administration and policy

Kleinke's book is itself oxymoronic. He complains that the current "system" is not a normal market, but that by placing purchasing power in the hands of "consumers," a normal market will emerge. WRONG. With rare exceptions, it is the supplier of medical services who determines the level of demand for those services. Compounding this perversion of ordinary market forces are two other significant realities: a). If potatoes are being purchased, the consumer would have a knowledge of the product and of its value that is fairly equivalent to the knowledge of the grocer. In medicine, the "consumer" usually has nothing approaching equivalent knowledge about the services to be provided, and must rely entirely on the word of the physician about the value of those services; b). The physician workforce in the U.S. is currently twice as large as would be optimal for the health status of the whole population, this according to an exhaustive study completed by the Pew Commission on the Health Professions, under the chairmanship of former Senator George Mitchell. The American people are paying for this huge oversupply in the physician workforce in lives as well as in money. Using publicly available Medicare data, the physician editors of The Dartmouth Atlas of Health Care have provided a specific characterization of the medical services that they have defined as being "supply sensitive:"
*Weak or absent scientific evidence for providing the service.
*Rather, care is provided under the assumption that more is better--or can't hurt.
*Use of the service is strongly associated with local supply.

The Atlas has established on hard evidence that the length of survival for Medicare beneficiary populations in areas of the United States that have a high concentration of "supply sensitive" physicians, hospital beds, and other medical service resources is shorter than for populations living in areas with an average or low concentration of such medical care resources:

"Medicare beneficiaries residing in regions with 4.5 beds or more per 1000 had a two percent increased risk of death compared to those living in regions with less than 2.5 beds per 1000. ...There were no population groups in whom greater hospital use was associated with improved survival. ...In conclusion, there are good reasons to be cautious about more medical care. In the absence of strong scientific evidence of benefit, there are real risks of harm that should be taken into consideration. ...[W]e see that increased capacity is generally devoted to care of uncertain benefit. Finally, we have no evidence of improved outcomes from greater use of supply sensitive care--and there is some research that suggests that residents of the highest intensity regions may be at risk of harm. ...[The] predicted impact of excess supply sensitive hospitalizations on Medicare mortality brackets the findings from our recent study--a three percent increase in mortality."

Other facts that underline the abnormality of the market forces at work in conventional American medicine include the following:
*The absence of effective clinical evaluative science is total.
*There is no general medical management. Specialists are dominant, and they function autonomously within their own field of practice.
*Barbara Starfield, MD, a faculty member of the Johns Hopkins University School of Public Health, published a Commentary in the June 2000 issue of the Journal of the American Medical Association in which she documents physician errors as being the third leading cause of death for Americans each year. Of course, this truth is never reported by the National Center for Health Statistics, but it is nonetheless a stubborn fact.
*The incidence of chronic disease is at epidemic levels in the American population. For example, with about four percent of the world's population, the United States accounts for twelve percent of new cancer cases each year.
*Since Nixon declared the "war on cancer," cancer deaths in the U.S. have risen from year to year without a single exception. Reporting by federal agencies has distorted this hard truth by utilizing "death rates" instead of the actual deaths.
*Although this fact has not been publicly stated, the medical profession has abandoned the search for a cure for cancer, and has concentrated its massive resources on devising new technologies for treating the large variety of malignant neoplasms now afflicting the population. For oncologists, treatment is where the profit lies. Cure would put them out of business.

I believe it was George Bernard Shaw who once said the height of political folly was reached by legislating financial incentives for surgeons to cut your leg off. In the United States, we have achieved this height. No physician can profit from fostering optimal levels of health in their patients. Profit flows almost entirely from illness or injury, and from the attendant diagnostic procedures. "Consumers" of medical services would be well advised not to pay attention to the angry ramblings of an "expert" like Kleinke. It is evident that he has no sound idea about what the problems are, much less about the changes that will be necessary to resolve them.

Kleinke's book sets forth the reasons why the healthcare system does not function - he is clear and thorough, there is no whitewash. The dissection of healthcare system is especially cleansing and refreshing to readers who are tired of hearing about lack of access to adequate healthcare - Oxymorons explains the "why" by peeling the onion of the system to reveal the rotten root. In addition, Kleinke puts together a plan to revise the system and put therapeutic choice back in the hands of the physician and the patient, rather than the treatment-phobic payer.

So often in the media we hear about overpriced pharmaceuticals and the cost of healthcare innovation. What we do not hear about is the plight of the physician who is hamstrung by payers from making therapeutic choices for patients. We hear about patients who look up new technologies on the internet for their conditions, but we do not hear about the payers who restrict patient access to innovation and science. Further, we do not hear about how payers purposefully shun simple and cost-effective electronic solutions to covering medically necessary treatment. As a result, payers are in the driver's seat to process claims inefficiently, make ad hoc coverage decisions, and make untimely and inappropriate payments to physicians and patients. Why don't we hear about these issues in the media? Why aren't electronic solutions embraced by the payer to increase the overall health of Americans while embracing the importance of physician decision-making and patient choice? Kleinke sets forth the rationale for the broken system.

Wouldn't it be great if payers actually embraced technology to the benefit of patients and physicians? What would happen if payers empowered innovations in medicine for patients to the benefit of the practice of medicine and science, rather than hiding from electronic solutions for the sake of making a few more bucks on the stock market? What would happen if a system existed in which patients could make informed choices about their plans, rather than the employer, to control their own treatment plans in conjunction with their physicians? Kleinke lifts the veil for all to see, and what is there is not pretty, it's broken and counter-intuitive. While some readers might call this a negative book, many readers will find this a refreshing look at what is really there. It is thought-provoking and interesting, not just a sound byte to make everyone feel good.

Oxymorons is an excellent follow-up to Kleinke's first book: "Bleeding Edge", a must read for anyone interested in learning more about healthcare and the economics of the system.

Oxymorons is the first book that dares to look at the whole mess that is the US health care system without a political or business agenda. The author explains exactly why the system is stuck in political and economic gridlock, and how this gridlock actually benefits all those denouncing it the loudest - the health insurance companies, consultants, lawyers, and various business schemers who make money on the system's complexity and dysfunction. After discrediting so much of the nonsense that pundits and policy types like to generate about health care using real data, Oxymorons then dares to put forth a concise and simple plan for how the federal government and a non-governmental non-partisan health benefits task force (notably not any one state government or any newfangled managed care scheme) can change a few simple rules, establish some actual standards, and flush out a lot of the waste that defines the non-system of health care in the US. Kudos to the author for calling it like he sees it, and still having the guts to propose a real solution.