Resuscitating American Medicine
Publication Year: 2009
Published by: Rutgers University Press
List of Figures and Tables
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I am a neurosurgeon, perhaps the last person you might expect to write a book calling for reform of the medical industry. Yet despite all the good in medicine, I have witnessed bedside tragedies that no one would expect in the United States. After studying the U.S. health care system, I became so disturbed by my discoveries and experiences that I left my practice and ...
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It was my great good fortune to work with Marilyn Alice McDonald almost daily for thirteen years, and for three of those years she toiled shoulder to shoulder with me on this book, as dedicated to its completion as I was. Together we undertook the primary research, and we constantly debated our findings and conclusions. Her conservative Midwestern judg- ...
Part I: Why the Uninsured Should Be Covered
Chapter 1. Not Business As Usual
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One hot Saturday afternoon in the summer of 1999 I was on neurosurgery call at Memorial Hermann Hospital in Houston, Texas, one of the largest trauma centers in the United States. Houston is the fourth-largest city in the country, and its metropolitan area is home to 5 million people.The page operator connected me with an emergency room doctor in the ...
Chapter 2. Unreliable Emergency Services
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In the late 1970s, I was a resident physician training in a public hospital. My colleagues and I had become furious at groups of neurosurgeons in two Texas towns who often referred to us patients with problems that they said were too complicated to manage in their hospitals. Hours later, we would go down to the emergency room to receive some poor soul who was ...
Chapter 3. An Eroding Infrastructure
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The value of treating emergency patients within the Golden Hour has been drilled into me since the day I began my surgical residency in 1975. The term refers to surgeons’ brief window of opportunity for saving trauma patients, and the concept has been the linchpin of what is the best emergency services system in the world, matched only by Germany’s. ...
Chapter 4. Fifteen Years Lost
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Hospitals are primarily financed by private and public health insurance. Their revenues come from care of patients with (1) private insurance, (2) Medicare, and (3) Medicaid and its affiliated programs. Hospitals earn income from investment of their profits and from services such as cafeterias, parking, and medical services that they contract out, but patient care ...
Chapter 5. Handed Health Care’s Leftovers
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One Sunday afternoon in 2004, I sat with other members of a panel on a dais before a large audience in a Houston church auditorium, listening as a group of people without health insurance shared their experiences. I heard two stories that illustrate the predicament of the uninsured. The first was told by an attractive woman, about forty years old and a single ...
Part II: Why Health Care Is So Expensive
Chapter 6. Where We Are Headed
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Medicare provides health insurance to seniors, regardless of income.The program’s cost has grown so much over the years that it will soon either burden taxpayers or place allocations such as defense spending, foreign investment, and education at risk. As happy as Medicare beneficiaries are with their Medicare, it cannot and will not continue on its cur- ...
Chapter 7. 30 Percent Waste—or 50?
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Hospitals, doctors, drugs, and outpatient tests and procedures account for most of health care spending. Hospital spending predominates at approximately 31 percent of all health care expenditures, followed by payments for physician and clinical services (21 percent) and prescription drugs (10 percent).1 Despite the overuse of emergency rooms, their cost is ...
Chapter 8. Poor-Quality Primary Care
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Although the story that follows is fiction, it is an accurate depiction of the results of a medical system in which patients are managed by a number of doctors, all of whom may be good at what they do. From the patient’s point of view, however, the results are not so good. The problem blood pressure, and high cholesterol complicated by diabetes. One ...
Chapter 9. Dangerous Hospitals
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Poor management of medical resources is not only expensive but dangerous. In 1999 the Institute of Medicine published To Err Is Human, a landmark book based on a study of medical errors.1 The institute concluded that medical errors in hospitals kill between 44,000 and 98,000 people per year. According to the authors, this number of deaths is equivalent to the ...
Chapter 10. Violation of Dignity: The End of Life
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Not only are patients’ rights at the end of life often violated, but money is also wasted. Indeed, at least a quarter of Medicare costs are spent on the last year of life.1 This in itself is not necessarily a bad thing, but how the money is spent is another matter. ...
