On Sunday the New York Times published an editorial that set out to analyze “The High Cost of Health Care.” The result might best be described as “muddled.”
What is exasperating is that about 85 percent of the facts in the editorial are true. But a good 15 percent are simply wrong. And the Times’ editors managed to weave truth and error together in such a way that it would take a knitting needle to separate the two. As Matthew Holt put it on The Health Care Blog: “the piece looks entirely as though it was written by a committee that couldn’t agree with itself.”
As you read the editorial, you can almost see the editors sitting around a table, negotiating. “Okay, we’ll let that sentence about the value we’re getting for our dollars stand—as long as well keep this sentence about ‘skin in the game.’” The result, a mix of propaganda and analysis, is far more dangerous than outright lies because the many true facts make the whole thing sound credible.
Because I hate to see our paper of record disseminate disinformation, I am going to try to separate the wheat from the chaff. Begin with the truth: Near the top of the story, under a sub-head that reads “Varied and Deep-Rooted,” the Times provides a nice summary of the main reasons why we lay out roughly twice as much as the average developed nation, without getting care that is twice as good:
“we pay hospitals and doctors more than most other countries do. We rely more on costly specialists, who overuse advanced technologies, like CT scans and M.R.I. machines, and who resort to costly surgical or medical procedures a lot more than doctors in other countries do. Perverse insurance incentives entice doctors and patients to use expensive medical services more than is warranted. And our fragmented array of insurers and providers eats up a lot of money in administrative costs, marketing expenses and profits that do not afflict government-run systems abroad.”
Spot on. If only this section of the editorial had not begun with a casual half-truth: “Contrary to popular beliefs, this is not a problem driven mainly by the aging of the baby boom generation, or the high cost of prescription drugs, or medical malpractice litigation that spawns defensive medicine.”
They first part of the sentence is correct: the aging of the boomers is not a major cause of health care inflation. The last clause of the sentence is debatable, though probably true.
What’s troubling is the middle clause: Why does the Times feel obliged to declare that the “high cost of prescription drugs” is not an important factor behind soaring medical bills?
Perhaps the Times’ editors have read the oft-cited “fact” that drugs
account for only 10 percent to 11 percent of the nation’s total health
care bill. But those numbers reflect only the cost of drugs purchased
retail, by the patient at the pharmacy. That 10-11 percent does not include drugs that
are administered in a hospital, a nursing home, or a doctor’s office.
Think of cancer drugs—an area where prices are spiraling. Morgan
Stanley reports that in 2002 cancer drugs accounted for 13 percent of
the nation’s drug bill; in 2007 spending on these treatments is projected to almost double, to 22 percent.
Meanwhile we’re popping more pills. According to the Kaiser Family
Foundation’s newest report on Prescription Drug Trends, from 1994 to
2005 the average number of prescriptions purchased in the U.S. climbed by 71 percent.
Over the same span, the price of prescription medications jumped 8.3
percent a year—more than triple the average annual inflation rate of
Direct-to-Consumer advertising has much to do with the rise in the
volume of pills that we ingest: In 2005 the drug industry spent fives
times more on consumer advertising than it did in 1996. Over that
period the budget for pitching to physicians barely doubled, showing
that the industry was shifting its priorities. Typically,
direct-to-consumer advertising is reserved for new drugs that are hard
to sell to doctors—because the drug companies don’t have enough
evidence that they work. Why else would the industry spend billions on
TV ads aimed at people who can’t even write prescriptions?
Looking ahead, despite the fact that many patients are switching to
generics, the Kaiser Foundation reports that spending on prescription
drugs is expected to rise from $188.5 billion in 2004 to $446.2 billion
in 2015, a 118 percent increase in eleven years. And again, this is
just the retail portion of the total bill.
Later in the editorial, the editors do acknowledge that “it would be
beneficial to allow Medicare to negotiate with manufacturers for lower
prescription drug prices and to allow cheaper drugs to be imported from
abroad,” but still they insist: “The prospect for big savings is
Why? Unlike Medicare, the Veterans Administration is allowed to
negotiate for deep discounts, and it has shown that when the government
uses its clout it can be very successful. The VA lays out 50 percent less than Medicare does for ten of the top 20 prescription drugs sold to seniors.
There is good reason to pay special attention to spending on drugs:
this component of our national health care bill is snowballing faster
than many other items on the list, including most physicians’ fees,
the amount that Medicare pays hospitals for specific procedures, and
the amount that private insurers take from premiums to cover
administrative expenses, salaries and profits for investors. On
average, insurers are spending roughly 85 percent of those premiums
directly on medical care, just as they did in the past. But the cost of
that care and the volume of over-treatment (which often includes using
the newest, most expensive drugs and devices) are climbing, pushing
premiums ever higher.
“Does It Matter?,” the next section of this fractured editorial asks.
After all, the writers assert: “By some measures, Americans are
getting good value. Studies by reputable economists have concluded that
spending on such advanced treatments as cardiac drugs, devices and
surgery . . . have more than paid for themselves by extending lives and
improving their quality.”
