This is the first of two posts on recent books on health care. The other, tomorrow, is The Health Care Mess by Julius B. Richmond and Rashi Fein. Neither book covers the subject all that well, and both come up short on solutions, but their partial views do help to illuminate some of the problems. I'll be looking for other views, and plan to develop my own ideas further -- one is to build on open source to extend transparency and promote science over business.

David Mechanic is director of the Institute for Health, Health Care Policy, and Aging Research and René Dubos University Professor of Behavioral Sciences at Rutgers University. I've been looking to get a better grasp on health care politics and economics, and his book The Truth About Health Care: Why Reform Is Not Working in America (2006, Rutgers University Press) caught my eye. It's relatively short (228 pages), but actually a rather slow, tedious read. He writes in cautious assertions like thin paint strokes, only gradually circling in on larger truths. I was surprised at the end of the book that I had marked so much of it as quotable.

(pp. 35-36):

Given the required trade-offs and the many uncertainties as we try to achieve a more coherent system of care, it is important to have credible spokespersons who can help the public understand its options. In earlier times the medical profession had the public's confidence, but it no longer speaks with one voice or has high credibility. Nor has government much credibility, and the public's respect for authority and expertise has generally very much eroded. This is a worldwide phenomenon across all sectors including medicine, which for much of the twentieth century was insulated from distrust because of the reverence that many had for their personal physicians. While trust in one's personal physician is still quite strong, distrust in medical leadership is now on par with distrust in other institutional leadership in government and the private sector. The majority of the public do not necessarily anticipate that their medical leaders will work in their interests.

The loss of confidence in leadership is characteristic of a mass society with many channels of information and communication. News reaches people immediately from all over the world, and the media focus on disagreement and conflict, betrayals of trust, and competing points of view. Thus, people gain the impression that the morals and trustworthiness of their leaders are less than in past times. More specifically, in the case of medical care, the media expose the population to disagreements about treatment and care, conflicts among specialists, the uncertainty of medical evidence, and stories about medical errors and poor-quality care. Thus, much of the public is skeptical about leaving health care decisiosn to medical leaders. They trust their chosen personal physicians, but that trust diminishes when they see their physicians constrained by larger institutional controls. Although it has been documented repeatedly that fee-for-service medicine contributes to overutilization, patients seem less concerned about unnecessary treatment than the possibility that something of value may be withheld. Patients are reluctant to accept that treatments they have learned about from direct-to-consumer advertising or from friends are unneeded, and physicians are faced by time pressures that make detailed explanations difficult. Unwilling to alienate their patients, doctors often give them what they wish. The media are an important part of this process and contribute to raising patients' insecurities and demands.

(p. 45):

When patients paid directly for their care the issue of who sought varying types of care was of limited social importance. In American society persons are free to spend their disposable income as they wish, and those who preferred more medical care to alternative expenditures did little harm. Under contemporary conditions, however, most people have health insurance coverage and excessive use affects everyone's premiums. Also, taxpayers in one way or another pay much of the bill, so frivolous and unnecessary uses have social relevance. Moreover, medical technologies can be harmful, so misuse of care, whether by patients' choices or physicians' decisions, has important consequences. It is no longer viable to support whatever patients demand and whatever physicians are willing to provide, if it ever was. We need more sophisticated ways of determining need and appropriate care. We probably would not want to be restrictive for less expensive visits that are important to patients in providing information, support, and reassurance, but we have to think carefully about the expensive and invasive technologies and treatments that some patients demand and that may involve serious risks.

(p. 80):

The criminalization of persons with mental illness is commonly noted, and we now have many more persons with mental illness in jails and prisons than in mental hospitals. These correctional institutions typically have poor mental health services, and persons with mental illness are commonly victimized by other inmates and sometimes staff. The large number of persons with mental illness in prisons is due to many factors, including poor community mental health services. But many patients are jailed for substance offenses that are by definition associated with DSM disorders. [ . . . ] It is also fair to say that these patients do not fall high on the average person's hierarchy of compassion or high on political agendas. But the criminalization of the mentally ill represents perhaps the greatest scandal of our health care system, and a situation that should embarrass all thoughtful citizens.

(pp. 81-82):

The pharmaceutical industry is a major player on the mental health scene. As it has expanded the markets for psychiatric drugs, the industry has an increased stake in framing how mental disorders are seen and how they are treated. Through its direct-to-consumer advertising, sponsorship of psychiatric meetings, research, publications, educational activities and other events, and sponsorship of mental health advocacy groups, it seeks to expand markets and definitiosn of treatable mental disorders. The industry forms coalitions with advocacy groups and supports activities to extend insurance coverage for new drugs, lobbies against formularies that restrict the availability of some drugs, and seeks to persuade physicians to use its drugs "off-label," that is, for uses not specifically approved by the Food and Drug Administration. It has encouraged treatment of more people, expanding and medicalizing the mental health arena for many ordinary problems of living. Increasingly, it is apparent that the published literature on the efficacy of many new drugs is biased, since drug-company-controlled studies with less positive results may not be published and disseminated. As evidence of this has become more apparent, the editors of major medical journals have made it clear that they will not publish papers from clinical trials that have not been publicly recorded prior to initiation, so it becomes possible to minotor biased reporting of the results of drug trials. The role of the pharmaceutical companies in the research process has raised troublesome questions, and this area now is receiving more attention as costs of pharmaceuticals grow much faster than other areas of medical and mental health care.

