you're looking better. narrator: welcome to the medical marketplace. christine, how long ago was your surgery?

to a time traveler crossing the boundaries of centuries, or a newcomer from a distant land, the complexity of the medical system in the united states is difficult to comprehend. gerard anderson, health policy specialist, has a simple way to explain it. gerard anderson: i take them to a grocery store, and i show them l the different cereals, and say,e want toave oicen america. t'ta and i show them l ththinus.rent cereals, it doesn't seem to give us better health ca, it doesn't seem to give us lower costs, but it does give us choice, and we value choice above everything. from a practical point of view, the first decision many consumers are confronted with

is how to finance their health care. the choices are simply to pay for it themselves, or to enroll in a private or public health insurance plan. a lot is said about the marketplace of health care. well, for half of people who are getting their health plan through an employer, their employer offers such a narrow range of plans that they-- the consumer-- feel that they are cut off from options they really would like to have. many employers only offer plans that require a patient co-pay or less expensive hmos. cost-sharing makes the assumption that the person can identify what's an appropriate and inappropriate service. and so you go to the doctor, and you're looking for help, and you have to pay maybe 20% of the doctor bill. so, because of that 20% of the doctor bill, you're supposed to be able to say, "doc, do i really need that service?

do i really need that lab test?" that's a very difficult thing for somebody who's dealing with an emergency situation, looking for the doctor for advice, to be second-guessing the doctor and doing that for financial reasons. hmos work well for patient who need routine services, preventive care-- simple things. hmos do not work well for patients who need advanced therapy, cancer treatments, advanced surgery, and so forth. this is because hmos receive a set amount of money for each patient enrolled in the plan. there is little incentive to make referrals or provide expensive services. i think in the long run, we'll probably have a combination of the hmo model with a fee-for-service model. the hmo model covering patients for their routine health-care needs. but when something really goes wrong, when they get cancer, when they have a serious health-care need,

that will be an insured type of risk, and the doctors and hospitals will be paid on some kind of a fee-for-service basis. if several insurance options are available, what criteria should guide the choice? peter clarke: the kinds of things that the consumer needs to think about are: will i always have to go through my primary care physician to get access to a specialist? if, for example, i have diabetes, do i always have to check in with my primary care physician before i can go see my endocrinologist? that's an issue on which plans differ. how does the plan react to if i seek emergency care-- i have a chest pain-- under circumstances that a reasonable person would be frightened that they're undergoing a medical emergency? is my plan going to cover that? what is my plan's range of specialists in areas that i suspect,

because of my family history, that i'm likely to need? these are some of the questions that you need to look into ahead of time. and then, the very important issue: what happens when my plan denies authorization for a procedure or for a piece of medical equipment? do i have access to an independent panel-- appeal board-- that i can take my case to? the plan that is selected often influences the choice of a primary care physician, usually an internist or family practice doctor who will provide periodic checkups, suggest preventive strategies, and respond when illness strikes. as general internists, there is a tremendous amount you can do for your patients before you need to call in subspecialists, or send your patients out and parcel their care out to other physicians. and that helps you to build trust, and that makes it a bit easier on the patients. they only have to come to one place, see one doctor.

but when the needs arise to get them elsewhere, initially, it is handled the same way. a phone call is made from my nurse, my social worker, my medical assistant to the patient, to the site where they may have an appointment. gary feinberg: quite often i will see a patient that's been referred to me by another doctor. i'll have a pulmonologist-- a lung doctor-- who will send me a patient who has asthma, and the pulmonologist wants me to assess whether or not the sinuses are causing the asthma problem. and after assessing the patient, getting the radiological studies, and determining that there's sinus disease, then i call the pulmonologist, and i call him on the phone or i call her on the phone and say we have this problem. the patient's going to need surgery... the patient will need to be in the hospital for a couple of days because of their lung problem or asthma. we work together as a team in taking care of the patient. this kind of coordination helps patients navigate the medical marketplace.

it is particularly critical for anyone with a chronic condition. laura mosqueda: it's scary to be faced with a disease that might go on for 10, 15 years, where there really isn't hope for somebody getting better from it. then i think we need to provide ongoing office visits in terms of availability for people, that we don't just give them the diagnosis and say, "see you in a year." i think fear is the most common denominator among patients. and the good doctor is the doctor who knows that and knows that the way out of fear is to give hope. and you give hope by giving a plan of action. we give them diagnoses and say, "i'm going to see you in six weeks to see how things are going, to see if you've been able to follow up with any of these resources." this is an area where physicians need to interact very closely with social workers, psychologists, occupational therapists, physical therapists-- a whole health-care team, because at some point in time, people or their loved ones are going to need that help

