(A review in two parts of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer by Shannon Brownlee.)

Americans spent more than $2 trillion on health care in 2006. That's almost as much as the world spends annually on petroleum. We currently spend more than two and a half times more per capita on health care than other industrialized countries do. The rising cost of health care is already a serious obstacle to our economic competitiveness in the international marketplace, and things are rapidly getting worse. Experts predict that within the next decade the cost of our health care system will consume almost 20 percent of the nation's gross domestic product.

Are we getting value for money? Is all this lavish expenditure resulting in longer and healthier lives? By any objective standard, the answer is a resounding no. Although we are constantly being told by politicians that our health care system is the best in the world, the facts tell a very different story. For decades, the US has been slipping steadily downwards in international rankings for life expectancy. Two decades ago, we ranked 11th in the world; we now rank 42nd. People in Canada, Japan and Western Europe have a significantly higher life expectancy than US citizens. The infant mortality rate - another reliable yardstick by which the quality of a nation's health care can be measured - is better in 27 other countries than it is in the US; we rank 28th, lagging behind countries such as Cuba and the Czech Republic.

Why does American health care cost so much, yet yield so little improvement in our health and longevity? There are undoubtedly many contributory factors. One is the lack of universal access to health care in the US: with 47 million Americans currently uninsured, and tens of millions more underinsured, health care can be excellent for some while others go without care entirely because of inability to pay. In 2007, for example, a twelve year-old Washington, DC, boy died as a result of an overwhelming brain infection that originated in a decayed and abscessed tooth. His mother was too poor to afford the $80 it would have cost to have the tooth extracted, and was unable to find a dentist who would accept Medicaid.

Those who defend our current system often claim that, for all its faults, it is still intrinsically better than the state-run systems in countries such as Canada, France and the United Kingdom, where health care is rationed and there are long waiting lists for non-emergency conditions. But when a team of researchers from Johns Hopkins Bloomberg School of Public Health made a comparative study of health care spending and waiting lists in the US and other countries, they found no basis for this assertion. Instead, they found that the fifteen tests and procedures that account for the majority of the waiting lists in other countries accounted for just 3 percent of costs in the US, and could not therefore account for the huge disparity in health spending between the US and other countries (Anderson 2005).

Besides, attempts to control costs by means of managed care - which is itself a form of rationing in all but name - have also signally failed. Instead, we have created a greatly expanded (and hugely expensive) bureaucracy that has interposed itself between patients and their physicians, placing strict constraints on clinical decision-making and micro-managing everything from how long physicians may spend with each patient to what services they are encouraged – or in some cases forbidden - to discuss.

Some consider that the rising cost of malpractice insurance is contributing strongly to the problem, and suggest mandatory caps on non-economic damages in malpractice cases. Others see this as simply a way of restricting patients' rights. Even malpractice insurers themselves seem far from united on this issue. For example, the nation's largest medical malpractice insurer, GE has admitted, in a filing obtained by the non-profit Foundation for Taxpayer and Consumer Rights, that non-economic damages awarded in malpractice suits represent only a small percentage of total losses paid. "Capping non-economic damages will show loss savings of 1.0 percent," the company states in its filing (FTCR).

In an intriguing new book - Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer - award-winning journalist and science writer Shannon Brownlee suggests another (and hitherto largely unexamined) reason for the rising and unsustainably high cost of health care in the US. Throughout the political discourse on our current health care crisis, she writes in the book's introduction, "…the most important piece of the puzzle has been consistently overlooked. There's one more factor that contributes to our medical bills, and that's unnecessary care. We spend between one fifth and one third of our health care dollars…between five hundred and seven hundred billion dollars…on care that does nothing to improve our health. And while overhead and high prices hurt our pocketbooks, the vast amount of unnecessary care in the system also makes our health care worse than it ought to be. Unnecessary treatment and tests aren't just expensive; they also can harm patients."

Superficially this looks like another exhortation to restrict care and introduce more de facto rationing - exactly the approach that has been most vigorously resisted by doctors and patients alike in the US. But while Brownlee acknowledges that her central thesis - that we are getting too much care, not too little - runs counter to conventional wisdom, her well-argued and meticulously documented book makes a convincing case that overtreatment is indeed the single most significant contributor to the spiraling cost of health care.

How did our collective infatuation with medical intervention come about? Brownlee traces its origins back to the mid-nineteenth century, when some of the most astonishing advances in medicine were made. She cites a survey conducted by a group of Harvard researchers that found that over a third of respondents believed that American medicine "can cure almost any illness for people who have access to the most advanced technologies and treatments." One of the physicians that Brownlee cites in her book sums it up thus: "We are the new priesthood, and the myth we are peddling is not everlasting life in heaven, but everlasting life here on earth."

TO BE CONCLUDED, WITH REFERENCES, NEXT WEEK

--Ralph W. Moss, Ph.D.