Reviews of Books about Healthcare

 

This webpage has reviews and comments about certain books on healthcare in the U.S. The reviewed books are listed below by date of publication.

 

It’s Enough to Make You Sick: The Failure of American Health Care and A Prescription for the Cure, by Jeffrey M. Lobosky, M.D., 2012.

How We do Harm: A Doctor Breaks Ranks About Being Sick in America, 2011, Otis Webb Brawley, M.D., with Paul Goldberg.

 

 

It’s Enough to Make You Sick: The Failure of American Health Care and A Prescription for the Cure, by Jeffrey M. Lobosky, M.D., 2012.

This revealing book by a medical doctor is easy to read and describes many of the problems discussed in the articles on this website. However, the recommendations tend to reflect the special interests of medical doctors.

The first 12 chapters in the book describe problems with the healthcare system, including virtually all of the points made in the articles on this website. Dr. Lobosky presents the results of research studies on the healthcare system, as well as examples from his personal medical experience. Key points include:

·        The high cost of healthcare has driven many families into bankruptcy and hurts the ability of the U.S. to compete internationally.

·        The evidence that healthcare costs in the U.S. are much higher than in other developed countries, but the resulting health of patients is not better and often worse than in the other countries.

·        There are glaring inequalities in healthcare in the U.S.—with healthcare rationed based on income rather than medical need.

·        The current fee-for-service system provides financial incentives to maximize expensive tests and procedures without regard for their effectiveness, and makes fraud easy.

·        Most doctors will not publicly acknowledge malpractice by another doctor.

·        “We [physicians] pay lip service to the importance of patient care, but when you look  at our proposals, it become obvious that the economic well-being of physicians and the autonomy of the practice of medicine are our first priorities” (page 198).

·        Managed care creates financial incentives to provide poor medical care.

·        Insurance companies reject older, higher risk people, or accept them and then find excuses to cancel their policies when they have health problems.

·        Large insurance companies make billions of dollars in profits for stockholders, pay their CEOs many millions of dollars in salary and bonuses, and spend many millions of dollars influencing politicians and government agencies.

·        Pharmaceutical and medical device companies keep prices high for their products in the U.S. through very aggressive lobbying and marketing efforts and severely exaggerated claims about the cost of developing products.

·        Lawsuits increase the cost of healthcare, particularly certain types of healthcare, and are an ineffective way to motivate good care.

·        The “American ‘experiment’ with market-based, profit-driven medicine has for the most part proven to be a colossal failure on many fronts” (page 71).

·        Lobbying by special interests dominate the political and regulatory processes governing healthcare.

One interesting feature of this book is that it describes the history and political forces that caused the current state of healthcare.

Recommendations

Dr. Lobosky’s first recommendation for fixing healthcare is to develop uniform national regulations for health insurance companies. He believes the different insurance requirements in different states hurt healthcare. He would go further than the Affordable Care Act (Obamacare) in implementing uniform national regulations for insurance companies.

However, this recommendation overlooks the experimental nature of healthcare in the U.S. It assumes that an effective regulatory program can be developed now. My perspective is that the available evidence is not clear as to what is a good strategy for healthcare in the U.S. and different options should be tried to see what works. The approach of allowing and encouraging states to try different strategies for healthcare is a good way to see what works.

Dr. Lobosky considers state-instituted insurance co-ops that compete with for-profit insurance companies as a good step. I agree. The Affordable Care Act promotes these co-ops. Competition with these co-ops will reveal whether the claim is actually true that for-profit companies are more efficient. My expectation is that the profits for shareholders, executive salaries, bonuses, marketing costs, and administrative costs of the for-profit companies will be reduced in an environment with true competition.

Dr. Lobosky believes that health insurance must be mandatory for everyone if good healthcare is to be achieved. I have reservations about mandatory health insurance. I think that effective measures to control costs and more diverse insurance options should be provided concurrently with insurance mandates. The current program of implementing insurance mandates without effective cost control measures and with special interests dominating the political and government processes will likely make healthcare problems worse rather than better.

Dr. Lobosky recommends that universal fees for healthcare services be set by the federal government in conjunction with physicians and medical economists. As is typical for medical doctors, he apparently does not consider competition as appropriate for his profession.

My perspective is that Dr. Lobosky’s recommendation would be a good experiment for some states to try. However, I think that other strategies should also be tried and I expect that a strategy with more competition among medical providers will be found to be better.

