A dose of common sense

By Lawrence D. Blum

After coping with cardiovascular disease for 38 years, my father-in-law suffered a massive stroke that killed most of the left side of his brain, leaving him irreversibly comatose. His doctor was conscientious and gracious to come to the hospital at 2 a.m., but I was alarmed when he told me, "Don't worry, we'll do everything we can to assure a full recovery."

Although it was obvious that recovery was impossible - that Max would never again be able to talk, feed, or toilet himself - he was given further CT scans, MRIs, and other tests over the next two weeks. My father-in-law, who was by nature frugal, would have been furious. Americans paid a whopping bill for it. But at least we did everything.

Americans like action. While European movies can be "talky," ours are full of shootings, explosions, and chases. American medicine follows suit: It is full of procedures, be they lifesaving, useful, needless, or harmful.

Insurance companies and Medicare pay American hospitals and doctors to perform procedures. But they pay almost nothing for listening, talking, and thinking. Ordering a new test is much easier than thinking about or discussing the results of yesterday's test.

Aging and ill Americans have the benefit of remarkable but expensive medical technologies. This kind of doing can be lifesaving, but it costs a fortune when done thoughtlessly, and even more when done with a profit motive.

American doctors reflexively order many more tests and procedures than their counterparts in other developed countries. They order still more when they own and profit from the facilities that perform the procedures. Yet the United States lags far behind on measures of both public health and satisfaction with care.

Insurance companies add to the problem, extracting health-care dollars for profits and advertising. In vain efforts to rein in the costs of so many tests and procedures, they employ armies of nonproductive functionaries and force doctors to do likewise; it may take 10 people to record, bill, justify, and pay for your medical visit. Ultimately, insurance companies add 20 to 30 percent to the health-care bill, compared with the 2 to 3 percent overhead for Medicare. (They are, however, similar to Medicare in that they overvalue procedures and undervalue talking and thinking.)

To compensate, insurers ration care. They deny it to those who have preexisting conditions or can't afford the premiums. They even limit (ration) the choice of doctor. For many of our citizens, we have the most rationed care in the developed world. And the rationing raises costs further: The uninsured get their care in the most expensive places - emergency rooms, refined temples of urgent doing.

In psychiatry, ill-considered attempts to decrease costs have rationed the thinking approach almost out of existence. Psychiatrists who work with insurance companies are required to do - to write a prescription - in minutes. Insurers require that listening, talking, and thinking - such as psychotherapy - be done by those with the least training, the cheapest to hire.

This is not only a victory of deed over thought, but also of an unfettered free-market ideology in medicine. The short-term savings are transferred to investors; the costs of illness and poor treatment are borne by everyone.

There are no simple solutions, but attention to a few principles would help. First, doctors must be paid to listen, talk, and think, rather than rely on expensive procedures for income. This would promote more humane care, better understanding of patients, and fewer unnecessary procedures: When Dr. Jones has the time to understand that Mrs. Smith's headaches occur mainly when her husband angers her, the MRI will be less urgent. Correcting the thinking/doing disparity can bring us better care at lower cost.

Tort reform would help prevent doctors from ordering extra tests out of anxiety. And proper regulation could stop drug companies from pushing consumers to demand expensive new drugs that have no advantage over older drugs.

We should also give up on the costly fantasy that health care is a market commodity. It takes only a moment's thought to recognize that doctors' and patients' decisions about care are not, and should not be, based simply on economics. The unthinking free-market fantasy also appears to justify the existence of for-profit health-insurance companies - a questionable notion that is usually taken for granted.

Although my father-in-law benefited greatly from advances in medical technology, in his last days he was subjected to well-intended but unthinking, heedless, and costly excesses of it. Let's find a better way.