Chapter 11. Unnecessary Surgery
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In my clinic I repeatedly saw unfortunate patients whose stories precisely matched this fictional one. Jennifer Allen’s story helps explain why there is such a thing as unnecessary surgery. Back trouble ran in Jennifer’s family, and she first began having mid-line low back pain when she was thirty. After this episode physical therapy ...
Chapter 12. Perverse Payment Incentives
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Medicare and private insurance pay doctors for each service they provide, no matter the circumstances or the results. Both have historically controlled their costs by setting the price they will pay doctors per service and then cutting prices across the board when the number of services becomes excessive (regardless of whether the services are required by the ...
Chapter 13. Three Pathways to Hospital Profitability
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This story illustrates one of the undesirable effects of rational business decisions that hospital administrators must make in order to maintain solvent hospitals. The problem is not bad people but good people working in bad systems that reward the wrong decisions. ...
Chapter 14. Pharmaceuticals: Remarkable Innovation, Shameless Puffery
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Americans’ average life span has increased by twenty-five years since 1900. The Centers for Disease Control concludes that twenty of those years are the result of simple measures such as sanitation, clean food and water, decent housing, and vaccination. Five years and three months of the increase are attributed to medical care, and pharmaceuticals contribute to ...
Chapter 15. Private Health Insurance: No Added Value
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What has the health insurance industry contributed to U.S. health care? It enjoys a bountiful profit simply by passing along costs. In 2006 the American public, reeling from high health care costs and anxious about the nation’s 47 million uninsured people, learned that United Health CEO Dr. William McGuire had been forced to resign after allegations of stock ...
Part III: Reforming American Health Care
Chapter 16. Three Options for Covering the Uninsured
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To achieve a high-performance health care system, the United States must do two things: (1) cover the uninsured and (2) reform the medical industry. The two are interrelated but separate policy undertakings. First, let’s consider the expansion of insurance coverage. ...
Chapter 17. No Coverage Expansion without Cost Control
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The cost of providing health insurance for the uninsured is not trivial, but it amounts to less federal money than is spent on any other single federal program or industry subsidy. In addition to what hospitals, doctors, the public, and the uninsured themselves already spend on the uninsured, the United States could cover them for an estimated 73 to 100 billion ...
Chapter 18. A Workable Plan for Reform
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If I believed that the unaided market forces of 247 million people (the U.S. population minus those enrolled in Medicare) would drive down the cost of health care and extract waste, I would not have been impelled to write this book. But the medical industry does not operate like a conventional market. Lowering cost and improving quality are not as simple as ...
Chapter 19. Establishing Standards
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It is ridiculous that people today are undergoing medical procedures of unknown or marginal value. Even worse, such procedures—many of them probably completely unnecessary—accounted for 4 to 8 percent of hospital spending in 2005, according to my calculations. ...
Chapter 20. Prioritizing Primary Care
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The Sumner Clinic is not much to look at from the outside. It is located in a strip shopping center on a busy street in the small town of Gallatin, Tennessee, about thirty miles northeast of Nashville. The clinic is managed by a general internist, Dr. Sid King. When I entered for my meeting with King, I was greeted by a trim, smartly dressed elderly woman sitting ...
Chapter 21. Reducing Spending on Hospitals and Specialists
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The United States is paying for high-performance hospitals but not getting them. What would a true high-performance hospital look like? I interviewed Dr. Lucian Leape, adjunct professor of health policy at Harvard School of Public Health, who is a pioneer in hospital safety and quality. When I asked how he framed the difference between safety and quality, ...
Chapter 22. Positioning of an American Medical Quality System
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The concept of a center that evaluates technology is not new. Support for the idea has been steadily building in the insurance industry and among many policy groups in Washington.1 What is new—and essential—is the concept of an entity that also reforms the medical industry by performing experiments in health care financing and delving into the ...
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Page Count: 304
Illustrations: 19 illustrations
Publication Year: 2009