Dr. Lobosky recommends that a federal agency implement a program to evaluate the effectiveness of medical treatments so that lucrative, but ineffective treatments can be identified. The evaluations would include recognizing treatments that have a low probability of success because of a patient’s age or condition. Reimbursements would be based on this evidence-based medicine. I agree in concept with evidence-based medicine.

However, I also think that moving away from fee-for-service systems to pay-per-performance systems based on medical outcome and patient satisfaction is also needed to reduce ineffective procedures and treatments. Here too, different strategies should be tried to see what works. Fee-for-service is deeply imbedded in the mindset of medical doctors and they are unlikely to propose an alternative. However, fee-for-service is a primary source of the conflict of interest for medical doctors.

Dr. Lobosky recommends that medical lawsuits be based on evidence-based medicine and handled by a special judicial council that has expertise in medical matters. He also recommends a limit of $500,000 on the subjective pain and suffering and related intangible, noneconomic factors, and that lawyers get no more than 25% of a lawsuit judgment. He also recognizes that physicians need to begin reporting colleagues who provide incompetent care rather than the current “wall of silence.” He advocates that the “culture” of medical practice needs to be changed, but offers no tangible methods to change this culture. I would feel better about changing the malpractice laws and processes if tangible efforts were being made by the medical industry to identify and self-correct medical incompetence, mistreatment, and fraud.

Dr. Lobosky believes that term limits and campaign spending limits are needed to control the influence of special interests in government. I agree, but also believe that elected officials and government employees in decision-making positions should be prohibited from being employees, consultants, or lobbyists for companies that they regulate for a period of at least two years after they stop government service. This restriction would apply only to those in decision-making positions and their immediate staff, not to lower level or technical government employees.

Dr. Lobolsky believes that Medicare regulations should be revised to allow Medicare to negotiate the price of drugs. This is a no-brainer that shows special interests currently control healthcare to an absurd degree.

Dr. Lobolsky proposes that new drugs only be approved if they are significantly better than current drugs, rather than being simply effective for treating a condition. This recommendation appears to me to be a step in the wrong direction because it would reduce competition in principle. Measures are needed to increase competition.

Dr. Lobolsky suggests that physician assistants and nurse practitioners handle a larger amount of primary care. He says his experience has been that the care by these professionals is typically as good as the care by much more expensive primary care physicians. He has not found any studies that are contrary to his experience. Here too, I agree.

Dr. Lobolsky supports the increasing efforts to detect and punish healthcare fraud. These efforts more than pay for themselves. This too is a no-brainer.

Dr. Lobolskly also recommends significantly enhancing programs promoting prevention and healthy lifestyles. However, he also notes that these programs do not decrease the net cost of healthcare because people with unhealthy lifestyles tend to die younger and require less healthcare.

 

How We do Harm: A Doctor Breaks Ranks About Being Sick in America, 2011, Otis Webb Brawley, M.D., with Paul Goldberg.

This is another revealing book by a medical doctor that describes many of the problems discussed in the articles on this website. The book primarily describes Dr. Brawley’s experiences practicing medicine. Key points include:

·        Other countries spend far less on healthcare than the U.S. and have results that are as good and often better.

·        America has the greatest healthcare system in the world for wealthy people with complicated diseases, but it is not good for consistent, basic healthcare, and particularly for those who are poor or do not have health insurance.

·        Healthcare is currently rationed in the U.S., with wealthy people receiving excessive treatment and poor people receiving inadequate treatment.

·        Many doctors maximize revenues rather than benefit for patients.

·        The system of paying doctors for the amount of services guarantees they will make decisions that are not in the best interests of the patient.

·        Profitable but unproven medical care is rampant. For example, over 20,000 women with breast cancer received bone marrow transplants at a cost of $60,000 to $150,000 per transplant and with severe side effects for the patients. When good research was finally done, the transplants were found to be ineffective.

·        Standard practices developed by medical organizations too often are based on profitable practices rather than good scientific evidence.

·        The medical profession does not police itself and allows incompetent and/or unethical doctors to practice without impediment.

·        Private insurers or the government need to be able to protect the public from the miscarriage of medicine.

·        “Patients need to understand that more care is not better care, that doctors are not always right, and that some doctors are not even truthful” (page 27).

·        Patients and doctors need to recognize when death is inevitable and not attempt futile, expensive measures in these cases.

 

Dr. Brawley does not make specific recommendations for changing healthcare. The book focuses on evidence that change is needed.

 

 

 

 [Version of 4/8/2013]

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