Download Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System fb2

First of all, a disclaimer. I have worked with Daniel Callahan (some years ago) and with the Hastings Center which he helped found. I have also reviewed (in another place) an earlier book of his, False Hopes: Why America's Quest for Perfect Health is a Recipe for Failure. His main thesis in both books is that we soon have to radically rethink the goals of medicine.

In this new book Callahan argues that the profligate use of medical technology is the chief culprit in the upward spiral of costs. When we evaluate medical technology based only on its impact at the individual level, all the incentives push us toward using the technology. We must evaluate medical technology against its population effectiveness.

In my review of False Hopes I argued that prior to this fundamental reform of medicine we must first achieve fundamental health care reform, including payment reform, before we can bend the curve of medicine more toward public health priorities.

This new book convinces me that I was wrong. We can't wait. We need to start talking now about the ends of medicine in terms of the common good. The next 10 years while we debate health care reform will be decisive.

Another reviewer tries to separate medicine and public health into two realms: one devoted to prevention the other to treatment. I once heard a dean of a very good medical school make the same distinction: medicine is responsible for the individual patient's good; public health if for the common good, or the health of the public.

This is a very common, and very wrong, distinction, as Callahan's books have long argued. Medicine is also responsible for the common good, the health of all of us together. More than this Callahan argues that we cannot hold medicine responsible for this task until and unless we determine what we mean by the good or full life. Callhan asks that we face the reality of death and the end of life when caring is what matters, not another heroic intervention.

I have watched friends my age (73) die in hospice centers when it came time to throw in the towel, and for my friends and for myself, accepting death is part of what is meant by the full life. I had another friend of the same age, a physician, finally decide to have back surgery for chronic pain despite the evidence of its dubious effectiveness and he suffered coronary arrest and died several days later. This occurred in one of the nation's premier teaching hospitals where my friend taught.

Callhan's book is the best book around for reviewing all of the various dimensions of health care reform, beginning with Medicare. He has a remarkable knowledge of the vast literature on Medicare reform and also is up to date on what's occurring in health care systems in the Western democracies as they struggle to control spending. I also have studied the health insurance schemes of Germany, and the tax-financed National Health Service in England, but Callahan's information is up-to-date, informed, and pertinent to the U.S. because it shows how all of these systems are faced with the huge pressures that medical technology is placing on medical spending, and are all systems are trying in various ways to cope.

I plan to recommend this book to every one who wants to try and grapple with the next 10 years as we move toward systemic reform. It is encyclopedic in its coverage of the vast range of topics, and its final chapter, where once again he returns to why public health and its population perspective is so central to the evaluation of medical technology and medical practice, should be read by everyone in public health.

The first reviewer's analysis of this book is a caricature of the importance of Callahan's achievement. Callhan's real message is that when it comes to health together, or health status, we must sooner or later decide what we mean by a full life and a normal life span. Public health, no less than medicine, needs to face this challenge.

We all need to ask ourselves, how much health together is enough and how do we get to that "enough"....with more and more enormously expensive technology or by eliminating health disparities by extending effective primary care to those who today are without coverage, or by reforming primary care for those who have coverage to preclude expensive testing that is accomplished more for the economic health of hospitals and clinics rather than the patient?

This is a very important book on the health care debate by an expert who has written many important books on the ends of medicine.

Health care economists attribute about 50% of the annual increase of health care costs to new technologies or the intensified use of old ones. Those rising costs now consume 18% of GDP, and contribute to the gradual decline of employer-provided health care (now down to 60%), and increase in cost-sharing, and half of all personal bankruptcies in the U.S. American health care has now become a disease itself, a cancer eating away at our economy. Even though technology is the main driver of cost increases, they are not one of its primary underlying pathologies - these include high administrative costs, fee-for-service medicine, and a profit-driven private sector that provides economic incentives for physicians to use and misuse technology. Ironically, the increasing pressures to 'reform health care' from conservatives and ideologues focus on Medicare, the most cost-effective source of health care in the U.S.; even more so is the fact that in adding prescription drug benefits they prohibited the government from negotiating lower drug prices for Medicare beneficiaries. The Medicare Advantage program is also flawed because it is subsidized by government and more expensive than standard Medicare coverage. As for Medical Savings Accounts - their chance of having any great cost benefit is slight because over 80% of national health care costs are incurred by 20% of the people who need catastrophic care - savings that would come from hesitation to use savings account money for lesser illnesses and cost-sharing would be minor. Private health insurance, mainly paid for by individuals rather than employers, have fewer incentives to contain costs, while publically-ruled systems have been more successful in doing so - often, however, at the expense of waiting lists. A Kaiser Family Foundation 2006 report surveyed current cost control efforts by payers (eg. better management of high cost and chronically ill patients, reducing payment rates to providers), consumers (eg. out-of-pocket payments, better information, tax incentives), and supply-side strategies (eg. electronic medical records, reduction of medical errors, rewarding efficiency and quality) and concluded that they may lead to efficiency and quality gain, they would not have meaningful impact on overall costs. Meanwhile, the political battle rages on, raging over uncertain data on both costs and benefits. Thus, the authors conclusion that focusing on technology provides the most fruitful path for controlling health care costs. The authors then review evidence on the effectiveness of competition in restraining health care costs, concluding it is mixed and not encouraging.

My criticism is 'Taming the Beloved Beast' is that its examination of other nations' efforts to limit health costs, all in Europe except for Canada, is rather weak/superficial and they fail to examine any Asian programs. Unfortunately, its the Asian programs that have been most successful - eg. Japan and Taiwan hold health care spending to 8% of GDP, and Singapore is at 4% - vs. the U.S. at 18%.