Originally posted August 18, 2009
Last week the president made some comments about the fact that the American health care system pays for treatments that may be unnecessary, such as certain surgeries, while it fails to pay doctors to educate patients and perhaps avoid these procedures. Many MDs were upset by these words, which may not have been chosen in the most politic matter. Their feelings were hurt, and they protested hotly. However, this point needed to be made, and as a society we need to discuss it.
Mr. Obama mentioned tonsillectomies as a potentially unnecessary surgery, and your article appropriately pointed out that in some areas of the country far more of the kids have them than in other areas. It’s obvious that medical necessity is not the only factor controlling this. A doctor’s medical judgment might be influenced heavily not only by economic factors but by what habits and traditions are common in that time and place. When I went to acupuncture school, I was the only student who still had tonsils, out of a group of 20 adults ranging from their 20s to their 50s. Tonsillectomies used to be more common, as far as I know, and that was because doctors and parents believed that they were a good idea, not because they were always necessary. Similarly, when I took cadaver lab, the instructor was overjoyed to find that our cadaver had a uterus. He almost never saw one that did. Hysterectomies were done far, far too often, sometimes by doctors who were known to be “knife-happy,” as my mother’s generation put it.
Thankfully, both doctors and patients seem to be a bit more cautious with these surgeries nowadays. However, it is absolutely true that doctors generally get paid for doing something, not for helping a patient avoid procedures or medications. We are famously told that in ancient China, doctors were expected to keep people well; the lowest form of physician was the one who treated illnesses, and the highest was the kind who taught people to live in a way that kept them healthy. If too many people got sick, the local doctor might be in big trouble! That is the tradition in which I was trained, yet I too am paid for the treatments I provide, not for teaching a patient skills which may allow them to stop needing treatment.
We give a great deal of lip service to preventive medicine, yet we hardly practice it at all. HMO, you may remember, means “health maintenance organization,” and the HMOs were originally supposed to save us money by emphasizing preventive care. Well, we know how that turned out. HMOs do pay for a certain amount of screening, but they also typically disallow care that is considered “maintenance.” That is, if you have acute back pain, you are covered, but if you’ve gotten better and you want to see your chiropractor or acupuncturist or physical therapist to keep you from becoming disabled again, your insurer isn’t going to be interested in paying. Programs that have shown success in improving the health of diabetics by providing people they can talk with about diet and other issues of daily management of their condition have often had their funding cut.
Charles Krauthammer, in a column printed last Saturday, argued that preventive medicine is not the “magic bullet” to reduce health care costs. “The idea that prevention is somehow intrinsically different from treatment– that treatment increases costs and prevention lowers them– is simply nonsense.” Yes, this is true if you accept Dr. Krauthammer’s definition of prevention. “Preventing a heart attack with statins or breast cancer with mammograms is costly,” he writes. Excuse me? Statins, which do not address most of the mechanisms behind heart attacks at all, and which deplete the body’s stores of CoQ10, thereby contributing to heart failure (not to mention the other side effects), are indeed expensive, but they aren’t nearly as useful as their manufacturers would like us to think. And no one expects mammograms to prevent breast cancer. Mammograms can only detect cancers that have already occurred. This is still a good thing, but it is not prevention. Prevention is more complicated, and requires more responsibility, than just showing up for a test.
Most real preventive care comes from the patient, from us as individuals, and costs little or nothing. Improving our diets, for example, is perhaps the single most important thing we could do to improve the health of the entire country, and it would reduce the costs associated with obesity, diabetes, cancer, and heart disease. For example, if Americans were simply to stop guzzling the incredible amounts of high-fructose-corn-syrup-filled sodas that we consume, we’d make big inroads on diabetes and osteoporosis even without making any other changes. Most of our chronic and degenerative diseases are caused by our own behavior, and only we as individuals can control that.
There is so much more that could be said here about the ways in which we make ourselves sick by pouring toxins into our bodies and our environment. Then there is all the illness caused by well-meaning but wrong-headed medical treatment, including the thousands of people who die because of prescription drugs each year, and the harm done by incompetence and poor procedures, like hospital-caused infections. Much of the care we pay through the nose for is to fix problems caused by the carelessness and stupidity of human beings as a group. Humans are probably not going to get a lot smarter or more sensible anytime soon, but we can certainly tighten up things like infection control.
What’s being proposed to reform health insurance is hard enough, but real reform of the health care system will require changing our habits and our attitudes– a feat which people usually try their best to avoid. It’s not easy to feel optimistic about that. Yet, we must.