer. Deaths from that smoking-induced malignancy have risen tenfold since 1930.
The death rate from heart disease has dropped by half since the mid-1960s. Yet studies consistently find that the improvement has less to do with treatment than with changes in diet and lifestyle. In a 1988 study Dr. Lee Goldman, a Harvard cardiologist, analyzed the decline in cardiac death between 1968 and 1976. Though he couldn’t account for all of it, he traced more than half to the drop in cigarette smoking and cholesterol intake. Roughly 20 percent of the drop was due to heart and blood-pressure drugs, and only 3.5 percent to bypass surgery. Goldman has recently updated his findings, and he says the same basic lesson still holds: “The impact [of the costliest interventions] is minimal.”
High-tech measures may not create a healthier population, but they can mean everything to a sick individual. Unfortunately many of our ostensibly lifesaving technologies have never been properly evaluated. The government doesn’t license new drugs without testing them for safety and efficacy, but doctors have embraced countless tests and surgical procedures on faith. By mistaking “new” for “improved,” San Francisco obstetrician David Grimes wrote recently in the journal of the American Medical Association, the medical profession has “squandered resources, wasted effort, and in some cases harmed or killed patients.” The problem isn’t a new one. From bloodletting to lobotomy, worthless innovations have seduced every generation of doctors–and valuable procedures have often found wider applications than they deserve. But never have the excesses been so costly.
Americans often experience their first questionable medical procedure before they’re even born. During delivery, obstetricians commonly attach an electronic monitor to the fetus to gauge its heart rate. An estimated 50 percent of all U.S. births are monitored. In theory, the device gives doctors a continuous sense of how the baby is faring, enabling them to extract it surgically at the first sign of distress. But eight controlled studies have found that electronic monitoring has no advantages over a stethoscope placed on the mother’s stomach, even in high-risk pregnancies. Throughout those studies, monitored babies have suffered the same rates of stillbirth and brain damage as those who are spared the procedure. Yet the monitoring boom continues, at a cost of $1 billion a year. In the liability-strewn world of obstetrics, forgoing any common procedure–even a useless one–can be risky, for it marks a departure from the “standard of practice.” If a patient sues over an unhappy outcome, it’s the community standard, not the scientific justification, that counts.
The same logic, combined with financial incentives, has helped make Caesarean birth the nation’s most common major surgical operation.
Nearly a quarter of all American babies–about 1 million a year–are delivered surgically. Back in 1980, the National Institutes of Health noted that the U.S. Caesarean rate had nearly quadrupled in 15 years (rising to 16.5 percent from 4.5 percent in 1965), without any demonstrable benefit to mothers or babies. Expert panels called for restraint, but the rate climbed steadily for another eight years. The practice has plateaued since 1988, and in a departure from tradition, many women who have had Caesareans in the past are going on to deliver babies vaginally. But the U.S. Caesarean rate still dwarfs those of most developed countries, and no one pretends that the rate is medically justified. A woman is no likelier to survive childbirth in the United States than in Sweden or Norway, but she is twice as likely to have a Caesarean.
She’s also six times more likely than a Swedish or Norwegian woman to have her uterus removed. U.S. doctors perform nearly 600,000 hysterectomies every year, at a cost of more than $5 billion. A third of American women undergo the operation by the time they turn 60. Yet no one knows how many of them gain anything from it. Although no one denies that cancer, a massive hemorrhage or a life-threatening infection can warrant a hysterectomy, such conditions account for only a small fraction of the operations performed each year. Most are triggered by nonemergency problems, such as endometriosis or benign “fibroid” tumors, for which less invasive treatments are available. Researchers are now working to establish better guidelines, by tracking the risks and benefits of hysterectomy in different kinds of patients. In the meantime, hundreds of thousands of women are undergoing a costly and invasive operation with no proven payoff.
Heart operations are even costlier than gynecological ones. Every year, some 400,000 Americans undergo bypass surgery (the use of a graft to divert blood around a narrowed artery). The cost some $12 billion–exceeds the budget of the National Institutes of Health. The operation clearly helps prevent fatal heart attacks in people with certain conditions (a blockage of the all-important left coronary artery or a combination of three blocked vessels and an ailing heart chamber). But studies showing that it’s no better than drug treatment for less dire conditions have yet to dampen surgeons’ enthusiasm. The bypass rate has climbed steadily since 1988, when a Rand Corp. survey found that half of the bypass operations in a sampling of hospitals were either questionable or useless.
