Prescription for reform
PERSON OF INTEREST: DR ARNOLD RELMAN
By Judith Graham
Tribune staff reporter
Published July 1, 2007
In 1980, Dr. Arnold Relman penned a famous article in the New England Journal of Medicine warning of the rise of a new, powerful “medical-industrial complex” in the U.S. The commercialization of medicine, he argued, was not in patients’ or society’s best interest and undercut the ethics of the profession. A longtime editor of the New England Journal and professor at Harvard Medical School, Relman tackles the issue again in his new book, “A Second Opinion,” published by PublicAffairs. This time he calls for a complete overhaul of the way medical care is delivered and paid for. Last week, Relman presented the case for radical reform of health care at the Union League Club in Chicago. Before that he spoke with the Tribune. An edited transcript follows.
Q. Many experts say the biggest problem in health care today is 46 million Americans with no health insurance. You say costs are the biggest problem in medicine today. Why?
A. When you step back and ask what’s going on, what’s the basic difficulty here, it’s that our health-care system is exorbitantly expensive. That’s the central problem. The lack of insurance coverage is secondary. If we get a grip on costs, we can afford to extend coverage.
Q. Why are costs so out of control?
A. It’s a complicated picture. Some causes are common to all modern health systems. People are living longer everywhere and chronic diseases connected with old age are becoming more common. Heart disease. Diabetes. Arthritis. These are expensive conditions to treat. Also, medicine has become very sophisticated and high-tech. The tests and procedures doctors order up are very elaborate and costly. What makes medicine in the U.S. more expensive than in all the other countries is the commercialization of our health-care system. Health care has become a big business over the last 30 years. It doesn’t matter if you’re for-profit or not-for-profit, every one is concerned about maximizing income. That includes a lot of doctors.
Q. What’s wrong with that?
A. There’s a basic conflict of interest. The assumption has always been when you to go the doctor he or she has a professional responsibility to put your needs above everything else. That’s changed. Now, when a doctor has a significant financial interest in a facility or in a piece of equipment, the doctor is torn between his or her own economic interests and the patient’s needs. … The patient can no longer be sure whose side the doctor is on.
Q. In your book, you say you’re convinced that the private marketplace won’t succeed in controlling costs or safeguarding quality. Why?
A The health-care market has failed, and if we continue to rely on the market the failure will only deepen. A very smart economist, Kenneth Arrow, a professor at Stanford, explained in the American Economic Review in 1963 that health care isn’t like any other market. The people who purchase medical care, patients, aren’t in the position to pick or chose what they want or need. When you’re sick and worried, you don’t know what’s wrong with you. And you’re not going to find it on the Web. It’s not like buying anything else. Then, you have the fact that doctors run the system. It’s not patient-driven. It’s not consumer-driven. It’s doctor-driven. And the doctors, for the most part, are paid on a piecework basis. Fee for service. You get paid for what you do. If there ever was a system that’s going to drive up costs, it’s a system like we have. Because the more doctors do, the more procedures, the more tests, the more money they get paid.
Q. What needs to be changed, then?
A. The fee-for-service system has to go. It won’t work anymore. … The vast bulk of medical service should be delivered by doctors paid a salary for their time and effort. That would bring medicine in line with most other lawyers and architects and engineers and accountants and teachers. And you need an integrated, organized system of doctors who manage their own affairs. The model should be prepaid group practices, like the Mayo Clinic and the Marshfield Clinic in Wisconsin and the Kaiser Permanente medical groups and many others.
Q. You suggest the entire delivery of health care has to be overhauled. Why?
A. Because medicine has become fractionated, divided up into multiple specialties that don’t communicate with each other and that duplicate each other’s efforts. It’s a jungle out there for a patient trying to find his or her way through the system. … In multispecialty practice, doctors work together as a team and share information and don’t compete with one another. … I believe We need a single-payer system of health care that covers everyone, like Medicare for the elderly. But first you have to change the incentives that drive the delivery of care and how that care is organized.
Q. Do you think doctors will ever accept this?
A. They will. … You know why? The practice of medicine is getting to be more and more stressful, and doctors are less and less satisfied. They’re beginning to realize, it can’t go on this way. … Ultimately, if the system doesn’t change in the fundamental way I’m predicting, what’s going to happen is the practice of medicine will be run by corporations or it’ll become socialized and doctors will work for the government.
Copyright © 2007, Chicago Tribune