Your Money or Your Life: Strong Medicine for America's Health Care System
http://www.100md.com
《新英格兰医药杂志》
The rising cost of health care — and what to do about this problem — is perhaps our nation's most pressing health policy issue. The recent spike in private-insurance premiums has alarmed both employers and employees. More telling is the lack of clear policy options designed to discourage the introduction and use of high-cost, low-benefit medical care. As if the problem were not bad enough, other research findings tell us that evidence-based medical care is dramatically underused.
David Cutler makes an important contribution to our thinking on this important issue in Your Money or Your Life. The book provides a nice forum for Cutler to present much of his research that has framed how we should think about rising health care costs and whether the additional spending is worth it. Most of the popular discussion concerning rising health care spending neglects the obvious questions — what we are buying with the additional spending and whether we are producing commensurate increases in health benefits. Cutler's conclusion is a clear "yes": the incremental health care benefits that patients receive exceed their costs. However, he provides the important caveat that we could produce the same level of health care benefits at even lower costs.
The book is a good introduction to the policy debate over health care spending. It starts by appropriately framing the issue that we cannot look at the rise in spending without first measuring and comparing the benefits purchased. Chapters 3 through 5 methodically track the growth in spending to treat low-birth-weight infants, patients with depression, and those who have had heart attacks. These initial chapters contain compelling information and should be read by all who are interested in health care policy. Underlying the growth in spending is the persistent march of science. The introduction of new forms of technology allows us to treat more patients with particular medical conditions, though generally at a high price per case.
The heart of the book examines these trends and, in the three case studies that it follows, compares the added spending to the change in health benefits. In each case, total spending per case has risen, driven largely by the introduction of new medical technology. In some cases, the medical returns have been impressive. In the treatment of low-birth-weight newborns, medical advances (e.g., incubator design, new drugs), although expensive, have produced a dramatic reduction in mortality rates. As discussed in chapter 3, each additional $1 spent on treating low-birth-weight babies has produced $5 of additional health benefits — an expensive, though worthwhile, investment. Chapters 4 and 5 present the same evidence for treatment, respectively, of depression (a seven-to-one return on investment) and heart attacks (a four-to-one return on each dollar spent). Chapter 6 attempts a broader extrapolation of the medical value of health care spending — a somewhat tougher sell. Some of the later chapters, such as chapter 8, which examines what went wrong with managed care, seem to wander slightly off target.
If the health care we are purchasing is worth it, why the general malaise? Some of it is clearly traced to the perceptions of purchasers and consumers that we spend too much, that we could buy the same benefits for far less money, and that the system is hopelessly complicated. Along these lines, chapters 9 and 10 attempt to address the issue of providing better care more efficiently. One suggestion is to give physicians bonus payments for providing high-quality, evidence-based medical care. Though controversial, the idea is a good one that should be debated seriously.
The final chapter wanders into the hornet's nest of universal health insurance coverage. Cutler proposes an expansion of the Federal Employees Health Benefits Program to those who want to join. This chapter is too short for such a complex topic, and it meanders slightly from the compelling story and analyses presented in the first five chapters.
Who should read this book? Health policymakers and people who are troubled with the rise in health care spending and are perplexed about what to do about it. Your Money or Your Life makes an important contribution to this debate, and I highly recommend it.
Kenneth E. Thorpe, Ph.D.
Emory University
Atlanta, GA 30322
kthorpe@sph.emory.edu(By David M. Cutler. 158 p)
David Cutler makes an important contribution to our thinking on this important issue in Your Money or Your Life. The book provides a nice forum for Cutler to present much of his research that has framed how we should think about rising health care costs and whether the additional spending is worth it. Most of the popular discussion concerning rising health care spending neglects the obvious questions — what we are buying with the additional spending and whether we are producing commensurate increases in health benefits. Cutler's conclusion is a clear "yes": the incremental health care benefits that patients receive exceed their costs. However, he provides the important caveat that we could produce the same level of health care benefits at even lower costs.
The book is a good introduction to the policy debate over health care spending. It starts by appropriately framing the issue that we cannot look at the rise in spending without first measuring and comparing the benefits purchased. Chapters 3 through 5 methodically track the growth in spending to treat low-birth-weight infants, patients with depression, and those who have had heart attacks. These initial chapters contain compelling information and should be read by all who are interested in health care policy. Underlying the growth in spending is the persistent march of science. The introduction of new forms of technology allows us to treat more patients with particular medical conditions, though generally at a high price per case.
The heart of the book examines these trends and, in the three case studies that it follows, compares the added spending to the change in health benefits. In each case, total spending per case has risen, driven largely by the introduction of new medical technology. In some cases, the medical returns have been impressive. In the treatment of low-birth-weight newborns, medical advances (e.g., incubator design, new drugs), although expensive, have produced a dramatic reduction in mortality rates. As discussed in chapter 3, each additional $1 spent on treating low-birth-weight babies has produced $5 of additional health benefits — an expensive, though worthwhile, investment. Chapters 4 and 5 present the same evidence for treatment, respectively, of depression (a seven-to-one return on investment) and heart attacks (a four-to-one return on each dollar spent). Chapter 6 attempts a broader extrapolation of the medical value of health care spending — a somewhat tougher sell. Some of the later chapters, such as chapter 8, which examines what went wrong with managed care, seem to wander slightly off target.
If the health care we are purchasing is worth it, why the general malaise? Some of it is clearly traced to the perceptions of purchasers and consumers that we spend too much, that we could buy the same benefits for far less money, and that the system is hopelessly complicated. Along these lines, chapters 9 and 10 attempt to address the issue of providing better care more efficiently. One suggestion is to give physicians bonus payments for providing high-quality, evidence-based medical care. Though controversial, the idea is a good one that should be debated seriously.
The final chapter wanders into the hornet's nest of universal health insurance coverage. Cutler proposes an expansion of the Federal Employees Health Benefits Program to those who want to join. This chapter is too short for such a complex topic, and it meanders slightly from the compelling story and analyses presented in the first five chapters.
Who should read this book? Health policymakers and people who are troubled with the rise in health care spending and are perplexed about what to do about it. Your Money or Your Life makes an important contribution to this debate, and I highly recommend it.
Kenneth E. Thorpe, Ph.D.
Emory University
Atlanta, GA 30322
kthorpe@sph.emory.edu(By David M. Cutler. 158 p)