Copyright © 2007 by Regina E. Herzlinger. Click here for terms of use.
The academic community that analyzes health care public policy also helped to kill Jack Morgan. Sure, they commit the usual academic sins of irrelevant pedantry—with laughable critiques of each other's work that note, for example, the failure of the author to note the reviewer's latest article. The impact of this kind of narcissistic criticism on our health care system is minimal.
Nevertheless, the academics have had important and deleterious influence on the agents meant to represent us. Their voices are ubiquitous—heard not only in academic outlets but also in the popular media when they seek "experts" to disentangle the complex world of health care. Because there is so little information available on the outcomes of health care, the experts serve as Oracles of Delphi, interpreters of murky events.
When it comes to health care, many academics favor schemes that give them considerable power over your money. A perennial favorite is a single-payer health care system—that is, the government's doling out all the money to be used for health care. Some of those educated by these academics conflate the term "single-payer" with the notion of "universal health care, " in which everyone has health insurance. But the two are very different. Universal health care can be achieved in many different ways, such as enabling all consumers, rich or poor, to buy their own health insurance. I discuss these different techniques in Part 3 of this book. A single-payer system, in contrast, achieves universal health care solely through the government.
Academics favor the single-payer solution for many reasons; but surely one of them, acknowledged or not, is that it puts them, as advisors to the government, in charge of spending $2 trillion. Failing that, managed care is the academics' next best solution, where they argue that it takes a lot of talent to manage your care, namely, their talent. And failing that, various "pay-for-performance" schemes are popular favorites.
The intellectual rationale for third-party control is the belief that productivity in service organizations, like health care, cannot be significantly improved. If this is valid, then the only way to control costs is to ration care through central control; but this view is badly mistaken. There are so many ways to increase productivity that service organizations, such as retailing, provided the mainstay for this country's productivity boom in the late twentieth century.
To be fair, the complexities of health care have defied so many reforms so often that a big, sweeping universal "reform" can seem appealing. But a single-payer system managed by Uncle Sam will kill many of the most promising innovations taking place in health care and medicine, just as it distorted kidney disease care. Don't forget that over the course of industrial history, our most important productivity-enhancing innovations earned little respect from the experts until they succeeded. When Henry Ford introduced the Model T Ford, he promised to make it the best and the cheapest, and he targeted customers in the middle class, not the rich who owned most of the automobiles back then. As with health care today, most observers who thought they knew something about the subject scoffed. At the time, a car in the United Kingdom cost more than many houses.1Yet in eight years, Ford slashed the price of a Model T by more than 50 percent. As the price dropped, volume soared—from 6, 000 in 1908 to nearly 600, 000 in 1916.2In 20 years, Ford's good car at a good price enabled ownership of automobiles to climb from 1, 770 to 1, 870, 000.3So much for the doubters.
The academics' praise for managed care and other top-down, technocratic health care "reforms" tilted the board in favor of disastrous policy decisions. These broad, utopian solutions for the cost and uneven quality of our health care system glossed over inconvenient facts: If Kaiser is so universally wonderful, why did its growth plans fail? If managed care is a panacea, why did many patients and health care providers deplore it? How will innovations in medicine be initiated and used in a top-down health care system? Then too their dismissive disdain for the competence of clinical physicians and for the ability of people like Jack Morgan to choose and manage their health care depressed and constrained both doctors and consumers and the public policy initiatives that could have empowered them.
There may be some legitimate intellectual reasons for the academics' favoring solutions that give them power over 16 percent of the GDP and disdaining solutions that grant power to the people or to creators of managerial or technological innovations. But let's be clear here: a major motive for academics' support of third-party management of the health care system and for technocratic, contentless solutions and their dismissal of the consumer's role is pure and simple self-interest.
In considerable measure, the U.S. Congress's paternalistic, autocratic oversight of kidney dialysis, discussed in the last chapter, reflects the academic training of its members and staff. Two trains of thought permeate public policy higher education in this country, and they have had a major effect on the health care debate: one is a relentless focus on the importance of statistical analysis, and the other stresses the shortcomings of business as opposed to nonprofits, governments, and nongovernment organizations (NGOs).
Statistical analysis—the ability to find patterns in data—can cause a smart person to believe that she can detect things that the experienced practitioner in the field misses. The ramifications of analytic techniques for the creators of public policy are clear: you do not need to be an experienced clinician to craft effective public policies. Indeed, the absence of experience or special skills honed in the health care arena may well enable you to see the forest for the trees and observe patterns that the expert misses.
