Question: Your book explores financial incentives in American medicine and argues that these incentives lead to more costly care without necessarily considering outcomes. The first section of your book explores whether physicians are the “cause or the cure” of this. You explore both sides, but overall, do you think physicians are the cause or cure?
Dr. Andrews: The first section describes how medical students (the vast majority of whom chose medicine to be able to care for patients) become indoctrinated during their training to view medicine as a profit-centered rather than patient-centered profession. Physicians in the U.S. have been unknowing victims (but frequently willing accomplices) in the conversion of healthcare from a societal good to a profit industry. However, physicians bear the responsibility to reform healthcare from a profit-centered to patient-centered profession. If physicians do not lead the reform of healthcare in the U.S., bureaucrats will do so — to the detriment of both the patients and the physicians.
Q: The second section of you book explores a number of forces you argue are “eroding the patient-physician relationship.” One of the forces you mention is the marketing of prescription drugs directly to consumers. How would you like to see regulations around this reformed?
RA: Many medications require a prescription because there is a risk to the patient if an educated medical professional is not involved in the decision to prescribe that medication. Prescription medications should not be advertised in the mass media — much as tobacco ads have been greatly restricted. Furthermore, making the first month — for example — of a prescription medication free to the patient would eliminate the very costly desire for drug companies to market their non-generic medications to physicians.
Q: Your book also discusses some of the steps that could be taken to “heal” American medicine. Can you share with us what you believe some of the most important changes or reforms needed are?
RA: It is telling that “universal healthcare” was off the table very early in the healthcare reform debate several years ago — even though every other developed nation has some form of universal healthcare. Healthcare for all should be an integral part of civilized society (like police and fire protection, clean water and air, and education) — not an industry whose goal is to be profitable for insurance companies, drug and device manufacturers, hospitals, and healthcare professionals such as doctors. There are numerous models of healthcare systems worldwide that are not essentially profit-driven as the U.S. system is. We can take the best from those systems and fashion a much more effective and efficient healthcare system for the U.S.
Q: Do you think any of the new models of healthcare delivery and reimbursement, such as ACOs, PCMHs, etc., will improve the problems that plague medicine today?
RA: The virtue of the PCMH is that it places the patient at the focal point of healthcare delivery. ACOs and other such reorganization efforts do not address the basic need to put the patient rather than the profit as the focal point of healthcare delivery. Clever, profit-motivated administrators will quickly figure out how to extract profits out of any such superficial restructuring (“deck chairs on the Titanic”). Until medicine becomes a service of society rather than an economic enterprise, the profits will increasingly be privatized while the losses will be socialized — much like the Wall Street meltdown and the TARP bailout. The losses consist of long-term costs to both (1) the government financially (e.g., the costs of untreated medical disorders and care provided to the uninsured, bankruptcies of patients unable to meet exorbitant copays and deductibles, and extra care necessitated by profitable but ineffective new drugs and devices), and (2) the populace as a whole in terms of health outcomes (e.g., deteriorating health statistics in the U.S, such as life expectancy and infant mortality).
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