I Have Seen the Promised Land of Health Care! It’s in another Galaxy!

You see, there’s no money in healthy people, and there’s no money in dead people. The money is in the middle: people who are alive, sort of, but with one or more chronic conditions… – Bill Maher

There is no health care system in the U.S., we only have sick care. The focus of the expenditures, research, education, and infrastructure design is for the care of the chronically ill. That is reasonable because we have done a spectacular job of maintaining the sick people in that situation. Health care should pull patients out of their maladies and not just prolong their lives to make it to their next medication refill.

At present, 6 in 10 people in the US have chronic diseases. 4 out of 10 will be sick with two or more conditions. Chronic illnesses are the leading drivers of the $3.5 TRILLION health care cost annually.

The sick-care system has multi-system organ failure.

To deliver sick -care, we need the following.

Payors. Medicare and health insurance
Infrastructure – hospitals, clinics
Medical information and research
Medications and devices – the primary tool of the sick care system
Health professionals

This article contains quotes from many other writers, and it reflects the general atmosphere of dissatisfaction about the present so-called health care system. The natives are getting restless. You see, anyone can be academic, cold, and distant about this situation, but once you or someone you know is on the other side of the physician-patient divide, then it becomes real and personal. You either become a victim or a combatant.

The following is the sad state of the present system.

Runaway Health Care Costs

Health insurance cost is skyrocketing. Some premiums can be as high as 31- 50% of incomes.
If you have insurance, not all services may be covered; some do not cover weight reduction surgery and long-term care. Here is a gem about health insurance. Screening colonoscopies are free. However, if a polyp is found and it has to be removed and then tested for precancerous or cancerous cells, then it becomes a diagnostic colonoscopy or intervention. Then you get a bill. Surprise!
Medicare is projected to be bankrupt in 2026.
In the event of hospitalization, patients can get overcharged by 80% of hospitals. How about getting a bill for $18,836 for a visit lasting three hours and 22 minutes in the emergency room?
This explains why the number one cause of bankruptcy in the U.S. is related to medical issues. There is no 100% money-back satisfaction guarantee in the system. If you survive or have a complication or die during the admission, you still have to pay.

The Food and Drug Administration is Asleep on the Job

Donald Light wrote in Risky Drugs: The FDA Cannot Be Trusted

“…over the past 30 years, approved drugs have caused an epidemic of harmful side effects, even when properly prescribed. Every week, about 53,000 excess hospitalizations and about 2400 excess deaths occur in the United States among people taking properly prescribed drugs to be healthier. One in every five drugs approved ends up causing serious harm, while one in ten provides a substantial benefit compared to existing, established drugs.
There is a revolving door between the big pharma and the FDA. Science Magazine has found that,

… much like outside advisers, regular employees at the agency, headquartered in Silver Spring, Maryland, often reap later rewards—jobs or consulting work—from the makers of the drugs they previously regulated.

The Pharmaceutical Industry Can Influence Medicine about the Formulation of Diagnosis and Treatment Guidelines

In, Drug Firms, the Codification of Diagnostic Categories, and Bias in Clinical Guidelines, by Lisa Cosgrove and Emily Wheeler,

In this article, we analyzed how drug firms influence psychiatric taxonomy and treatment guidelines such that these resources may serve commercial rather than public health interests.

Inventing a diagnosis to sell your drugs. Create a demand for what you sell. Neat idea!

The Problems with Medical Guidelines

Medical guidelines are recommendations formulated either by government health agencies or specialty groups. Even though guidelines are formulated to be suggestions for the physicians, they become the de facto “standard of care.” But they have some issues.

