Overhauling America's Healthcare Machine: Stop the Bleeding and Save Trillions.
Overhauling America's Healthcare Machine: Stop the Bleeding
and Save Trillions, by Douglas A. Perednia, M.D., hardcover, 369 pp,
$34.99, ISBN-13 9780132173254, Saddle River, N.J., 2011.
In many ways, this book is a complement to Dr. Richard Fogoros's book Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare, which was reviewed in the Fall 2012 issue. Indeed, the plan itself is borrowed, with attribution, from Dr. Fogoros.
There is unfortunately the same basic fallacy that the calculus of medical value is based on the Quality Adjusted Life Year (QALY). Quality is visualized as a linear function with values from 0 to 1. This completely overlooks the enormous discontinuity between life and no life. It is determined only by mobility or other abilities or factors related to health. A "quality" life appears to have nothing to do with the virtuous life, the happy life, or the purposeful life. This radical utilitarian, materialistic view of human life is perhaps inevitable if that life is to be sustained through a system of third-party payment, a pool of resources belonging to the collective.
Perednia's idea that we need to "simplify, simplify, simplify" is very appealing. Administrative machinery is intolerably complex and laden with mindless busywork. It could of course be radically simplified, and in most cases vanish altogether, were it not for the third-party payment system.
In contrast to insurance, medicine is not a machine, and it is unavoidably complex because it is more like a living organism. This book, like most writings on "reform," tends to conflate coverage with care, or insurance with the practice of medicine.
Ironically, for all his calls for simplification, Perednia calls for assembling "complete, accurate, and current QALY data," a task that he says "might be more challenging than landing on the moon." He notes that it would require a total investment of hundreds of billions of dollars and years to complete, and that ongoing funding would be needed to continually update and disseminate the information gathered. He believes that the federal government is "the only organization with the ability to finance this work, and it is proper and appropriate that it should do so." I would argue that, unlike landing on the moon, the task is impossible, and while the federal government could well pour billions of dollars into the task, the idea that it could do so with transparency and without pervasive corruption is contrary to all previous experience.
Can we or should we "develop an exhaustive list of condition-treatment pairs"? He admits that the task would be daunting, but thinks that if we could only review just half of the various medical conditions and treatments and calculate the cost/benefit ratios on QALY, a considerable benefit could be derived. How many such potential pairs exist? A thousand? Millions? What about treatments that we don't know about yet? As a general internist, I have found that a substantial fraction of the "conditions" I encounter might be described as "I'm not sure what's going on here." And the treatment option is often "wait and see." Perhaps Perednia's experience is different from mine--he is also an internist, and in addition a dermatologist. These days, doctors are under a lot of pressure to write down a diagnosis code to five significant figures, and to write some sort of prescription from a drop-down menu. Perhaps, having become accustomed to doing this, we have unconsciously assimilated the concept.
When physicians disagree with the prescription for reform that politicians and policy makers are trying to force upon us, there is always a demand to come up with a comprehensive prescription ourselves. I think that Perednia has taken the bait, but we need to resist this temptation.
While I disagree with Dr. Perednia's answer, he certainly asks a lot of the right questions and presents much useful data. For example, he notes that the physician salary ratio between the U.S. and Canada is only 1.43 for specialists and 1.51 for general practice physicians. However, physician charges in the U.S. are roughly six times higher than the equivalent fees in Canada for the same period. What happened to the rest of that money?
Perednia notes that about one-quarter of our hard-earned healthcare dollars simply vanish into thin air, and they disappear without providing a single medical good or service. Others consider this a gross underestimate.
In 1971, the U.S. had about three administrators for every four practitioners. Just 15 years later, Perednia states, there were almost 5.5 administrators for every four practitioners. There are 5 million people whose jobs consist of doing paper work rather than providing any care.
The process of credentialing, Perednia observes, to reassure the public that medical professionals are competent and not frauds or imposters, has come "to resemble paranoia at best, and institutionally incited panic at worst." One of my favorite sections in chapter 7 is entitled "Gilding the Lily, The Multibillion Dollar Certification Industry. "The book also has a good discussion of the AMA's process of updating the relative value scale--which is determined not by any patient need or market-based economic consideration, but by "what amounts to political horse-trading by RUC members."
While he is a supporter of computerization, Perednia has an excellent critique of existing systems, and points out that it has been necessary to add a new medical term to the dictionary: "E-iatrogenesis." Thirty percent of electronic medical records systems purchased by private practices end up being scrapped. He calls it inconceivable that 1 out of every 4 cars, copiers, pieces of accounting software, or cell phones would be scrapped so readily.
Perednia gets a lot of the principles right. He thinks that no matter how well intentioned, we should never create regulations, programs, or policies that interject themselves into the actual provision of medical care. He also believes that we should never mandate the use of any healthcare technology. He questions the value of collecting data for its own sake. Unfortunately, his answer to the role of government in medical care is not the same as ours; he evidently believe sit should be substantial.
Despite these caveats, Perednia makes a valuable contribution to the discussion of healthcare reform, and I am glad to have a much marked-up copy on my shelf.
