Medical Economics

Machiavelli's Laboratory is a free ebook that I published on April 13, 2010. It is a satiric discourse on scientific ethics, from the perspective of an unethical scientist. Please don't take any of the advice and opinions in the book (or the excerpts featured in this blog) seriously.

In the United States, there is no healthcare system. What we have is a medical technology system wherein the provision of medicine is determined almost exclusively by the method and amount of reimbursement obtained for the different technologies employed. Basically, the practice of medicine is pre-determined by money, not disease.

Here is an example. A 300 pound, 30 year old smoker comes to his private physician, complaining of difficulty breathing. After a quick history and physical examination and some simple blood work the physician finds that the patient has hypertension, hyperglycemia, a complex dyslipidemia, osteoarthritis of knees and ankles, chronic bronchitis, sleep apnea, back pain, GERD (gastro-intestinal reflux disorder), halitosis, chronic fatigue, depression, and frequent absenteeism from work.

The doctor knows that all of these problems are the direct result of the patient's morbid obesity. If the patient were put on strict diet, with exercise, all of his medical issues would soon vanish - even the halitosis (which is secondary to GERD). The most effective approach to the patient's treatment would be a lengthy discussion, with the physician, in which the doctor would explain that all of these disorders stem from dietary excess or dietary indiscretion, coupled with a lack of regular exercise, and exacerbated by smoking. If there were an effective public health system, the patient would be tracked to a personal trainer, who would plan the patient's diet and exercise program and supervise a smoking cessation program. His family would be brought into the discussion, and instructed how they must support his efforts to reduce weight. His employer would participate in his therapy program by providing a supervised period, in the morning and afternoon, when employees would engage in light exercise. Employers are happy to cooperate, when they know that a program will reduce absenteeism and enhance staff productivity. The cost of this kind of treatment is small. The benefit to society is immense. Of course, this description does not characterize the practice of medicine in the United States.

In the United States, an obese smoker with attendant ailments is a medical gold mine. The doctor tells the patient that he is a diabetic and will develop blindness and almost certainly require amputations of his legs, if he doesn't begin lifelong treatment with oral hypoglycemic agents, and, eventually, insulin. The patient will learn that his hypertension is out of control and that he will start treatment with two expensive medications. His treatment for hypertension will be a life-long process. His dysplipidemias will require life-long treatment with the most recently marketed statins. His sleep apnea would require an expensive evaluation followed, with an assistive breathing device (CPAP, Continuous Positive Airway Pressure) that would be fitted to the patient and worn through each night, for the remainder of his life. GERD will require endoscopy, esophageal biopsies, and medications to reduce the production of stomach acid. Chronic bronchitis, will require a consultation from a pulmonary medicine specialist, who will follow the patient indefinitely, providing a rich array of agents intended to cleanse airways and open bronchi, oxygen therapy as needed, and antibiotics for attendant lung infections. An orthopedic consultation will be called to evaluate the patient's knees and ankle arthritis. He will probably recommend arthroscopic procedures. Back pain will probably require various pain killers, muscle relaxants, corticosteroid treatments, and possibly surgery. Fatigue and depression will lead to psychiatric examinations and trials with various tranquilizers, anti-anxiety, anti-depressent medications. The many daily, long-term medications will interact with one another in an unpredictable, and malevolent manner, producing strange incapacitating symptoms that no doctor will be able to diagnose correctly. The patient will continue to smoke and to gain weight at a rate that is alarming, even to himself. The patient's work absenteeism will worsen, as his many doctor visits increase in frequency and his various complaints multiply with age. His employer will become obsessed with finding a way of firing the patient without violating the patient's employment contract.

In a healthcare system, the patient would be treated for the primary problems that caused all of his symptoms: over-eating and smoking. But the U.S. does not have a healthcare system. We have a health technology system, which is geared toward providing tests (e.g., laboratory tests on blood or tissue biopsies, various imaging scans), procedures (e.g., endoscopies, biopsies, surgical interventions), and medications (particularly, expensive new drugs that are protected by patent). In a health technology system, doctors are paid for the technology that they employ. In a health technology system, there is no satisfactory way to reimburse a doctor for the hours spent coaching an obese patient to participate in a healthy, effective diet. Consequently, patients are treated on a symptom-by-symptom basis. It's an expensive and ineffective way of practicing medicine, but that's the whole point. A health technology system is aimed at generating reimbursed costs.

Has this discussion been realistic? Has the American health technology system done more harm than good? Or have I irresponsibly mischaracterized the problem?

Jump to tomorrow's blog


- © 2010 Jules Berman


key words: medical-industrial complex, American healthcare, reimbursement for prevention