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Dysfunctional American Health Care


The breathtaking width and depth of the problems in American health care have led to widespread confusion and consternation to the point where it is difficult to figure out where we can even start to improve things.

Over the last few weeks I have been running down some of the big areas in American health care that are in serious need of improvement or replacement. It is the breathtaking width and depth of these problems that have led to such widespread confusion and consternation with people talking at and past each other.

Congress, insurance companies, employers, docs, the man on the street — all are looking at the elephant, but from many different keyholes and not understanding even where to start. Unfortunately, this is all so wasteful of time, money and human lives. I'm hoping that it may have some utility just to see many of the big problems listed in one place.

Let's start this week with a simple one: the pharmaceutical mess in this country. We have a welter of regulations and legal decisions that require up to $1 billion (with a B) to get a new drug developed, proven and to market. Yet, Big Pharma has some of the highest profit margins — even after that billion dollar expense is recovered — this side of the cosmetics industry. But developing a new drug still shouldn't be so slow, costly and bureaucratic, pretty much everyone agrees. There's got to be a better way.

Also on the drug front, the over-the-counter med/supplement industry has spent untold millions in Congress to keep their products away from FDA scrutiny. If the FDA had oversight to ensure purity, efficacy and safety, the shelves would be empty tomorrow. So the public ultimately gets to pay for the drug interactions, gratuitous side effects and the delay in getting proven effective care for medical problems that is often inherent in the use of these nostrums.

Another dysfunctional cluster — this one near and dear to all docs' hearts — starts with the high debt being incurred by current docs in training. This development has aggravated the skewed distribution of docs into procedural-based specialties because these are (artificially?) more highly paid and it only makes common sense to go where you can pay off your debts more easily. And make disproportionately more thereafter, of course.

The geographic misdistribution of specialties also needs fixing. In many ways, docs are incentivized to cluster in urban medical centers, but equitable distribution is required for effective delivery of health care to the entire population.

As just one idea to solve this cluster of problems, the government could foot the relatively small bill for all medical training and get the graduate doctors to practice for a few years in an underserved area.

As for the specialty skew, how about Medicare taking action, which all insurance companies will immediately ape, to more equitably balance payments for cognitive and procedural treatments? Voila! Elimination of student debt and rational distribution by specialty and by location... Okay, okay, I know, but I can dream, can't I?

Moving on, how about bundling the EHR transition, HIPAA excesses and the proliferation of widely varying insurance forms into one big rat's nest of confused processes. Whatever the theoretical benefits of each, the convoluted execution of these has almost hamstrung the current practice of medicine and led to wasted time, wasted money (no doubt in the billions) and untold frustration. I once gave a talk to medical students at Stanford University about this kind of thing and it was an interesting phenomenon to see the disbelieving gawks of the students contrasted with the nodding heads of the doctors in attendance.

There is much more unresolved inefficiency in medicine to enumerate if you keep peeling back the layers. But my original intent was just to touch on the biggies. And my attempted focus on 10 has turned into 20-plus.

Health care is woven through all aspects of our society and improving these problems will be a perennial struggle, I'm afraid. Notice that I didn't say “solve the problems.” For just as the science in medicine is evolving rapidly, so are our economic, cultural and governmental lives.

Next week, let's review some of what is "right" with current American health care. You know, to be fair and balanced…

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Victor J. Dzau, MD, gives expert advice
Victor J. Dzau, MD, gives expert advice