Tuesday, September 25, 2012

A PBS Documentary Asks Why is U.S. Health Care So Expensive?

Sept. 24, 2012

"Money and Medicine," a documentary set to air Sept. 25 on PBS, investigates some of the most notorious factors in driving U.S. health care costs. Ray Suarez speaks with director Roger Weisberg about how some of those costs are moving the nation toward financial crisis while still producing relatively mediocre medical results.
EDITOR'S NOTE: The transcript below is complete and unedited to include additional information cut from the produced video.
RAY SUAREZ: Why does American medicine cost so much? And if we're going to pay so much for it, why don't we getting better results? A film coming up on PBS next Tuesday night, the 25th, takes that question on directly. It's produced and directed by Roger Weisberg. Roger, welcome to the online NewsHour.
ROGER WEISBERG, "Money and Medicine": Thank you.

RAY SUAREZ: You showed us instead of just telling us a lot of the cost drivers in "Money and Medicine." What are the main culprits for making American medicine so expensive?

ROGER WEISBERG: Well, I think there are a lot of drivers. There's the aging of our population. There's technologic innovation and explosion. 
But I think the biggest single driver is our fee-for-service system that rewards volume instead of value and quantity of medical services instead of quality. And as a result, we end up doing a lot of things that cause more harm than benefit for patients.

RAY SUAREZ: But if we said to people, "Hey, I can do less or I can do more." If they're sick or someone they love is sick, "Hey I can do these extra things that might work or I can do nothing." Isn't it human nature that they'll choose more?

ROGER WEISBERG: I think there's a pervasive view that more is better among consumers and among a lot of health care providers, as well. But what I think we're beginning to learn is you reach a point where excessive diagnosis and treatment reaches the point where you're doing more harm than benefit in a lot of cases. 
And as we look at medical evidence, comparative effectiveness, and outcomes research, we're discovering that often places that do less have better health outcomes for their patients.

RAY SUAREZ: But you know, health care is one of the things, of all the things we buy in our lives, where most people are not paying the full cost. So when they make these decisions, they're making them kind of in a vacuum as far as cost and benefit because they're not paying the bill.  
ROGER WEISBERG: There's no doubt that patients are insulated from the costs and consequences of the medical decisions they make and yet we know from research that when patients are really given a true, fair choice, that is they're given all the information about the costs, benefits, risks, tradeoffs, of elective procedures, they tend to choose about 30 to 40 percent less treatment and their rate of consumption drops to about to the level that doctors choose when they're confronted with those same medical problems.

RAY SUAREZ: And when that rate of consumption drops, what happens to the outcomes?

ROGER WEISBERG: The outcomes are generally better. It turns out in our film we contrast two medical centers, world-class medical centers:
UCLA, one of our great academic medical centers and Intermountain Medical Center in Utah. It turns out that, for example, in Utah, during the last two years of life, patients are spending half as much time in the hospital, having half as many physician visits, and having a third the number of ICU days.
And when you look at the outcome measures that Medicare uses in terms of quality ranking, the place that's doing less gets higher marks in terms of quality.

RAY SUAREZ: We get a tremendous amount of access into patient decision-making and doctor's counsel during tough, tough times in a family's life. 
I think one of the most striking passages in the film has to do with the mother and son. She's been in the hospital for months, she's unconscious, she's unresponsive and yet the son doesn't want to give up on her getting better and doesn't want the hospital to stop treating her, no matter what the cost.

ROGER WEISBERG: That's absolutely right. It's kind of a tragic situation where this woman who's completely incapacitated and has absolutely no chance for recovery doesn't have the opportunity to tell her health care providers or her loved ones what kind of treatment she would want.
And so, often what happens is family members caught in that situation feel a tremendous amount of responsibility, feel guilt and insist that doctors do everything. 
Well in the case that you cite, the doctors were being forced to provide care that they considered futile and ultimately they had to draw a line because it really is a breach of their own professional medical ethics to offer care that's futile or that's harmful.
And yet this woman languished in the ICU or in a very intensive hospital bed for over 10 months. The son estimated the cost to Medicare -- and therefore to us as taxpayers -- to exceed $5 million since this incident started.

RAY SUAREZ: One of the things that's striking about the presentation is that it reminds you this isn't one country, one unitary approach to medicine. Because with malady after malady, you break out of all the different ways they're treated across the country.
Some places treat some diseases, some conditions much more intensely, operate much more frequently. For instance, Caesarean sections, prostate surgery. This isn't really one country with one approach to the common ailments that eventually affect many of us.

ROGER WEISBERG: It's staggering to look at those geographic variations which can be as high as 20 fold. For example, there are hospitals doing  20 times the per capita rate of prostatectomy or coronary artery bypass surgery or spinal surgery than other medical centers. 
What that dramatic variation tells us is that there's a lot unnecessary medical care that's being delivered and a lot of room to eliminate some of that  wasteful spending.
You know, the National Academy of Sciences' Institute of Medicine just last week came out with a study that suggesting that 30 cents on every dollar spent on health care is waste.

RAY SUAREZ: You know, I think people will come away from "Money and Medicine" struck by the kinds of conversations that doctors are having with patients, patients are having inside their families, because you're given a kind of access into this very intimate, very time-based set of decisions that struck me as unique.
These people let you into their lives and we got to see the consequences of their decisions in a way that's probably sobering and instructive to a lot of Americans.

ROGER WEISBERG: Yeah, it was critically important for me to try to capture the decision-making process and then to follow-up to see the procedures and the consequences of those decisions.
And I think that medical decision-making is of critical importance if we're going to address this health care crisis because the old paradigm is you refer to the white coat, "doctor knows best."  We ask the surgeon, "Do I need surgery?" and not surprisingly, the surgeon is going to say "yes."  
So one of the major innovations we see in places that achieve in high-quality outcomes is that they're involving patients much more in the medical decision-making process. It takes into consideration patient values and preferences and not just the common-practice patterns that are prevalent in the community.
When you give patients truly informed choices, they tend to make decisions that involve less invasive and less aggressive care.

RAY SUAREZ: Talking of truly informed choices. One of your experts mentioned that between drug interaction, medical mistakes, and hospital-acquired infections, getting medical treatment is one of the highest-rated causes of death in the United States.

ROGER WEISBERG: All of those situations combined account for the third leading cause of death. That is a shocking number for patients. I think more than anything else, that statistic ought to convince us to abandon the pervasive view that more is always better in health care.

RAY SUAREZ: Roger Weisberg is the producer and director of "Money and Medicine." He joined us from New York. Good to talk to you.

ROGER WEISBERG: Great talking to you. Thanks so much. 

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