This simply is not true. As Dartmouth economist Jonathan Skinner and
Dartmouth Medical School’s Dr. Elliott Fisher pointed out in Health Affairs last year,
“When you look at Medicare costs and survival gains for acute
myocardial infarction (AMI) from 1986–2002 (as David Cutler and Mark
McClellan did in earlier work), you find that overall gains in post-AMI
survival more than justified the increases in costs during this period”
(Cutler and McClellan are the “reliable economists” the Times cites.)
But when the Dartmouth researchers honed in on the newest data they
discovered that “Since 1996, survival gains have stagnated, while
spending has continued to increase.” [my emphasis]
In other words, we have reached a point of diminishing returns.
The New York Times’ own health care reporters know that when it comes
to many cardiac procedures, we are squandering billions every year. In
story after story, they have revealed how, when it comes to cardiac
care, supply drives demand. For example: “a study published in The
Journal of the American Medical Association in March found that in
regions where cardiac hospitals have opened, the overall rates of
angioplasty and open-heart surgery more than doubled after four years.”
Did patients in those regions suddenly need twice as many
procedures? Build the beds and they will come.
Meanwhile, the same article reported
“recent studies are raising doubts about the value to many patients of
widely used medical devices like heart defibrillators." Or turn to the
article that begins:
“Many heart patients routinely implanted with stents to open arteries
gain no lasting benefit compared with those treated just with drugs.”
Finally, consider the story where a Times reporter describes what he calls
“a nearly perfect example of what’s wrong with our health care
system…See, there was an elephant in the hearing room last week that
went almost entirely ignored. One study after another has found that
whether or not a stent is coated, angioplasty — the process of opening
up an artery before a stent is inserted — and stenting do not actually
reduce the risk of heart attack or extend life span for most patients.
‘There’s a much more liberal use of angioplasty and stenting than there
needs to be,’ [the Cleveland Clinic’s] Dr. Eric J. Topol, a member of
the panel, told me last week.
“Dr. Calvin L. Weisberger, the top cardiologist at Kaiser Permanente,
said, ‘A large pool of angioplasties and bypass surgeries are being
done without scientific evidence.’
“The problem is that there’s nobody whose job it is to say no. The
F.D.A. steps in when there are safety concerns. But no federal agency
or medical group takes action when an expensive form of treatment
becomes far more common than it needs to be — which is a big reason
that health care spending is rising so rapidly.”
Note to the New York Times editorial board: If you don’t read some of your paper’s best stories, who will?
I could go on, but I’ll offer just one more example of how the Times
editorial contradicts what it’s own reporters have shown. First the
editors acknowledge “the sad truth that less than half of all medical
care in the United States is supported by good evidence that it works,
according to estimates cited by the Congressional Budget Office. If
doctors had better information on which treatments work best for which
patients, and whether the benefits were commensurate with the costs,
needless treatment could be junked, the savings the savings could be
substantial, and patient care would surely improve.” But, they add:
“It could take a decade, or several, to conduct
comparative-effectiveness studies, modify relevant laws, and change
The first two sentences are true; the last one is not. Granted,
comparative-effectiveness research is still in its infancy. But there
are many things that we do know: for instance, that we’re doing too
many angioplasties, without evidence that we’re saving lives. And this
is just one of many areas where Times reporters have exposed waste
while citing important research from the best medical journals.
In some areas—for example, treatment of low-back pain—specialists have
begun to set up guidelines to avoid over-treatment. (See the story in
the most recent issue of JAMA.)
These are not hard and fast “rules”—no rule could apply to all
patients—but guidelines can set parameters. Clearly some guidelines
are needed for cardiac procedures.
Would it take “decades” to “change doctors’ behavior?” Not if Medicare
refused to pay for procedures that fell outside of the
guidelines—unless the physician could explain why an exception should
be made. And once Medicare decides not to pay for a service, private
insurers are quick to follow.
But for some reason, even after offering every solution ever proposed
by any interest group (or favored by any individual on the writing
committee) including “More Skin In the Game,” “Managed Care,” “ Pay
Providers Less,” “Information Technology,” and “Single Payer,” in the
end, the Times’ editors seem bent on concluding that far-reaching
health care reform just isn’t possible. At least not anytime soon. After all, it is not the Times’ custom to call for revolution.
Moreover, one suspects that the editors who put their thumbprints on
this piece may have been divided on whether we really want to rein in
health care spending. On the one hand, that might be best for the
nation—not to mention for the many middle-class Americans who cannot
afford health care today. But on the other hand, does this mean that a
New York Times editor might not get an MRI for his unspecified back
pain when he wants one—just because the guidelines (and his doctor)
say he doesn’t need one?
By the final paragraph, the writing committee seems to have given up
any hope of rational compromise. Here, the group allows the editorial
to collapse into a confusion of contradictory clichés: On the one
hand, we’re told, “there is no silver bullet.” On the other hand, a
wide range of factors “need to be tackled” with “no guarantee they will
have a substantial impact anytime soon.” Nevertheless, “we need to get
cracking” on solving this problem, all the time keeping in mind that
“the cascade of knowledge flowing from the human genome project, new
nanotechnologies” etc. “may well accelerate, not mitigate, the rise in
medical spending.” And “if we want the benefits, we will need to make