“50% of evidence-based medical guidelines have methodological flaws” in the formation and have “questionable content with respect to the primary evidence” that is according to Wrong guidelines: Why and how often they occur, from the British Medical Journal.
The other problem is that even if well designed and properly made, guidelines may not necessarily apply to everybody. Here is a quote from “What’s Wrong with Guidelines?” from the New England Journal of Medicine podcast,

…the bottom line is that the data which these guidelines are based on are very very nonreflective of the patients that we have in the community, who very often have multiple morbidity, who may be old, may be frail. You know it staggers me that we are applying the same kind of guidelines to someone who may be 85 and on 12 different medications with a 42-year-old who is otherwise fit and well. And the risks and benefits in these situations are quite different.

Another quote from Lisa Cosgrove and Emily Wheeler from Drug Firms, the Codification of Diagnostic Categories, and Bias in Clinical Guidelines,

“Clinical guidelines and protocols have essentially become marketing tools for drug companies.” thus creating “the potential to expose many patients to harm from unnecessary treatment or from treatment that is not evidence-based.”

That quote was evident to me during my review for my recertification for internal medicine. It seemed to me at that time that the best way for internists to become familiar with your new drug is to get it included in the guidelines, medical review materials, and Continuing Medical Education.

Many Published Medical Studies Are Wrong

I always imagine a doctor with his nose up in the air and looking down at commoners, saying, “We have to practice evidence-based medicine.”

The problem arises if the evidence is incorrect. The error may be in design, bias, methodology, sample size, and statistical parameters. There is also the heavy hand of the drug company that happens to pay for the research and salaries. Conclusions derived from these studies have a significant impact on medical decision making. To make the logical connection. The incorrect investigation leads to wrong decisions. Garbage in, garbage out.

Take it from the editor of the well respected medical journal Lancet, Tim Horton, who said: “A lot of what is published is incorrect.”.
John P. A. Ioannidis, director of the Stanford Prevention Research Center, wrote in An Epidemic of False Claims, “Many false positives, exaggerated claims, and conflicts of interest are present in peer-reviewed scientific studies.”
Dr. Marcia Angell, the former editor in chief of the New England Journal Of Medicine, one of the most prestigious medical journal, wrote,

“It is simply no longer possible to believe much of the clinical research that is published or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor.”

Prescription Drug Risks

Prescription drugs are a major health risk. In that piece, Donald Light wrote, Over the past 35 years, patients have suffered from a largely hidden epidemic of side effects from drugs that usually have few offsetting benefits. The pharmaceutical industry has corrupted the practice of medicine through its influence over what drugs are developed, how they are tested, and how medical knowledge is created.”
In Serious Risks And Few New Benefits From FDA-Approved Drugs, D. Light again, “The Center for Drug Evaluation and Research (CDER – pronounced “C-DER”) is the FDA division responsible for determining whether new drugs should be approved. It’s funding, however, now mainly comes not from taxpayers but from the companies submitting their drugs to CDER for review. This apparent conflict of interest and approving so many new drugs with few clinical benefits serve corporate interests more than public interests, especially given the considerable risks of serious harm.
Again from Harvard University Center for Ethics, New Prescription Drugs: A Major Health Risk With Few Offsetting Advantages, “…even properly prescribed drugs (aside from misprescribing, overdosing, or self-prescribing) cause about 1.9 million hospitalizations a year. Another 840,000 hospitalized patients are given drugs that cause serious adverse reactions for a total of 2.74 million serious adverse drug reactions. About 128,000 people die from drugs prescribed to them.”
Study Finds Nearly 400 Medical Devices, Procedures, and Practices That Are Ineffective, “Through an analysis of more than 3000 randomized controlled trials (RCTs) published in three leading medical journals (the Journal of the American Medical Association, the Lancet, and the New England Journal of Medicine), we have identified 396 medical reversals”. Medical reversals are changes in medical practices that are opposite to what was recommended before.
Commercially funded clinical trials are at least 2.5 times more likely to favor the sponsor’s drug than non-commercially funded trials – Serious Risks from New Prescription Drugs
Pharmaceutical industries often turn to “key opinion leaders” to influence other doctors to spread scientific information, according to Sergio Sismondo. It is

The issue here, as in many other cases of institutional corruption, is that a few actors have accumulated the power to shape the information on which many others base their decisions.