But it is all too easy for these analysts to see connections that don't really exist, especially if they lack any practical experience in the subject they are analyzing. Statistical correlations are meaningless or misleading, absent an experienced person's insight into the subject being analyzed. For example, the tides in the Atlantic Ocean correlate with peak flow of traffic on our highways. What does one have to do with the other? Do tides cause a high flow of traffic? Of course not. But tides do correlate with the movement of the moon—that is, morning and evening hours. And the flow of automobile and truck traffic is, of course, determined by the time of day.
Notes 1988 Economics Nobel laureate Maurice Allais: ". …All my work rests on the conviction that…the only two really fruitful stages in the scientific approach are firstly a thorough examination of the initial hypotheses; and secondly a discussion of the meaning and empirical relevance of the results obtained.…The mathematical rigour of the reasoning can never justify a theory based on postulates if these postulates do not correspond to the true nature of the observed phenomena. … "4
Yet another tenet of public policy is that businesses, funded by their owners, are thought to be less altruistic than nonprofits and governments, which are organizational forms that have no owners. But, as for the ostensible altruism of nonbusiness organizations, firms come in various shapes, sizes, and ethical flavors. For every Enron, there's a Johnson & Johnson. For every mismanaged Red Cross disaster intervention, there's the Salvation Army, one of the most effective organizations anywhere. All organizations are shaped by the rewards and penalties faced by those who lead them, not by simplistic distinctions in the sources of their funding. (Chapter 9 contains a detailed analysis of the roles of nonprofits, businesses, and governments in health care.)
But, understandably, since academics have traditionally thrived in the nonprofit sector and government sectors—universities, think tanks, government advisory panels, and so on—and have used them to advance their careers, they favor and feel more comfortable with these institutions. Successful academics know how to become powerful in these settings. This bias helps to explain some of the misplaced analyses, shallow theories, and reckless generalizations made by the academic health care community for government-sponsored "single-payer" or managed-care health systems.
The core tool that would be used to allocate resources in a single-payer or managed care system is "systems" or "operations analysis" —a set of techniques for analyzing the impact of individual actions in large, complex systems. Just as the techniques of managed care were thought to enable a group of analysts to oversee and override the decisions of practicing doctors, the techniques of systems analysis were thought to enable a group of economists to oversee the military's conduct of our war in Vietnam. I would have thought that the Vietnam experience would have disabused them of the notion, but, sadly, it did not.
Alain Enthoven, a distinguished Rhodes Scholar and Ph.D. in operations research, was the assistant secretary of defense charged with this type of analysis during part of the Vietnam War. Not surprisingly, he was one of the most visible advocates of managed care.5
Modern-day systems analysis began innocently enough. It was first used in Great Britain, prior to World War II, to install radar devices.6At one time, radar devices were installed in locations that minimized their individual chances of being jammed. The systems analysts, in contrast, successfully designed an installation process that minimized the probability of jamming the whole system. After this early triumph, systems analysts were entrusted with ever-larger problems, beginning with the development of a construction schedule for a weapons system and culminating in a plan for major military operations.
So successful were these applications that the techniques of systems analysis were brought to the U.S. Department of Defense in the 1960s by its then secretary, Robert McNamara, a brilliant Harvard MBA.7 McNamara wanted to reshape what he viewed as sloppy, unsystematic military decision making by using a disciplined mathematical approach.8
Systems analysis had proved useful primarily for developing schedules, but not for determining policy. The McNamara Defense Department catapulted the techniques to new, different, vastly more important applications: determination of military strategies. In the heyday of systems analysis, brilliant, young, politically appointed economists suddenly wielded enormous military power. As one observer of the Defense Department notes, "The revolutionary manner in which McNamara made his decisions transformed the 'expert' [military] career bureaucrat into the 'novice' and the 'inexperienced' appointee into the 'professional.' "9 Precisely because the analysts were trained in economics, operations research, and statistics and because they were not professional soldiers, they were presumed to be free of the military's parochial interests and able to attend to the best interests of the public.
The application of systems analysis was not limited to military problems. Soon its use spread to other government organizations. In 1967, President Lyndon Johnson ordered all the agencies of the federal government to adopt it. Many state and local governments fell into line too. New York City's Mayor John Lindsay, one of its many advocates, boasted in a large 1970 recruiting ad that his staff, along with McKinsey & Company consultants, was "creatively utilizing quantitative analysis and computer technology. But all the problems are not [yet] solved and we need more talented individuals."10
Virtually all these applications of systems analysis were disasters, most poignantly those that conducted the war in Vietnam. They brought New York City to the brink of bankruptcy too.