Jane M. Orient, M.D.
Tucson, Ariz.
In many ways, this book is a complement to Dr. Richard Fogoros's book Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare, which was reviewed in the Fall 2012 issue. Indeed, the plan itself is borrowed, with attribution, from Dr. Fogoros.
There is unfortunately the same basic fallacy that the calculus of medical value is based on the Quality Adjusted Life Year (QALY). Quality is visualized as a linear function with values from 0 to 1. This completely overlooks the enormous discontinuity between life and no life. It is determined only by mobility or other abilities or factors related to health. A "quality" life appears to have nothing to do with the virtuous life, the happy life, or the purposeful life. This radical utilitarian, materialistic view of human life is perhaps inevitable if that life is to be sustained through a system of third-party payment, a pool of resources belonging to the collective.
Perednia's idea that we need to "simplify, simplify, simplify" is very appealing. Administrative machinery is intolerably complex and laden with mindless busywork. It could of course be radically simplified, and in most cases vanish altogether, were it not for the third-party payment system.
In contrast to insurance, medicine is not a machine, and it is unavoidably complex because it is more like a living organism. This book, like most writings on "reform," tends to conflate coverage with care, or insurance with the practice of medicine.
Ironically, for all his calls for simplification, Perednia calls for assembling "complete, accurate, and current QALY data," a task that he says "might be more challenging than landing on the moon." He notes that it would require a total investment of hundreds of billions of dollars and years to complete, and that ongoing funding would be needed to continually update and disseminate the information gathered. He believes that the federal government is "the only organization with the ability to finance this work, and it is proper and appropriate that it should do so." I would argue that, unlike landing on the moon, the task is impossible, and while the federal government could well pour billions of dollars into the task, the idea that it could do so with transparency and without pervasive corruption is contrary to all previous experience.
Can we or should we "develop an exhaustive list of condition-treatment pairs"? He admits that the task would be daunting, but thinks that if we could only review just half of the various medical conditions and treatments and calculate the cost/benefit ratios on QALY, a considerable benefit could be derived. How many such potential pairs exist? A thousand? Millions? What about treatments that we don't know about yet? As a general internist, I have found that a substantial fraction of the "conditions" I encounter might be described as "I'm not sure what's going on here." And the treatment option is often "wait and see." Perhaps Perednia's experience is different from mine--he is also an internist, and in addition a dermatologist. These days, doctors are under a lot of pressure to write down a diagnosis code to five significant figures, and to write some sort of prescription from a drop-down menu. Perhaps, having become accustomed to doing this, we have unconsciously assimilated the concept.
When physicians disagree with the prescription for reform that politicians and policy makers are trying to force upon us, there is always a demand to come up with a comprehensive prescription ourselves. I think that Perednia has taken the bait, but we need to resist this temptation.
While I disagree with Dr. Perednia's answer, he certainly asks a lot of the right questions and presents much useful data. For example, he notes that the physician salary ratio between the U.S. and Canada is only 1.43 for specialists and 1.51 for general practice physicians. However, physician charges in the U.S. are roughly six times higher than the equivalent fees in Canada for the same period. What happened to the rest of that money?
Perednia notes that about one-quarter of our hard-earned healthcare dollars simply vanish into thin air, and they disappear without providing a single medical good or service. Others consider this a gross underestimate.
In 1971, the U.S. had about three administrators for every four practitioners. Just 15 years later, Perednia states, there were almost 5.5 administrators for every four practitioners. There are 5 million people whose jobs consist of doing paper work rather than providing any care.
The process of credentialing, Perednia observes, to reassure the public that medical professionals are competent and not frauds or imposters, has come "to resemble paranoia at best, and institutionally incited panic at worst." One of my favorite sections in chapter 7 is entitled "Gilding the Lily, The Multibillion Dollar Certification Industry. "The book also has a good discussion of the AMA's process of updating the relative value scale--which is determined not by any patient need or market-based economic consideration, but by "what amounts to political horse-trading by RUC members."
While he is a supporter of computerization, Perednia has an excellent critique of existing systems, and points out that it has been necessary to add a new medical term to the dictionary: "E-iatrogenesis." Thirty percent of electronic medical records systems purchased by private practices end up being scrapped. He calls it inconceivable that 1 out of every 4 cars, copiers, pieces of accounting software, or cell phones would be scrapped so readily.
Perednia gets a lot of the principles right. He thinks that no matter how well intentioned, we should never create regulations, programs, or policies that interject themselves into the actual provision of medical care. He also believes that we should never mandate the use of any healthcare technology. He questions the value of collecting data for its own sake. Unfortunately, his answer to the role of government in medical care is not the same as ours; he evidently believe sit should be substantial.
Despite these caveats, Perednia makes a valuable contribution to the discussion of healthcare reform, and I am glad to have a much marked-up copy on my shelf.
Jane M. Orient, M.D.
Tucson, Ariz.
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| Author: | Orient, Jane M. |
|---|---|
| Publication: | Journal of American Physicians and Surgeons |
| Article Type: | Book review |
| Date: | Jun 22, 2013 |
| Words: | 1054 |
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