Fake Drugs

Fake drugs kill more than 250,000 children a year. According to the World Health Organization,
A National Public Radio report says many medicines, including vaccines and diagnostic kits, may be counterfeit.
Where Are Your Drugs From? Reviews the book, China Rx, that reported that the vast majority all of the prescription medications, including the ones taken by the U.S. military and the top reaches of the government is manufactured and imported from China. Does that sound like a serious national security issue?

Physician Issues, Student Debt, Shortages, and Burn-outs

The average student loan of a medical school graduate is $196,520 for 2018. Some may be higher if they also have a college loan, which could be around $200,000. A new medical graduate who wants to start a practice, family, and get a mortgage for a house needs income to pay for all.

That is why fresh graduates would instead go into residency programs with the potential for higher pay. That means fewer American medical residents in internal medicine, pediatrics, and family medicine. Less new doctors working in underserved and rural communities. The areas with a more chronically ill population.

2019 marks the first time that employed physicians outnumber the self-employed, according to the American Medical Association report. Based on the current difficulty in costs, overhead, and red tape involved in setting up a private practice, we will see this direction go higher in the future.

There is a growing trend of hospitals buying medical practices. From the report, Updated Physician Practice Acquisition Study: National and Regional Changes in Physician Employment
2012-2018

● The percentage of hospital-employed physicians increased between 3%
and 7% in most regions.
● The percentage of hospital-owned practices increased between 1% and 8%
across regions

This makes me ask this open question, Whose interest will the employed physician, who is deep in debt, put first?

Other concerns are the looming shortage of physicians. Could it be from the burnout because of a broken medical system?

Ultimately, the one who pays the price is the patient. In this study from Johns Hopkins University. Medical Error – The Third Leading Cause of Death in the U.S. the deaths are estimated to be more than 251,000. Number one is cardiovascular disease, second is cancer. That report is here.

In summary

Getting sick will require procedures and medicines that may have adverse side effects that are based on guidelines formed with conflicts of interest that originated from dubious drug research. All in the hope that a bankrupt Medicare will cover part of a hyperinflated hospital bill that will only be partially covered by medical insurance with an expensive premium.

What Can we do?

Do everything to stay healthy. It is worth it. Don’t give disease an inch.

No amount of Medicare or insurance coverage and no drug can prolong life.

A healthy lifestyle of proper nutrition, physical activity, and adequate sleep, quitting cigarettes, and avoiding alcohol abuse goes a long way in preventing diseases.

References:

Institutional Corruption of Pharmaceuticals and the Myth of Safe and Effective Drugs published in the Journal of Law, Medicine, and Ethics of Harvard University.
Harvard University Center for Ethics.
Light, Donald W., and Lexchin, Joel and Darrow, Jonathan J., Institutional Corruption of Pharmaceuticals and the Myth of Safe and Effective Drugs (June 1, 2013). Journal of Law, Medicine, and Ethics, 2013, Vol. 14, No. 3: 590-610. Available at SSRN: https://ssrn.com/abstract=2282014
Light, Donald W.. New Prescription Drugs: A Major Health Risk With Few Offsetting Advantages
June 27, 2014
Light, Donald W.. Risky Drugs: Why The FDA Cannot Be Trusted. Harvard University Center for Ethics
https://retractionwatch.com/2011/07/11/so-how-often-does-medical-consensus-turn-out-to-be-wrong/
Piller, Charles. FDA’s revolving door: Companies often hire agency staffers who managed their successful drug reviews. Science Jul. 5, 2018
Piller, Charles, You, Jia. Hidden conflicts? Pharma payments to FDA advisers after drug approvals spark ethical concerns. Science Jul. 5, 2018
What’s Wrong with Guidelines? from the New England Journal of Medicine podcast. June 9, 2016
Sismondo, S. Key Opinion Leaders and the Corruption of Medical Knowledge: What the Sunshine Act Will and Won’t Cast Light On
Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S.