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Book Reviews   |    
Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System and Still Broken: Understanding the U.S. Health Care System
Reviewed by Leslie R. Pyenson, M.D., F.A.C.P.
Psychiatric Services 2011; doi: 10.1176/appi.ps.62.4.436
View Author and Article Information

The reviewer reports no competing interests.

Copyright © 2011 by the American Psychiatric Association.

Reading the title of Taming the Beloved Beast, I cautiously wondered whether its central theme would be a diatribe against medical innovation and progress. However, the author, Daniel Callahan, is a senior researcher and president emeritus of the Hastings Center, a nonpartisan bioethics research institute that he cofounded in 1969, and the author of many books and articles on ethics and health policy. This book reflects the author's expertise not only as a researcher but also as a philosopher. He presents his arguments, discusses alternatives, and anticipates counterarguments, all with ample citations.

Relying on a number of studies, Callahan presents evidence that 50% of the annual increase in health care costs results from new technologies, the intensified use of old ones, or a combination. Moreover, he maintains that the U.S. annual rate of inflation of health care costs, about 7%, is not sustainable and must be reduced to about 3%. In order to support this proposition, Callahan notes that the United States currently spends 16% of its gross domestic product (GDP) on health care, compared with the 8%—10% allocated by other developed countries. He asserts that the constant introduction of new technology has failed to generate a commensurate, cost-effective improvement in treatment of disease, quality of life, or life expectancy. Essentially, Callahan suggests that the significant influence of technological, pharmaceutical, and private insurance interests on Congress has quashed any legislative efforts to control health care costs or to assess the effectiveness of new treatments.

Callahan purports that "There is no moral obligation or imperative to continually improve the general health of populations already at historic high levels. But we can, and should, work to improve the general health of populations … [which] are at much lower levels." His proposed solution rests on three main points, which he acknowledges may not be attainable: restrain the development of technology, establish a government-regulated universal health care program for cost control, and provide the highest benefits for children, which would remain high during midlife and then taper on the basis of the individual's remaining quality-adjusted life years (QALYs).

Callahan likely views the Patient Protection and Affordable Care Act (PPACA), passed in March 2010, six months after this book's publication, as an inadequate solution. The legislation addresses some of his concerns: establishment of an institute for comparative effectiveness research, a program for the uninsured, and estimated reductions of the federal deficit of $143 billion from 2010 to 2019 and of a trillion dollars over 20 years, according to the Congressional Budget Office (1). However, the PPACA does not mandate Callahan's Orwellian approach. Nevertheless, this book will engage readers seeking to gain insight on health care reform and cost control from the perspective of a pragmatic philosopher.

Still Broken, written by Stephen M. Davidson during the Congressional debate on health care reform, was published shortly after the passage of the PPACA. Davidson, professor of strategy and policy at Boston University, has researched our health care system for over 35 years and published widely. In Still Broken, he deviates from his stance in his other works by taking a position on controversial policy questions. He illustrates the evolution of our current health care system and, rather than debate its inadequacies, focuses on presenting evidence-based solutions. These solutions concentrate on correcting the most commonly mentioned systemic problems: high cost, limitations on access to care, quality of care, and safety issues. Furthermore, advances in medical science and technology, with their increasing potential benefits, have resulted in a growing complexity of health care delivery. Like Callahan, Davidson points out that despite its disproportionately higher spending on health care, there is no measurable indication that health care in the United States is superior to that of other developed countries. Davidson emphasizes the dynamic forces—economic, sociologic, and clinical—that have played a central role in the development of these inadequacies and honestly confronts the political strategies needed to pass a health care bill—a topic not often discussed in policy-oriented books.

The author believes that a set of separate dysfunctional incentives (profit, coinsurance, copayment, deductibles, reimbursement policy, and so on) for employers, insurers, individuals, providers, and government drives our current suboptimal system. These incentives motivate decisions that inappropriately affect utilization and, when combined, act to limit access, decrease quality of care, and increase costs.

Davidson maintains that a change in the overall incentive structure is imperative; this change is best achieved through a mandatory, comprehensive health insurance program that provides access to all. Within that construct, he proposes a plan that provides positive incentives, emphasizing, for example, the electronic sharing of information, the use of appropriate and evidence-based technologies and treatments, and the promotion of prevention, aspects of which are part of the new PPACA. In his view, these revised incentives would lead individuals, providers, insurers, and government to make decisions benefiting themselves and society. His plan would ultimately lower medical costs, increase access, and improve quality of care. A recent actuarial study supports Davidson's thesis. Using composite models of best health care practices from locales across the country, actuaries from Milliman demonstrated that, by eliminating waste in our current system, a cost reduction from 16% to 12% of GDP is feasible (2).

The political strategy that Davidson considers necessary to pass a health care reform bill was apparent during the PPACA debate. This strategy includes a determined effort to counter the criticism of opposition groups, the ability to compromise and address concerns of all interested parties, and a sustained effort to mobilize public opinion.

Still Broken is an excellent primer on the U.S. health care system, requirements for reform, and the political maneuvering involved in effecting change.

 An Internist's Practical Guide to Understanding Health System Reform .  Washington, DC,  American College of Physicians, Division of Governmental Affairs and Public Policy,  Sept2010
 
Pyenson  B;  Fitch  K;  Goldberg  S:  Imagining 16% to 12%: A Vision for Cost Efficiency, Improving Healthcare Quality, and Covering the Uninsured .  Seattle, Milliman,  Feb2009. Available at publications.milliman.com/research/health-rr/pdfs/imagining-16-12-RR02-01-09.pdf
 
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References

 An Internist's Practical Guide to Understanding Health System Reform .  Washington, DC,  American College of Physicians, Division of Governmental Affairs and Public Policy,  Sept2010
 
Pyenson  B;  Fitch  K;  Goldberg  S:  Imagining 16% to 12%: A Vision for Cost Efficiency, Improving Healthcare Quality, and Covering the Uninsured .  Seattle, Milliman,  Feb2009. Available at publications.milliman.com/research/health-rr/pdfs/imagining-16-12-RR02-01-09.pdf
 
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