Yet many academics, entranced by their newfound power to determine public policy, became true believers. They perpetuated the myth. As McNamara's assistant secretary of defense, an economist, noted in Economics of Defense in the Nuclear Age, a widely read primer on systems analysis, "We regard all military problems as…problems in the efficient allocation and use of resources."11 Who could solve such problems better than the systems analyst? Programs in public policy analysis that trained acolytes in the field flourished in schools of government, public health, education, and social service.
Enthoven, now an emeritus professor at Stanford University, began to apply systems analysis to the problems of health care in the 1970s. His influential preferred solution of "managed competition" advocated competition among vertically integrated managed care health insurance plans, each offering identical benefits. A consultant to Kaiser Permanente, Enthoven frequently presented that giant as an example of the efficacy of managed care.12
The intellectual basis for his views was clear: managed care organizations place decision-making analysts in the center of power—above the practicing doctors—to determine patients' care. As the New York Times noted, "The fact that an HMO has a management structure…appealed to Enthoven's passion for rational systems."13 He particularly admired its "set of documented practice protocols, " that is, detailed plans for patients' treatment. Its triage system, which permits primary care physicians to treat most illnesses, appealed to him too because in his opinion the number of specialist physicians in the United States could be reduced by 67 percent.14
These systems could be wonderful if medicine were a powerful science, with a clear understanding of what causes and cures illness and disability. But currently, it is more art than science. Dictating protocols to doctors is as meaningless as forcing artists to paint by numbers.
Don't get me wrong: Alain Enthoven is a fine person; but habits of mind, no matter how inappropriate or unsuccessful, linger. Enthoven's academic successors are equally devoted to similar top-down techniques of "disease" or "case management" that enables an analyst to tell the practicing doctor what to do. They teach these techniques widely in schools of public health and health care administration. Virtually every one of these schools has many courses with titles such as "Decision-Making Techniques, " "Statistical Analysis, " and "Health Policy" but only a handful of courses in the United States in 2005 focused on entrepreneurship in health care.
More than any other academic medical publication, the New England Journal of Medicine (NEJM), likely the world's preeminent medical journal, has published a steady stream of articles purporting to demonstrate the lack of charity of business and the efficiency and quality of nonprofit and government organizations in health care.
The attacks began in 1980, when its then editor, Dr. Arnold "Bud" Relman, published his article "The New Medical-Industrial Complex":
The most important health care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home care and emergency room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to +$40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming, " and it may also exercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study are necessary to ensure that the "medical-industrial complex" puts the interest of the public before those of its stockholders. 15
Favorable editorials in leading media, such as the New York Times, followed.16Bud Relman was suddenly elevated from an obscure, albeit able, academic doctor and journal editor to a business guru, an expert on comparative organizational forms. His opinion was regularly solicited by the press.17
This was heady stuff, and Relman, hardly a shrinking violet, made the most of it. His initial view, which acknowledged the likely superiority of efficiency from services provided by businesses, disappeared. Relman, whose primary laudatory interests were in protecting physicians, concluded that their interests were best served in nonprofit health service organizations. Newly anointed as a guru in organizational behavior, he began the publication of a series of articles purporting to demonstrate the lower quality and higher costs of for-profit health services providers, typically accompanied by supportive editorials, a tradition his successors continue. In 1999, for example, the NEJM published an article averring that patients treated in a for-profit dialysis center incurred higher mortality rates and were less likely to be placed on a list for kidney transplants than those treated in a nonprofit.18Yet a 2005 review by advisors to Congress on health care found no distinction in quality between the two.19
But the NEJM 's espousal of nonprofits was overshadowed by its ardent support for the government-run, single-payer health care system views of Stephanie Woolhandler and David Himmelstein. Their claims that Canada's single-payer system was administratively more efficient than ours and similar assertions appeared 17 separate times in the NEJM. Indeed, Marcia Angell, who became Relman's partner and briefly served as the acting editor of the NEJM, subsequently joined Woolhandler and Himmelstein in a "Physicians' Working Group for Single-Payer National Health Insurance, "20a small band of physicians who lobbied for a government-run health care system.
The Woolhandler-Himmelstein single-payer articles published by the NEJM were simplistic, seizing on one variable—administrative cost—to justify draconian restructuring of a $2 trillion sector. To calibrate the magnitude of the suggested government takeover they have advocated, our health care sector is about the size of the GDP of the United Kingdom or China. The single-payer group was essentially advocating that the United Kingdom turn to and China return to government-led economies because of the efficiency of having a single buyer.
