WNYC’s Freakonomics Radio–named after a book series by journalist Stephen Dubner and economist Steven Levitt–recently ran a two-part series about the American health care system. The first hour (about randomized controlled medical trials) was interesting enough, but its sequel proved highly relevant to subjects this blog has covered over the past four years, like the increasing role of technology in the field of medicine.
The episode, “How Many Doctors Does It Take to Start a Healthcare Revolution,” was largely centered in Camden, NJ, and called for real reform, including “shifting the system from a top-down, profit-first industry to a back-to-earth healing enterprise.”
Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers, says his organization’s goal is to “improve care while also reducing costs,” which runs counter to a lot of large providers, whose aim is to “get bigger and bigger and bigger.” “The way you get bigger,” he claims, “is getting more money, more market share, more customers.” As host Dubner notes late in this episode, spending on healthcare accounts for over 17 percent of the United States’ GDP, the highest proportion of any developed country in the world (by way of comparison, Canada spends about 10.9 percent of its GDP on healthcare, the UK around 9.1 percent).
Brenner’s argument is that though many of the actions a doctor may take are incentivized, they may not be best for the patient. He points out an asymmetry in price between two courses of action. One would be for a doctor to sit with a patient and his or her family, to build a trusting relationship, and to improve behavior in a safe and healthy way (perhaps discussing diet, exercise, smoking, drinking, and stress). Another involves getting individuals tested and screened with little meaningful discussion.
“We pay a whole lot of money if you cut, scan, and hospitalize patients. If they have procedures, if they go through machines, we pay an enormous amount of money for those things. If you talk to a patient, you actually lose money in many instances,” he notes. “The doctor is losing money every moment they stay in a room with your family member. The way they make money is by getting you out of that room back into the scanner that they’re leasing […]. That’s not their fault. That’s the fault of how we’ve structured the incentives in the system.”
A proponent of so-called “evidence-based medicine,” Brenner indicates that many practices are not adequately backed up with research. Medical education, he claims, is largely based upon memorization (at the expense of critical thinking and problem solving) followed by “a very steep hierarchy where you learn to do what you’re told and you don’t challenge or embarrass the senior physicians.” He goes on to say that medical history is full of stories of inadvertently causing patients harm due to entrenched practices, like doctors skeptical of hand-washing as a safety measure a hundred years ago: “I think, you know, we’re still doing it, unfortunately.”
The healthcare system may seem too big to fail, remarks the humble family doctor, but so did many other things that have been supplanted or improved. “There comes a point in a system in America where it no longer serves any of the purposes that it was originally set up to serve,” says Brenner. “I don’t see a lot of horse and buggy manufacturers. I don’t see the steel industry [in Camden], right? No one saved Blockbuster. I mean, there will come a point when, you know, sooner or later we’re going to let this thing go.”
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