Cardiologists once touted angioplasty (the passage of a balloontipped catheter through a narrowed artery) as a less invasive alternative to the bypass operation, but both procedures have skyrocketed since the ’70s. Americans now get 300,000 angioplasties a year–even though drug treatment usually yields similar benefits at a fraction of the cost. The $10,000 procedure has never been shown to prevent heart attacks, but some practitioners defend it as a remedy for angina. In one recent six-month study, patients receiving angioplasty did report less chest pain than those on medication. They also performed slightly better on a treadmill test. But the angioplasty itself caused several nonfatal heart attacks and 16 of 100 recipients required a second or third procedure within six months. “Advocates call that an improvement in quality of life,” says Dr, Thomas Graboys, director of Massachusetts General Hospital’s Lown Cardiovascular Center. “I think it’s baloney.”
Most everyone now agrees that taming health costs will involve reining in the use of high-tech procedures. Unfortunately, we often assume that the only alternative to the status quo is a system in which lifesaving technology is cruelly rationed, consigning people to die waiting in line for an MRI or a bypass operation. Tough choices will surely arise. But it’s a little early to talk about denying people the tests and treatments they need. The challenge for now is to eliminate the huge number of procedures that are either unwarranted or avoidable. Meeting that challenge will require at least three kinds of reform.
First, experts agree, doctors need to know more about the costs and benefits of particular treatments. “We know less about what works in health care than we know about the used cars we buy at the lot,” says Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota and a member of the ethics group of the president’s health-care task force. “That’s inexcusable for a $1 trillion part of the economy.” To remedy that situation, the federal government has launched a massive review of common procedures. Groups of experts (known as PORTs, or patient-outcomes research teams) are reviewing old studies and conducting new ones to determine which treatments actually work, and under what circumstances. At the same time, at least half a dozen private companies are creating electronic databases to help doctors and insurers think more rationally about the best way to treat particular conditions. Physicians may not like having checks placed on their clinical judgment, but more and more are now conceding that personal opinion is no substitute for scientific evidence.
Information alone won’t stop the spread of unproved treatments. A second task is to change the incentives pushing doctors to embrace them. Traditional fee-for-service insurance plans have generously reimbursed invasive procedures, often paying little or nothing for checkups and vaccinations. The Clinton administration hopes to reverse those incentives. Under the “managed care” arrangements its health plan encourages, a doctor might receive a fixed yearly fee for tending to all the needs of his patients. Physicians would still have incentives to provide the best possible care (they’d have to compete with each other for business), but the cost of unnecessary procedures would come out of their own pockets. in theory, the most efficient care would be the most profitable.
Eliminating waste might shave billions from the nation’s medical bills, but it’s only a first step toward cheaper, more effective health care. The larger challenge is to reduce the need for high-tech intervention. “If [health reform] isn’t undergirded by a strong and broad ethic of prevention,” says Dr. C. Everett Koop, the former surgeon general, “we’ll be talking about these same things a few years from now.” Prevention alone could virtually eliminate AIDS and lung cancer, and dramatically reduce heart disease, still the nation’s leading killer. And though it costs money to give everyone access to a family doctor, routine medical care can help quell the demand for pricier services. It costs $600 to provide prenatal care for a pregnant woman, $2,500 a day to keep a premature baby in intensive care. Eight dollars will buy a measles shot, but treating a serious case of the disease can cost $5,000.
That lesson is starting to take hold. More and more employers and health plans are banking on prevention to lower costs, and the effort is paying off. Consider the case of Birmingham, Ala. In 1983 the city government’s health-care expenses were rising at twice the national average. In desperation, officials launched a screening program to identify and counsel workers who were at high risk for disease. Fully 13 percent of those screened had multiple risk factors, and 40 percent of the high-risk group had no doctor -even though they were covered by insurance. Using caps and T shirts as incentives, the program lured the employees into counseling to help them lose weight, quit smoking, manage stress, reduce their cholesterol, control their blood pressure and prevent back injuries. The payoff came quickly. In just one year, a fitness program for fire and rescue workers reduced the cost of job-related injuries from $250,000 to $65,000. And from 1985 to 1990 the city’s health bills held steady, even as the price of care soared. By investing $3 million in health promotion, Birmingham officials figure, they saved $10.5 million over five years.
Such results should come as no surprise. Dr. Kenneth Pelletier of Stanford’s Center for Research in Disease Prevention has reviewed the 48 studies of work-site health-promotion programs published since 1980. The result: every program but one has shown positive effects on the workers’ health, as measured by risk factors and by rates of actual illness. And of the 30 or so programs analyzed for cost-effectiveness, every one has saved money. As Pelletier observes, “More significant innovations in health promotion and disease prevention have taken place in work sites, from small to large, in the last 10 years than since the Industrial Revolution.” What could prevention accomplish? No one knows, but by all indications, it could succeed where a thousand high-tech treatments have failed. Indeed, low-tech community medicine may ultimately do for America what Dr. John Snow did for the city of London during the cholera outbreak of 1854. Instead of wrestling vainly with symptoms, Snow discovered a cure. He traced the epidemic to a contaminated well. Then he took the handle off the pump.