One can question both the data used in these analyses and their analytic frameworks. It is difficult to compare the costs of private and government-run health care systems in various countries because of differences in their accounting practices. For example, governments do not reflect the depreciation expenses of most of their assets, whereas private firms do, and the substantial employee pension expenses of many governments are typically accounted for separately from the health care entities.21
But most importantly, their analytic framework is deficient. The assertion that governmental control of the health care sector would lower administrative expenses ignores all other aspects of the health care system, such as quality, convenience, and innovation. It assumes that our sole interest is minimizing administrative expenses. But our interests are much more complex: we want excellent, high-quality, convenient, consumer-responsive care, delivered at a reasonable price.
The inappropriateness of the framework is illustrated by the following question: why not have the government buy our cars? Government purchase of cars would eliminate all the dealerships and online merchants we currently use. It might lower administrative expenses. But would the government buy the cars we want at a price we are willing to pay? And how many innovators would want to enter a business in which only one customer exists, especially if that customer is a government?
Elsewhere in the economy, we typically prefer a system of diverse buyers because businesses' competition to attract those buyers creates better value for the money. Nevertheless, the single-payer ethic is deeply embedded in the curricula of schools of government, health policy, and public health. When I lectured at the Harvard School of Public Health in the spring of 2006, the students in the standing-room-only lecture hall told me it was the first time they had heard of any "reform" other than the development of a single-payer system.
Sadly, after Relman's departure, the New England Journal of Medicine continued its business-bashing ways. In 2004, the editor assigned the long-retired Bud Relman to review my book Consumer-Driven Health Care, despite his lack of experience in the subject matter—various forms of health insurance, tax laws, and recent innovations in health care information and delivery.22Relman, who is foremost an advocate for physicians, failed to understand that consumer-driven health care was a boon for doctors. Although the book was well received by reviewers elsewhere, his review was a mugging. When I wrote to protest the selection of the long-retired Relman as a reviewer—noting his lack of relevant experience—the editor refused to publish my letter. When I wrote again to dispute some assertions in a subsequent New England Journal of Medicine 2006 article on Consumer-Driven Health Care, the editor once again refused to publish my letter, although, unlike Relman, I am a currently active and well-recognized participant with real-world experience in the field.
Despite Bud Relman's ostensible disdain for profit-making businesses and the conflicts of interest they create, the Boston Globe revealed that he had options to buy 14, 000 shares of a company that had obtained exclusive rights to place the content of the NEJM on the Web.23Relman had received the options when he served on the board of directors of the firm, HealthGate Data Corp. It was planning to go public with an offering slated to bring in about $200 million. Relman's options were worth a tidy sum, about $500, 000, under this valuation. When the Boston Globe broke the story, Relman claimed he was unaware of the fact that he owned the options.
As for Marcia Angell, she accepted her job as the NEJM 's acting editor only after she received assurances of "complete editorial independence…and…full control over the commercial use of the journal's name and content."24Unfortunately, Dr. Angell's "full control" of the resources needed to discharge her editorial responsibilities did not protect her from embarrassing revelations that "nearly half of the drug therapy review articles published since 1997 had violated the NEJM 's own financial disclosure policy—the researchers selected by the journal to write the reviews had undisclosed ties to the drug companies that manufactured the therapies evaluated in the articles."25
Ironically, while these advocates of government takeover of health care had difficulty in tracking their personal finances or those of the institutions they managed, they, nevertheless, present people like themselves as the perfect managers of our $2 trillion health care system.
For decades, many have urged adoption of universal health care in the United States. I agree with them: all Americans should have access to health care. Equality is what the United States is all about.
But once more the devil is in the details.
Most of the universal health care crowd wants the government to run the resulting system, either by managing the provision of health care, as in the United Kingdom, in which most of the hospitals are operated by the government, or by determining the budget the government pays to ostensibly private providers, as in Canada and most of the developed countries in Europe. They argue that having only one payer—the U.S. government—will reduce the administrative costs incurred by having many competing health insurers.26
This "detail" is where they lose me. Government control smothers competition under a blanket of uniformity, but it is competition that will improve the quality of health care services and will create the best opportunities for cost control. Consumer-driven entrepreneurs will compete to offer the best health promotion strategies, the best health care services, and the best technology by creating more for less. This kind of competition ultimately controls costs and raises quality. If single-payer economies suppress the innovations that increase productivity, significant cost control can come about only by rationing health care services, an action that invariably leads to waiting lists for treatment and untold inconvenience, suffering, and even death.
