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Why We Can't Have Nice Things, Like A More Rational Health Care System

As health care politics began making headlines again this week, I tried to feel hopeful about our prospects for progress. But I was in the midst of reading a persuasive new book called "Unhealthy Politics" and it did not, shall we say, incline me toward optimism.

The introduction quotes this striking description by medical ethicist Daniel Callahan:

"American health care is radically American: Individualistic, scientifically ambitious, market intoxicated, suspicious of government, and profit-driven."

(Princeton University Press)
(Princeton University Press)

"Unhealthy Politics" focuses on the related fact that American health care also frequently ignores scientific evidence in ways that may harm patients and certainly harms the national budget.

The book explores why American doctors, politicians and members of the public tolerate so much medicine that is not based on rigorous evidence about what works best for patients. I spoke with Brown professor of public policy and political science Eric Patashnik, who co-authored the book with colleagues Alan Gerber of Yale and Conor Dowling of the University of Mississippi. Some highlights from our conversation, lightly edited:

How do you define the problem?

We spend about 18 percent of our gross domestic product on health care. That's more than any other country in the world, and our outcomes are not consistently superior. That's partly because our prices are very high, and our administrative costs are excessive. But another part of our problem is that many of the treatments that patients receive are actually not as effective as they could be. Medicine is not always based on sound evidence.

Some experts believe that less than half of all medical care is based on adequate evidence about its effectiveness for patients with different conditions. Many treatment options have never been compared head-to-head with alternatives.

So for example, let's say you're a patient with back pain. There might be a variety of ways to treat your condition. There could be surgery. There could be physical therapy. There could be a drug regimen. Which one really works best for you? The answer is: Often, we don't know. And that means that doctors often don't have the hard evidence they need to make the most informed treatment decisions. They may rely on what they learned decades ago in medical school, or norms in their local practice area, or even on conjecture and anecdotes.

We have a Food and Drug Administration that evaluates pharmaceutical products and medical devices. But in many cases, FDA review isn't set up to ensure that patients get the most effective treatments.

For example, when it looks at a new drug, the FDA is often looking at whether a drug works better than a placebo, not whether it works better than an alternative drug or other treatments for the same condition. Also, we don't have an FDA for surgery. Oftentimes, surgeries are not even grounded in strong animal studies.

As a result, treatments can diffuse into widespread practice before they are rigorously evaluated, and sometimes these treatments have real risks for patients.

"The rate at which evidence shapes and improves medical practice is much, much more sluggish than people realize."

So the core problem we're talking about in our book is not that there's no evidence in the health care system, or that doctors are never paying attention to good science, but rather that key evidence is often missing, and that the rate at which evidence shapes and improves medical practice is much, much more sluggish than people realize.

All of this can lead to overspending, to inefficiency, to both over-treatment and under-treatment, and to practices that can put patients at risk. And it basically means we don't get good value for our health-care dollar.

So why doesn't our system do more to solve these problems? Starting with the doctors...

Society grants physicians professional autonomy and control over the delivery of medical services. There's a lot of power and respect that goes along with those benefits, and the implied social contract is that in exchange for those professional privileges, that physicians will use their training and authority to make sure that patients receive the best health care possible.

Every doctor believes in the importance of evidence. But what we've seen in many specific cases is that when science challenges treatments — when, for example, a study comes out that says a new back surgery doesn't work as well as advertised — rather than embracing the science, we see that medical societies often challenge it. They often try to maintain the status quo.

There's a variety of reasons why that may be, from good scientific reasons and skepticism to organizational inertia to financial incentives, psychological reasons why it can be hard to adapt to new information. Whatever the cause is, the result is that physicians have not consistently used their professional authority to move the American health care system to a more evidence-based system.

And what we found is that this failure to exercise professional responsibility on the part of medical societies and individual clinicians is not really noticed by the public.

As part of our research, my co-authors and I did five national public opinion surveys over the last decade or so, to try to understand how ordinary Americans think about these problems of lack of evidence and waste in American health care. What we found is first, Americans want better information about health care. And if you ask Americans, "Would you like to be warned if a particular treatment is dangerous?" Absolutely. But we found Americans are extremely nervous about anything that would interfere with the doctor-patient relationship. The public is really easily spooked.

We found that overwhelmingly, the public has a high degree of trust not only in their personal doctor but in the medical profession as a whole. It's true that there has been some loss of faith in the American medical profession over the last several decades, but compared to all the other actors in the health care system — government, insurers, pharmaceutical firms — the medical profession is the one that is seen as protecting patient interests.