(pp. 89-90):

Consumerism takes place in an entrepreneurial context. Pharmaceutical companies, health plans, technology companies and hospitals among others seek to influence how consumers view disease and medical treatments. In the year 2001, for example, the pharmaceutical industry reported that it spent $19.1 billion dollars on marketing, most of it targeting physicians directly, but also including $2.7 billion for direct-to-consumer (DTC) advertising. Marcia Angell, former editor of the New England Journal of Medicine, has analyzed these data and argues that a more accurate estimate is $54 billion constituting 30 percent of members of the Pharmaceutical Research and Manufacturers of America's (PhRMA) $179 billion in revenues in 2001. Expenditures on DTC almost tripled between 1997 and 2001, with television ads accounting for almost two-thirds of such advertising. This vast DTC expenditure is relatively small compared with the massive funds spent on direct promotion to physicians by sales representatives, and through a variety of techniques from providing free drug samples and knickknacks to promoting drugs through sponsorship of continuing education. The Industry Profile reports that companies employ far more people for marketing (86,226) than for research and development (51,589).

The efforts to influence consumers and their physician agents is very big business. Pharmaceutical companies fund consumer groups and team up with them in efforts to lobby state Medicaid programs and others to add new expensive drugs that have not been shown to be superior to less expensive generic drugs to drug formularies. In its quest to gain brand allegiance and increased sales, the pharmaceutical industry is a major presence at meetings of almost every medical professional organization as a significant sponsor of their activities, happily providing gifts small and large, and lucrative consultancies for major figures. Thus it seeks to influence not only the drugs patients ask for but, even more, the inclinations of physicians to provide those drugs. Much is at stake in the choices physicians make under ordinary prescribing circumstances, which explains why so much marketing is directed at physicians. Drug expenditures are larger than necessary as physicians prescribe expensive new drugs that are often no better, and sometimes less effective and more dangerous, than inexpensive generic alternatives. There is some case to be made that DTC advertising may alert people to treatments from which they could benefit and make it less stigmatizing to seek assistance, but the overall influence of pharmaceutical industry advertising has added vast expense with little demonstrated advantage. As editors of major medical journals have learned, it is increasingly difficult to identify persons who have appropriate expertise to review pharmaceuticals who do not have significant potential conflicts of interest because of consultancies with the industry.

(pp. 96-97):

Consider some of the issues already discussed. Consistent implementation is impossible when each health plan has its own preferences and guidlelines and no one can speak for the profession. In some locations, plans come together to agree on a common format, but this is more the exception than the norm. Pharmaceutical companies spend massive amounts to influence (they say educate) physicians about drugs and consumers about treatments. It would be sensible to tax all pharmaceuticals and have this informational function performed by an agency that reviews the evidence objectively and disseminates accurate information to doctors and patients. Such public "detailing" has been advocated for decades and has been proven to work successfully, but it is hard to imagine the politics that could make it a reality in the United States. Other health systems, like the English National Health Service, have agencies such as the National Institute for Health and Clinical Excellence (NICE) whose role is to provide advice to the NHS and encourage doctors to use medications in a more evidence-based way, and the NHS uses its large buying power to bargain over price of pharmaceuticals. In contrast, the recent Medicare bill that extended pharmaceutical coverage explicitly forbade the government fromusing its purchasing power to keep drug prices down.

(p. 116):

The Institute of Medicine's (IOM) estimate that between forty-four thousand and ninety-eight thousand deaths and hundreds of thousands of injuries each year are dur to medical error has been widely disseminated. Some experts who work in the medical-error field believe this range to be an underestimate, while others see it as inflated. Nevertheless, there is no disagreement that we have a profound problem that requirse major interventions. Since the first IOM report in 2000, many corrective efforts have gone forward, but progress has been slow. It is difficult to change complex systems and the cultures and values they embody and get individuals to modify habitual work patterns. Improving quality of care is a multidimensional challenge that invovles technology, economic incentives, organizational coordination, and individual behavior-change strategies.

(p. 127):

As I repeatedly note, and it can't be overstated, the key to quality improvement is the implementation of an electronic medical record, the ability of systems to communicate, the capacity to identify high-risk situations and take preventive action, and the use of well-organized feedback to provide information about best practices, alerts, and opportunities to assess and correct performance. Many vendors offer a bewildering variety of informational systems and disease-management programs. Understanding and choosing wisely among them is challenging. CMS has a program to help physicians in small- to medium-sized practices adopt high-quality information technology, but it refuses, for understandable reasons, to endorse any particular vendor product or service, and this is often the kind of assistance doctors most need as they confront bewildering choices. Research on choice suggests that while people want choices, too many choices become bewildering, leading individuals to opt out.