In 1989, the New England Journal of Medicine published this paean to the government-funded health care system in Canada:
The large and growing gap between the United States and Canada [in the uninsured] drives home the point that…the form of funding adopted by Canada does permit a society to control its overall outlays on health care. Furthermore, it is unnecessary to impose financial barriers to access in the process.27
But in 2005, Chief Justice Beverley McLachlin of the Supreme Court of Canada quarreled with this rosy view of the ease of access in the Canadian health care system in a decision that struck down the Quebec government's prohibition against private health insurance and payment for health care. George Zeliotis, a Quebec, Canada, resident, brought the case forward when he learned that he would be placed on a year-long waiting list for a replacement for his painful hip. The law did not allow him to pay anybody in Canada to perform the surgery. Other than waiting, his only options were to emulate the many Canadians who have escaped to the United States or to illegal, for-profit health care centers in Canada for prompt treatment, and to pay for the care himself, or to sue. In her decision, the chief justice noted that "access to a waiting list is not access to health care."28
This legal victory will inevitably cause other Canadian provinces to change their laws; but in some ways, it merely recognized a reality of the Canadian health care system. Increasingly, "rogue" for-profit health care service enterprises are filling the void left by the government-funded system. Perhaps "rogue" is a misleading term. These businesses are so well accepted that the president of one, Vancouver's Cambie Surgery Centre, became the 2007–2008 president of the Canadian Medical Association.29
The fabled equity of the Canadian health care system had also become a myth. Many of those who could afford to receive their health care elsewhere have done so. Former Prime Minister Paul Martin got his annual checkup at a private clinic, and a Quebec premier chose to have his deadly skin cancer treated in the United States.30 Queues are routinely jumped by the well connected.31
At one time, the Canadians, a reserved, stoical people, were so proud of their health insurance system that this old joke was legend: "What's the difference between a Canadian and an American?" "The Canadian has health insurance and doesn't have a gun." They are not telling that joke anymore. In Toronto, a desperate father took a physician hostage in an effort to obtain quicker treatment for his sick child. He was shot to death by the police.32
Stringent government funding caused the system to implode and stifled the entrepreneurs who could have made it better and cheaper.
When I lectured in Canada to the Ontario Hospital Association about one of my earlier books, Market-Driven Health Care, the results of their first-ever patient survey were announced. It revealed that almost half of those with a recent stay in a hospital graded their quality of care as barely passing.33Other Canadian polls revealed especially high dissatisfaction with waiting times for specialized surgery. And these waits were not costless. Some waiting patients suffered major and irreversible losses in health status.34
By 2006, the average waiting time to see a specialist was more than four months, 90 percent longer than in 1993.35And Canada has fewer facilities for diagnostic imaging than most other developed countries.36Further, existing capacity can sometimes be hazardous to your health. A deadly infection that caused the deaths of almost 100 patients in Quebec's University Hospital in 2004 was partially blamed on lack of sanitation in its old building.37
As for one-payer regimes in other countries, consider the cruel fate of British women diagnosed with breast cancer or those stricken with heart disease. They suffer from one of the worst survival rates among developed countries. The reason? The shortage of doctors, nurses, and beds in the British health care system and the difficulty in obtaining referrals to hospitals or specialists.38The World Health Organization in 2000 found that 25, 000 British cancer deaths per year would not have occurred, for example, in the United States.39
Although the long-suffering, stoic British are so wedded to the goal of social equality that 50 percent of them have rated their medical care as excellent or very good,40their 2005 evaluations of their actual health care experiences belie these overall ratings: 41 percent endured waiting times of four months or more for elective surgery. In contrast, among U.S. respondents, only 8 percent have had a wait of similar length.41
Worst of all, like the Canadians, the deprivations the British have endured has not led to equality of health status. One English study has concluded: "Social inequalities in health care continue to be a major (and increasing) problem."42Similarly, a Canadian review of cancer incidence has noted, "Despite Canada's universal health insurance,…the association between lower socioeconomic status and the incidence of many common cancers is just as strong in Ontario as it is in the United States."43Providers of cardiovascular care in Ontario have concluded that preference in accessing care is given to those who are politically or economically powerful or potentially litigious.44
The current health care market does not work at all like other markets. Unlike cars, computers, or retailing, for example, health care services have not become better and cheaper over time. Instead, they have become more costly, and people worry about quality too. Why? Because of gross distortions in supply and demand. Consumers, the demanders, have little of the information that interests them, cannot express their feelings about the price because they rarely see the real cost of their health insurance or health care purchases, and have an artificially constrained range of choices. And when it comes to supply, hospitals suppress competition and innovation, and health care's key suppliers, the physicians, are increasingly marginalized.