The public believes strongly that no outside group should come between doctors and patients in making treatment decisions. They're very worried about government and insurance companies using evidence-based treatment guidelines as a way to control cost and ration care. That's the "death panels" scare. And they're very worried that if there's an effort to have evidence-based guidelines, that they're not going to keep pace with medical innovation.

These arguments came up in the debate over the Affordable Care Act, when there were some modest reforms contained in the law to try to improve the evidence base of American health care. And of course there are powerful actors that are trying to make the public nervous about reform — pharmaceutical firms and other industry interests. So that's one reason why it's really difficult to build consensus for change: the public is so nervous about anything that would interfere with doctor patient relationship.

On the hopeful side, we did a series of survey experiments to see if there is any way to build support for the kinds of reforms that we think are necessary, to make American health care more efficient and evidence based. And the answer is yes. The key is telling the American public that doctors support these reforms.

That's what we really found. If the public is told doctors believe these reforms are necessary to improve the health-care system, you can overcome a lot of the resistance. So doctors have an opportunity to play a leadership role in moving our very expensive and wasteful and inefficient and often irrational health care system to a better place.

How about politicians?

Our surveys suggested that if doctors are not providing that leadership, politicians have a very weak incentive to do anything.

What we found in our public opinion surveys is that if you're a typical member of Congress looking to build your career, wading into these waters is really risky.

With Medicare, for example, you might think politicians in their role of overseeing the Medicare program would seek to be good stewards of taxpayer dollars and really push the Medicare bureaucracy to conserve taxpayer funds by not paying for treatments discredited by evidence. But this is a very risky place for the typical politician to be.

So what is to be done?

I would say the first thing to be done is for the public to gain a greater awareness of these problems.

When we began this project some years ago we were under the assumption that yes, the U.S. health care system is really expensive and yes, too many Americans lack insurance and access to needed care, but at least the scientific basis of medicine is really strong. And we were frankly a bit naive.

What motivated our research in the first place was a landmark study published in the New England Journal of Medicine in 2002 that found that a very common operation for osteoarthritis of the knee, paid for by the Medicare program, actually did not work better than a fake operation in which a surgeon merely pretended to operate. When we — three political scientists — saw this, we said, "What the heck is going on here?"

We found that the original evidence arguing for this procedure was really weak. There were a lot of medical studies published along the lines of "I'm a surgeon. I performed some of these operations and my patients feel better." So that was eye-opening, that medical procedures could diffuse into practice on the basis of weak evidence.

And then we found, much to our surprise, that the initial reaction of the orthopedic medical societies was very hostile toward this study. They tried to defend the status quo.

"The way in which information improves medical practice is shaped by the political and economic incentives of our health care system."

It's not that evidence doesn't matter at all, or that scientific studies are ignored entirely, but the way in which information improves medical practice is shaped by the political and economic incentives of our health care system. And that can result in treatments that are not the most effective for patients continuing in practice for long periods of time. That can also mean that we are spending our health-care dollars in ways that don't always maximize health benefits for the population.

So public awareness. What else?

I would say the key is physician leadership. Medical societies, to their credit, in recent years have begun to recognize this problem. There was an effort called "Choosing Wisely" to identify treatments that are less effective. That was a hopeful step. On the other hand, I would say the results of Choosing Wisely have been somewhat disappointing thus far. It has not had a big impact on clinical practice.

There also needs to be greater training and self-awareness among physicians to understand how they themselves practice medicine and how their practice style compares to peers as well as to best practices. We also really need the medical societies to take it upon themselves to really embrace science and educate their members about problems such as over-treatment and over-diagnosis.

I want to be clear: We certainly don't think we could ever move to a completely guidelines-based system. The core argument of the book is that, though our current health care system is way out of balance and there's much too little reliance on general evidence about treatments, we can improve that evidence base even while retaining the discretion of individual clinicians to listen carefully to their individual patients and tailor care to what their patients want and need.

So what can a patient or voter do?

As a patient, you should ask good questions when you meet with your physician — not only which treatment they recommend or what is most commonly used, but what are the alternative treatments? What are the pros and cons of each of them?

We also need to support the the agencies that do work in this area, like the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality.

And as voters, we want to support politicians who take steps to improve the quality and efficiency of our health care system, including being willing to consider changes to our coverage and reimbursement policies for programs like Medicare and Medicaid, to try to give these programs more tools to reduce spending on health care that is not fully effective for patients.

One way or the other, we're going to be living with scarce resources in the health care system for a long time to come. We're inevitably rationing — explicitly or implicitly. The question is: Are patients, physicians and payers going to make decisions that are informed by science or not?

Readers, thoughts? Personal experiences of medical care that lacked an evidence base?

Carey Goldberg Twitter Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth blog.

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