(Not So Brief) Book Review: Catastrophic Care

One of the most fascinating books I have read, “Catastrophic Care: American Healthcare Killed My Father” (http://www.amazon.com/Catastrophic-Care-American-Health-Father/dp/0307961540) offers no answer to its central question of how to save the lives of hundreds of thousands of Americans who die each year of “iatrogenic” causes. Instead, in a long, repetitive and begrudingly persuasive diatribe, it offers a sensible economic solution to our health care crisis while steadily losing sight of its ostensible raisôn d’ètre.

For me, Goldhill’s persuasive hook was that health insurance is not insurance in the traditional sense of the term insurance. It does not seek to spread risk of rare events across a large population. In a world which has medicalized human existence from cradle to grave, it is not a rarity but a certainty that we will rack up huge hospital bills somewhere along the way. The only question is when – not whether – six figure bills will be thrown our way. Health insurance purports to protect us from those oscillations. .

Lost in the shuffle, somehow, is any evidence that market-based reforms can improve quality and outcomes. Ironically, for a book motivated by the death of his father due to medical error, Goldhill offers slim evidence that increased marketplace competition will reduce medical errors. One need only to read the newspaper for a few days (or go to a store or restaurant) to note the alarming rate of errors made even in the most competitive marketplace segments. Now, one might argue that the marketplaces disciplines those actors over time, and that might be true, but I would like to see some evidence before believing that claim.

Also lost in the shuffle is the evidence that many physicians are motivated by pecuniary gain. In the training and practice environments that I am familiar with, financial considerations are minimized. Granted, I don’t work at a private institution and have never trained at one (few training programs are based at for-profit hospitals, for obvious reasons). And while “efficiency” and profit concerns are always present in the background, I have not yet seen a treatment performed or not for financial reasons.

And what would a more blatant capitalist system look like? As a model, I propose the only market-based physician I am aware of, Dr. Mehmet Oz. A recent fantastic article by one of my favorite nonfiction authors, Michael Specter, in the New Yorker showed a fascinatingly terrifying glimpse into this world (http://www.newyorker.com/reporting/2013/02/04/130204fa_fact_specter).

For instance, in neurosurgery, one of the core competitive areas is the treatment of intracranial aneurysms. Thanks to a few clinical trials in the early 2000’s, most people believe that endovascular therapy (treating aneurysms using wires threaded through the blood vessels) is superior to open brain surgery if endovascular therapy is deemed possible, except in a few specific conditions. Having spent a good bit of time around cerebrovascular surgeons, I can say that the biggest determinant is the opinion of the open surgeon vs. the interventionalist – and while financial considerations don’t exactly get into play openly, I am sure that job security is always present in the back of the surgeon and interventionalist’s minds when they compete/bargain for cases. I’m not sure that the open competition, though, is really best for patients since both sides push the limits of their technology and skills.

Anyhow, this post is now 300 words longer than “brief” – so I’ll wrap up by saying that the book is well written and a worthy read for anyone who will participate in health care as a physician or patient, and I strongly recommend it.

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