Absent information, the market cannot work. How can people choose effectively if they lack the information needed to make intelligent choices? If Jack Morgan had known the prices and outcomes of different kidney transplant units, such as infection and death rates, he could have easily chosen the one that gave him the best value for his money. Although Jack was only a high school graduate, his successful career testified to his continued capacity to learn. And yet some academics staunchly believe that information will not help consumers.
Some question consumers' ability to interpret information and use it effectively. As an example of this train of thought, a professor of public health notes the following problems with consumers' use of information. First, he claims that an astonishingly high 48 percent of American adults have "inadequate literacy skills" and only about 20 percent can independently read and understand "most patient education material and consent forms." Then too he notes that because health care information is typically complex, "there is no reliable way to give consumers information adequate to clarify the [choice] among plans…until federal policy makers standardize benefits, proscribe risk selection, [and] enforce quality standards, and take other legislative steps to smooth the rougher edges of competition."45
In other words, consumers are so dumb and health care information is so complicated that it can be understood only when choice is standardized and regulators tell health care providers how to practice medicine. The "rough edges" this academic proposes so casually to "smooth" are the essential elements of a truly competitive market—differentiated products.
This critique implicitly assumes that professionally trained people are more capable of interpreting complex information than are average consumers. Yet health care policy analysts, the very technocrats who pooh-pooh the abilities of others, are hardly wizards when it comes to information. For example, in a simple algebraic test, only 53 percent of them could answer all the questions correctly.46After all, if the experts who control the health care system are so wonderful, how did we get into the present mess?
Yet the professor of public health is hardly alone in his assessment of consumers' limited ability to manage selection of their health care. The many studies that demonstrate consumers' ignorance of the ABCs of health care are a perennial favorite topic in the health policy journals. For example, in 1995, one group complained that only 60 percent of the public thought the health care system was changing slowly or not at all, in contradiction to the experts' view of the subject; in 1997, researchers noted that many could not explain the terms "HMO" and "managed care" to their satisfaction;47and a 2001 report pointed out that "fewer than one-third of all consumers accurately reported all four health plan attributes."48Consumers are depicted as not only ignorant but also obdurate, failing to heed useful health care information. For example, consumers are legendarily indifferent to the health plan performance data contained in the Health Plan Employer Data and Information Set (HEDIS).49
But these analyses ignore the fundamental tenet of consumer behavior: consumers seek only the information that is directly pertinent to their needs.
I cannot describe exactly how cars work. Nevertheless, I am an intelligent buyer of cars because I seek the information that assesses those qualities of an automobile in which I am interested. Health care consumers are most interested in provider outcome data for medical conditions similar to their own, for people like them.50Thus, it should come as no surprise that Americans cannot describe an "HMO" to the questioners' satisfaction or that they are uninterested in data about their health plan processes. Consumers clearly attribute health quality to their providers, not to their health plans.51And they are much more impressed by outcome data—data about results—than by reports of process measures, which track how the health care was delivered. Indeed, HEDIS rankings—a data set that tracks primarily process measures such as the health plans' rates of immunizations and mammograms—have no correlation with consumers' assessments of care by their health plans.52
The lack of use of the available information is appropriately an indictment of the irrelevancy and the poor quality of the data more than it is an indictment of consumers. The information provided frequently is not sufficiently comprehensive and relies excessively on the process of care (for example, mammograms received) rather than the care outcome (for example, breast cancer death statistics by provider). And when outcome data are available, they are "so broadly aggregated that the results may be of only limited value to consumers" —that is, they do not identify specific doctors, hospitals, or other providers.53 Further, many users do not trust the data, which are typically not audited, and they cannot readily access them; for example, Pennsylvania's useful information about hospitals' risk adjusted cardiac surgery outcomes—that is, the results achieved when hospitals operated on people with different degrees of illness—were mailed out only once.54 Last, most consumers cannot act on the data because they lack choice and control.
Mother Nature is the best doctor. She alone understands how the kidney functions. She alone knows the consequences of the various interventions to improve its function. She alone knows the natural order of the kidney.
Many brilliant men and women have worked hard to try to better understand this natural order. Where they've succeeded, they have used their discoveries to help relieve pain and suffering to damaged individuals and to restore health to the critically ill. The unraveling of the structure of the human genome and the mapping of genes and their mutations will be of immense help to future doctors. But currently, our knowledge of cause and effect in medicine, of the natural order that Mother Nature created, remains minimal.
