If you missed the latest episode of Bill Moyers’ Journal, during which he showed a film based on  Maggie Mahar’s excellent book “Money Driven Medicine,” here are a few things to chew on before the rationing discussion you are all invited to on September 25.

Over the last 12 years the number of people visiting America’s emergency rooms has soared. Yet here’s what’s surprising. The number of low-income people going to ERs has not increased. The increase has come almost entirely among middle-class people and many of them have insurance.

There are not enough resources for insured patients either

Costs may be going up, but access to care is going down as young doctors who graduate from medical school hundreds of thousands of dollars in debt opt for better-paying specialties than primary care. Doctors surveyed for this film were passionate about the declining quality of care in this country, what’s happening to their profession and how little power they have. They admit that for rescue care — advanced cardiac surgery or chemo– we’re the best, but that’s not what most health care is about. For primary, preventive or community based care we are not the best, which makes us 23rd in infant mortality in the developed countries, and twelfth in the rate of mortality that could have been prevented by health care.  Worse,  all the countries ahead of us spend less than we do. If we received this kind of value in any other service, we’d be boycotting it.

Mahar demonstrates that dedicated caring people are stuck in a stupid system, in which they are paid for doing things, regardless of outcome.  Primary care, which does less with technology, pays the lowest, and most people coming out of med school today can’t afford to be primary care physicians.

On the other hand, no one ever  asks a specialist  what good his or her treatment it does for a patient, and services that prolong life for five months with poor quality (end of life chemotherapy) are often “worth” more than services that keep people alive for thirty years without an amputation (diabetes).

“Medicine should be a process, not a procedure”

Doctors complain that we now treat medicine as an industrial product, in which they are judged by throughput. They see patients for 12-15 minutes like on a production line, and they are very conflicted. Most of them would like to get to know a patient before they make an assessment, but insurance companies and employers are in the room with them. enforcing  brokered and negotiated contracts. The incentives are to do more to make more money.

Just as everyone with heart disease doesn’t need a stent, most people don’t need an MRI for back pain. But once they get one, they  then have to make a decision about surgery they may not need. Over a third  of the money we spend is wasted on new procedures that are no better than those they replaced, and medical outcomes are not better — and sometimes worse– in states where Medicare spends more money on treatment, like New York and New Jersey, than in states where it spends less, like Iowa. (See our recent post on sham surgeries).

Once medicine became a business in the 1970s, everyone had their eyes on lowering costs. In the 80s, the HMO movement was started to control costs by managing care. But when insurance companies started saying no, and it was because of cost, not effectiveness,  there was a huge public backlash. By the end of the 90s, they decided it was better to say yes than no, and to pass the costs through to us in the form of higher premiums. And that’s why, since the late 90s, premiums have gone up so fast that 72 million Americans had trouble paying for medical care last year.

Treatments have risks

Another contributing factor to the rise in costs is that patients don’t get enough info about the risks of treatment. They’re told there is a quick fix, and they want it. Or worse, if they refuse a suggested treatment, the doctor threatens to sue them or  worse, their children are taken away by Child Protective Services. The doctors determine the protocols, and the patient is often forced to accede. For many reasons, doctors don’t give patients the tools to empower themselves, yet when patients participate fully in the decision about their care, surgery rates fall and outcomes improve.

But while that may contain costs, its not good for hospitals, which have overbuilt and now  want their beds and technologies used. They see their cutting-edge protocols as a competitive advantage to attract the best doctors with the richest, sickest patients. You can see where this is going.

Until we change the incentives to overdiagnose and overtreat, we will not only fail to lower costs, but we will continue to needlessly endanger patients.