Critical Condition: How Health Care in America Became Big Business and Bad Medicine • The Big Fix: How the Pharmaceutical Industry Rips Off American Consumers

Critical Condition: How Health Care in America Became Big Business and Bad Medicine, by Donald L. Bartlett and James B. Steel, and The Big Fix: How the Pharmaceutical Industry Rips Off American Consumers, by Katharine Greider, join a growing body of work exploring the crisis in American health care and the pharmaceutical industry. Both books are written primarily for health care consumers and effectively alternate case histories of patients who are ill-served by the current system with statistics that provide evidence of the chaos within the system. These books also raise important criticisms of "the illusion that market-based medical care will cure the American Health System."

Critical Condition makes a strong case that although many consumers benefit from the current system, these consumers are the "winners in a lottery" that ignores "44 million uninsured and tens of millions of underinsured." Bartlett and Steele assert that these imbalances result from a "market approach" to medicine. Their basic premise, expanded on throughout the book, is that although "fostering competition among multiple producers works when commodities are cars or computers, the glaring exception to the theory is health care." The authors explore a number of high-profile problems, including the closing of hospitals, diversion of patients from emergency departments, medical errors, and the withholding of information by pharmaceutical companies. They conclude that, "We have a system in such constant turmoil that almost everyone is unhappy—patients, doctors, nurses, aides, and technicians. But for a lucky few the turmoil is worth a lot of money."

The book then reviews the "trauma of upheaval" caused by mergers and spin-offs endemic to for-profit medicine. The authors state that profit became policy during the 1980s to "unleash" market forces and control costs but note that health care costs have risen from 10 percent of gross domestic product in 1984 to approximately 15 percent currently. They review systemic changes well known to physicians: micromanagement by insurance companies and HMOs, medication formularies, the automatic downcoding of current procedural terminology (CPT) codes, limiting of hospital stays by restrictive guidelines, billing-guideline "nightmares" created by the large number of health plans, and poor communication exacerbated by the use of long distance call centers. They state that "a generation after introducing business practices to healthcare, the United States spends a higher percentage of its health care dollars just to administer the system than any other country."

The Big Fix explores the causes of the dramatic increase in the cost of drugs, now increasing by approximately 15 percent a year. The author notes that as drug companies have consolidated and grown, they have required increased earnings growth. Companies, she states, now must produce blockbuster new drugs that can be sold at "high enough prices, and to large enough swaths of population to bring in billions in annual sales." The trouble is, "this is a requirement of the drug industry, not of public health." Greider acknowledges that the increase in drug costs stems in part from the fact that more people are taking more medications, and that this is certainly in part due to the increased frequency of some chronic diseases, such as diabetes and asthma, as well as an aging population, and the discovery of new medications for chronic conditions such as AIDS and hyperlipidemia.

However, she argues that the increase in the number of prescriptions and the large company profits are attributable to a small number of expensive best-sellers. She states that drug companies are focusing on patent extensions and drug modifications of these "blockbusters" and notes that product line extensions—those that add "no significant benefits"—account for a very significant percentage of drug sales. To the pharmaceutical industry's response that profits are necessary to support research and development, Greider argues that drug company estimates of huge budgets for research and development and the $800 million figure for development of a new drug are grossly inflated. She also argues that pharmaceutical companies spend twice as much on marketing and administration as on research and development. Greider also confronts what she sees as a number of significant conflict-of-interest issues involving pharmaceutical companies and physicians, private research companies, those who control research data, and the Food and Drug Administration.

The strength of both books is in their critique of industries in crisis. Both less clearly present a framework for remedy. Greider alludes to a more critical review structure for pharmaceutical products but otherwise does not address this thorny issue.

Both Bartlett and Steel argue for basic universal health care. They suggest the creation of one agency to collect medical fees and pay claims. To criticisms that this would create a "large federal bureaucracy," they argue that "the present market based program has created a massive bureaucracy with administrative costs many times that of any other country." They propose an independent U.S. council of health care and present a funding proposal to support their model.

Both Critical Condition and The Big Fix are quite readable and are welcome additions to a growing body of work questioning the cost and efficiency of "market-based medicine" and the pharmaceutical industry. Critical Condition is particularly strong in its presentation and documentation of the "costs" of modern medicine. The Big Fix raises important questions and criticisms of the pharmaceutical industry but suffers from an absence of documentation and a vision for the future. Reviews of the pharmaceutical industry are more strongly presented in other recently released books: The $800 Million Pill: The Truth Behind the Cost of New Drugs, by Merrill Goozner (1), and, particularly, The Truth About Drug Companies: How They Deceive Us and What to Do About It, by Marcia Angell, M.D. (2), both of which are better referenced and propose concrete and viable recommendations for solving the ongoing crisis within the drug industry.

Dr. Hurter is affiliated with the department of psychiatry of Herb Lipton Community Mental Health Center in Leominster, Massachusetts.