To improve our knowledge, we should examine a wide variety of theories and treatment protocols. For example, we should not impose simplistic recipes on the management of kidney disease. The U.S. Congress's recipe—specifying the nature and amount of dialysis services, physician services, and drugs to be used in the "managed care" of the disease—throw the whole lot out. Instead, Congress and we must permit brilliant providers to apply their differing ideas of optimal kidney care for different kinds of people and scientifically evaluate their outcomes. In the next part of this book (Part 3), I discuss how to make this happen.
But a whole generation of academics disagrees with this view. They favor "system," not "diversity" top-down "management," not a "natural order" their ability, not Mother Nature's. They try to impose an unnatural order on the natural chaos of innovation.
To explain why academics must play a central role in the health care system, some ganged up on its key and most vulnerable part— the independent doctor who worked for herself or with a small group. In 2001, these doctors accounted for only 23 percent of the total, down from 41 percent in 1983.55Nevertheless, they remained an important access point to the health care system, and because of their fragmentation, they were the most vulnerable to attack. If the academics attacked the hospitals, they were likely to get a sharp rap on the knuckles from this incredibly well financed and organized sector. The object lesson of the specialty hospitals was not lost on them.
If you are going to tout yourself as the best, you have to show that you are better in some relative sense. And it is easy to pick on the independent docs. Notes an official at the Institute of Medicine, part of the National Academy of Sciences, for example:
Studies conducted by the Institute of Medicine have demonstrated a serious gap between what the American health care system provides and its full potential.…These developments require medical educators and health professionals to move from a 20th-century paradigm of the physician who was in solo practice, held autonomy as a central value, prided himself or herself upon continuous learning and the acquisition of new knowledge, and laid claim to infallibility when confronting patients and colleagues. The 21st-century paradigm is that of physicians who understand teamwork and systems of care in which they can provide leadership."56
Earlier in this book you met the two genius physicians who have kept the victims of kidney disease alive. One of them invented the field of artificial organs, and the second performed the first kidney transplant from a living donor. If the academics had had their way, these two innovations in kidney disease treatment would likely never have seen the light of day.
The inventor of the kidney dialysis machine was out on the fringe—one of those obsessed, self-centered guys who jump from job to job because they do not play nicely with the other children. His personal life was no more sedate: lots of work and hard living.
The second appears more corporatized. He has held on to one job and one wife. But although his personality fits better with today's conformity-driven medical environment, his ground-breaking mind does not. His life-saving advances were simply ignored. So much so that he had to switch careers to earn a living.
Both performed their work 40 or more years ago. Would they flourish in today's medical environment, smothered by a blanket of enforced conformity—peer reviewed, evidence based, meta-analyzed—with its simplistic ideas about how to practice medicine, cooked up by the academics and implemented by the managed care and HR crowd and the U.S. Congress?
I doubt that people like these geniuses would even enter medicine today. Why should they when the intellectually wide open frontiers in fields such as biotechnology and high technology beckon?
"Kolff" —the name was elegantly engraved on the giant lintel of the building in which I met him.
But Professor Willem Kolff was packing his boxes, once more leaving his job. Or rather, his graduate students had "volunteered" to do the packing. Kolff, a thin man with a big nose and a long, bony face, was bouncing around, clad in khaki pants and sneakers, supervising the work.
"Yes, they threw me out. Just like the others, they could not bear to have me around, " he noted in an accent that retained vestiges of his native Dutch tongue.
Kolff was in his eighties then, but he had the mind and energy of a 20-year-old. A new artificial organ was in the works. This one, an artificial eye, was as wonderful and gruesome as the rest. Wonderful because it would enable the blind to see. Gruesome because it required some major excavation in the skull to make room for it.
Kolff invented an artificial kidney in Holland in the midst of World War II. It failed on his first 15 patients. They died. A lesser person, one who lacked Kolff's certainty, ego, vision, and energy, would have given up; but he persisted. Kolff's first success was bittersweet: the patient was a Dutch Nazi sympathizer. She was so roundly disliked that when Christmas fell during her hospital recuperation, she received only one gift, from Kolff, dressed as St. Nicholas.57
His Dutch mentors urged him to leave Holland. "You are just too wild to succeed here, " they advised. "Only the United States would welcome someone like you." Kolff ultimately wound up at the University of Utah.
