Outside the Mayo Clinic's Gonda building in Rochester, Minn.
Ezekiel Emanuel got a memorable introduction to our haphazard health-care system on his first visit to a cancer ward as a medical student. The white coats were ordering a transfusion for a teenage girl, and since shyness does not run in his family — brother Rahm is President Obama's famously foulmouthed chief of staff, brother Ari a similarly silence-deficient Hollywood agent — he interrupted to ask why. Because she had Hodgkin's disease and her platelets were below 20,000, the team explained. Emanuel still had questions: Was there evidence for that protocol? Don't some hospitals wait until 10,000? Why 20,000? Because that's what we do here, one doc replied.
Now a noted oncologist turned White House health adviser, Emanuel has spent much of his career battling the that's-what-we-do-here mentality of American medicine. "It drives me nuts — the ignorance is overwhelming," he says. "I'm a data-driven guy. I want to see evidence." It turns out that Emanuel's boss, budget director Peter Orszag, is also a data-driven guy, as is Orszag's boss, the President of the United States. They've already stuffed $1.1 billion into the stimulus bill to jump-start "comparative effectiveness research" into which treatments work best in which situations. Now they're pushing to overhaul the entire health-care sector by year's end, and they're determined to replace ignorance with evidence, to create a data-driven system, to shift one-sixth of the economy from "that's what we do here" to "that's what works."
The U.S. spends more on health care than any other country does, and studies have suggested that as much as 30% of it — perhaps $700 billion a year — may be wasted on unneeded care, mostly routine CT scans and MRIs, office visits, hospital stays, minor procedures and brand-name prescriptions that are requested by patients and ordered by doctors every day. Orszag is particularly obsessed with research by the Dartmouth Institute for Health Policy and Clinical Practice, documenting huge regional variations in costs but virtually no variations in outcomes. For example, chronically ill patients in Los Angeles visited doctors an average of 59.2 times in the last six months of their life, vs. only 14.5 times in Ogden, Utah; they still ended up just as dead. Medicare now pays three times as much per enrollee in Miami as in Honolulu, and costs are growing twice as fast in Dallas as in San Diego. Patients in higher-spending regions get more tests, more procedures, more referrals to specialists and more time in the hospital and ICU, but the Dartmouth research has found that if anything, their outcomes are slightly worse. "We're flying blind," says Dartmouth's Dr. Elliott Fisher. "We're getting quantity, not quality."
Why Less Would Be More
Americans tend to assume that more is better, especially when it comes to the heroic brand of try-everything medicine we've watched on ER and House M.D. But overtreatment is a national scandal. It's bad for our health: with medical errors now estimated to be our eighth leading cause of death, drugs, procedures and hospital stays can be risky (as well as painful, time-consuming and wallet-straining) even when they're necessary. It's also bad for the economy: health costs are bankrupting small businesses and even conglomerates like General Motors as well as millions of families. And it's awful for the country: Medicare is on track to go broke by 2017, and our long-term budget problems are primarily health-cost problems. At current growth rates, health spending by the Federal Government alone would increase from 5% to 20% of the economy by 2050; Social Security, by contrast, would increase only from 5% to 6%.