(pp. 141-142):

We pay an extraordinarily high price for our reluctance to allocate care more thoughtfully and fairly. The inequities in access and provision of high-quality care contribute to our embarrassingly poor performance on morbidity and motality indicators compared with countries that are much less affluent. People lose not only by having too little care but also by receiving too much unneeded care, with the risk of injuries resulting from health care itself. Demand on government for more unrestricted health care provision and the rapid growth of health care expenditures compete with other important priorities and make it less likely that those priorities will be adequately financed. The need to pay more for health care requirse employers to limit wages and makes it difficult for individuals and families to balance their budgets. And despite the trade-offs between wages and salaries, total compensation packages, particularly in companies with aging workforces and many retirees receiving health benefits, make companies less competitive in global markets and more motivated to outsource work. Beyond the failure to get value for money, the willingness of our society to tolerate the health disenfranchisement of much of the population and the maldistribution of services in relation to need undermine a sense of community and furthers divisions between socioeconomic groups, races, age groups, and geographic areas.

From a section titled "Why Is Trust Important?" (pp. 145-146):

Life would be quite impossible if we couldn't trust that most people we deal with on a daily basis behave as we expect consistent with their roles, responsibilities, and relationships to us. Similarly, life would be very difficult if the less personal organizations and institutions we must deal with commonly failed to meet our expectations. We all understand that deviance and betrayal occasionally occur in personal relationships, and organizational malfeasance is not rare, but we hope and anticipate that these patterns are disruptions from normal states and not the usual state of affairs. In most activities -- whether driving in traffic, banking, purchasing stocks, filling prescriptions, or using public transportation -- where we have transactions with people we don't personally know, in order to get along reasonably we must assume that the norms and regulations in place to ensure order and responsible behavior will protect us from exploitation and harm. We know it is quite possible that another driver might disregard red lights and potentially threaten our lives, but we can't reasonably stop at every intersection to make sure that doesn't happen. We have to trust that the rules of the road are in place.

Trust involves expectations of how individuals and institutions will behave in their transactions with us, and it always involves risk, because there is no certainty. In many interactions the stakes are trivial and we can trust easily and not be much harmed if we are wrong. But the stakes also can be high and involve our fortunes, reputations, self-esteem, and even our lives. Being treated badly, and even lied to by an occasional storekeeper, may be no big deal; being lied to or betrayed by a lover, spouse, or dear friend is. Putting up with an incompetent and unresponsive telephone company, airline office, or automobile dealership may be frustrating and even a bit costly, but depending when one is seriously ill on an incompetent and unresponsive doctor or dysfunctional hospital involves bigger stakes.

Medical care is an aggregation of both small- and big-stake transactions, but trust is particularly important in patient-doctor relationships because of the intimate nature of aspects of taking medical history, physical examinations, and treatment; the effectiveness of the relationship may depend on the patient revealing intimate and privileged information. Also, successful treatment often depends on patients' cooperation and willingness to adhere to medical advice. Patients who distrust are less likely to share important information or follow the doctor's advice. Distrustful patients are also less likely to attain value such as encouragement, emotional support, and realistic optimism from the relationship. Misplaced trust can be costly, but to get the advantages of trust one has to assume some of the risks.

(pp. 147-148):

In the mid-1960s confidence in the federal government and most other institutions began to fall precipitously for many reasons; perhaps the most important was the war in Vietnam. It was in this period that public distrust of experts mounted and willingness to express dissent over government policy grew impressively. In the 1950s and early 1960s, approximately three-quarters of those surveyed said they trusted government, but by the mid-1970s it was approximately one-third. Among the attitudes associated with loss in confidence was the belief that government was run by big interests looking out for themselves, that public officials don't care what people like me think, and that quite a few people running government are crooked.

Many othe rinstitutions suffered a similar fate in loss of public confidence; by 2002, only about one-third of the public had confidence in major institutions such as government, business, labor, and the press. Confidence in medical leaders suffered a similar fate, falling sharply between 1966 and 1976 and continuing to fall, although more slowly, since then. Medicine retained some advantage over other institutions, since it had a larger distance to fall, but by the late 1990s medical leaders shared low standing with leaders of other major institutions. Social trust has much eroded in modern society, but personal trust in agents of at least some institutions has eroded much less. While most people have a low opinion of the American Congress, most people trust their specific member of Congress. Similarly, while people hold many negative beliefs about medical leaders and medicine as an institution, most trust their personal physicians. During the approximate period when trust in medical leaders was falling, surveys found little loss in patient faith in their doctors or in their satisfaction with care. Studies of patients noted increased questioning of doctors an dsome erosion of confidence in the doctor's authority, but the more significant pattern was the large gap between what people thought about medical leaders and doctors in the abstract and what they said about their own doctors and experiences.