Kolff, now 95, is building an artificial heart with the aid of a female companion who is a fellow retirement home resident. Kolff had taken over part of the home's arts and crafts room to fashion the heart, built from parts found in the local hardware store.58
You just have to love this man.
But his peers do not share this view.
One of the greatest scandals in the scandal-plagued history of medicine is that this great doctor has not yet won the Nobel Prize in medicine.
A hunk stands in my garden. It is a 20-foot-tall rhododendron that bears flowers as big as salad plates when it blooms. And even when it is not in bloom, it is still the majestic, gorgeous, glossy, green-leaved focal point of this corner of my garden.
I am especially proud of this rhodie because I rescued it. The rhodie was once planted under a huge, take-no-prisoners beech tree that commands every resource in its wake. It was starved of water and nutrients, dwarfish and leggy. But I admired its survival instincts and transplanted it to a spot where it could flourish. And flourish it did. Encouraged by this success, I now not only regularly transplant my plants, but I also take cuttings of those survivors I like—such as my friend the rhodie—and graft them onto strong stock.
I am an autodidactic gardener, but the idea of grafting and transplantation is so intuitive that even I thought of it. I know to respect parentage when I graft—my rhodie cannot be grafted to rose stock—but grafting is not too complicated, and most of the grafts and transplants succeed.
Doctors have long had the same grafting and transplantation ideas; as early as 400 B.C. Samhita, an Indian book, describes grafting skin to reconstruct noses and ear lobes.59 Grafting and transplantation kicked into high gear in the early twentieth century with attempts to transplant organs from animals and cadavers into humans.
But humans are much more complex biologically than plants. None of these transplants worked until a couple of geniuses discovered the immune response—the ferocious defense mounted by our bodies against tissue that it recognizes as a foreign invader. In 1954, Dr. Joseph ("Joe") E. Murray and others performed the first successful kidney transplant. One key to their success was that the transplanted kidney came from an identical twin, and thus engendered a lesser immune response.
Murray won the Nobel Prize. Joe Murray is the anti-Kolff. His smiling face is kindly, his manner mild. Fellow parishioners consult him when he attends daily Mass at his local church. You want Dr. Kolff to invent the life-saving device and Dr. Murray to use it.
World War II stimulated the inventive genius of both. The ravages of war that Murray observed as a soldier interested him in plastic surgery. Sometimes scraps of skin were grafted to protect badly burned men. Murray noticed that grafts from genetic relatives adhered better than others. As for Kolff, the supply deprivation in Nazi-dominated Holland caused him to cobble together the first artificial kidney from discarded scraps.
Yet despite Murray's charm and good fellowship, the medical community of Boston and elsewhere initially dismissed the kidney transplant as an isolated event, especially considering the donor was an identical twin. "As the field of transplantation developed…there was no ringing endorsement of the…live donor program at international scientific meetings."60To the contrary, Murray was accused of playing God,61even of practicing unethical medicine. It took decades for Murray's ground-breaking work to be widely replicated. Meanwhile, to support himself, Murray became a plastic surgeon.62
In his 1990 Nobel Prize acceptance speech, Murray begins his thanks with a paean to a hospital: "If gold medals and prizes wereawarded to institutions instead of individuals, the Peter Bent Brigham Hospital of 30 years ago would have qualified. The ruling board and administrative structure of that hospital did not falter in their support of the quixotic objective of treating end-stage renal disease despite a long list of tragic failures that resulted from these early efforts."63
But even then, the hospital protected itself first and foremost. And the doctors knew it. Writes Murray, "The donor asked whether the hospital would be responsible for his health care for the rest of his life if he decided to donate his kidney.…The surgeon for the donor said, 'Of course not.' But he immediately followed with the question, 'Do you think anyone in this room would ever refuse to take care of you if you needed help?' "64
The kidney's donor was made to understand that his future depended on doctors' sense of their professional responsibility. But today this sense has been eroded by a barrage of attacks from academics, hoping to supplant individual physicians' roles; from hospitals, hoping to employ and direct individual physicians; from insurers, hoping to "manage" the medical care that doctors provide; and from the U.S. Congress, which is replacing physicians' decisions with its own.
The work of both of these great doctors has been a blessing to the victims of kidney disease. Kolff's artificial kidney extends the lives of people like Jack Morgan, and Murray's transplant would most likely have allowed Jack to lead an almost-normal life.
How many Kolffs and Murrays can exist in today's environment, in which an Ivory Tower academic establishment continually denigrates the professional judgment and economic ethics of the doctors who actually practice medicine?