from these different health-care professionals. and i've even had physicians call me and say, "you know, i have a group of people who are getting this kind of treatment which i know is a very tough treatment. what can you offer them?" and we'll talk about how do we set up a group for them, or how do we make sure that they get referred to us so that we can provide that comprehensive psychosocial care? i need you to sign that right...here. physicians who play this critical role admit their frustration with rules and regulations that limit their ability to serve patients. i feel that there is some pressure to have less access to specialists, to decrease the number of specialists. that can be frustrating at times because there are certainly complex problems that i'm not equipped to deal with, and i want a patient to see a specialist quickly and promptly to have a thorough evaluation. david goldstein: nobody can be the master

of all those technologies. you can learn them, but you can't be the masters of them. at least get the patient the best care. so integrity is a really important issue, and the integrity of our payers-- of our insurance companies-- needs to be held up there. - you all right? - okay, fine. - see you later. - great. we have a trauma center here. the trauma surgeon, he will have a patient with a gunshot wound to the head and neck. he'll have a patient with a motor vehicle accident where they have abdominal, chest injuries, facial injuries, and he'll say, "i need the thoracic surgeon, i'll need the orthopedist, i need the otolaryngologist, i need the facial plastic surgeon." which is what i do, and i get called in. and i will coordinate with the other doctors. i said, "okay, who's going to the operating room first? can we do this at the same time? what can be staged, what needs to be done?" and it works as a team, and it can work extremely well. developing a productive relationship with your primary care physician

is not automatic. as peter clarke terms it, you may encounter unexpected "potholes." peter clarke: well, the first pothole is being able to communicate effectively with a physician. we were in the examining room with an older woman who was coming to her physician for a routine post-adjuvant chemotherapy session. and she came in in a bright green jumpsuit, and she was vivacious and energetic, and her physician asked what she'd been doing. she said well, you know, i've just come from my jazzercise class. and he exploded in indignation that she, in her physical condition would do jazzercise. well, she fled the examination in tears and, as we learned, never again visited the physician. and, a number of months later, finally succumbed to her condition. that's such a pointless and needless... expression of deference to a physician,

rather than standing your ground and saying, "this is why i'm doing this. this is keeping me alive emotionally. this is providing the energy that i need to continue my life." barbara korsch: everett koop has made statements that 90% of the errors in medical diagnosis are due to poor communication. there's a famous study by a fellow researcher in the area, dr. beckman, who did one study of a hundred visits in an internist's office and found on the average that the doctor interrupted the patient after 18 seconds. the patient's story... often adds things that, if you were just getting the task and the measurements, you wouldn't get-- which are crucial even from a biologic point-of-view, if not from a psychologic-- for the patient. if they haven't had a chance to tell the story, they feel they haven't been understood. most doctors are looking for a patient who they can get in and get out in a short period of time,

and give good quality care to. what doctors will respond positively to, however, is the patient who takes initiative, the patient who says, "you know, since our last visit, i've got some questions on my mind i'd like to go over with you." for example, i have a patient with cerebral palsy whose speech is altered, and so it's very hard to understand her speech, and to also feel that in a 20-minute office visit that we communicate everything we need to in such a short amount of time. so we make good use of our in-office time by maximizing other avenues. she will type at home on a computer and bring in a list of things she needs done, a list of medications she needs refilled, a list of questions or new symptoms she might have, and we'll take care of some of those things by e-mail or by typing from her and answers from me. in some cases, it's also helpful to have a friend or relative along.

and that so dramatically improves the visit. it's an extra pair of eyes and ears, it's someone to remind you to ask a question, or to ask one him- or herself. and it says to the doctor, here's a patient who's really determined to get well. the entire medical team needs to be aware of just how complex this communication factor can be. david goldstein: when the daughter comes and says, "i don't think my mom can handle the information. why don't you tell me?" you don't just routinely say, "no. it's the patient's business, not yours." or we don't routinely say, "sure, that sounds like a good idea," because we're going to get burnt. what we need to do is to be able to talk to the patient, turn around and said, "you know, i just had a very loving conversation with your daughter. she seems to care for you a great deal, so much that she wants to be able to screen the information. how do you feel about that?" and let them talk.

gary feinberg: my goal in dealing with the patient who is mature-- specifically one who comes in here on her own, who's living on her own, like this patient was-- is that she understands that she's going to get better, and she also understands that she is not having a problem. her major fear, as you heard at the time-- "do i need surgery?" so i want to educate them. i don't want to say, "honey, you're going to be fine. take my medicine and go." but yet she's the type of patient, i think if i said that, she would have been fine. i think there are some patients who do well with a doctor who makes an assessment fully in their own mind, makes a decision, informs the patient what's best for them, gives them the prescription, and the visit is over. there are other patients where that just isn't going to work because they won't take the medication if they haven't been told more what's going on, the reasons why, the possible side effects and risks of medication, and their other choices, and the possible outcomes of those choices. another pothole is there are some systematic errors

that we make in judging one alternative versus another, one treatment versus another, for example. one product versus another. and so we need to be alert to ways that we can circumvent these errors in judgment, ways, for example, that we can interpret the kinds of words that physicians use to indicate probabilities, likelihood of side effects, likelihood of remission. well, what does... "most patients get better" mean? is this three out of four? is this nine out of ten? is this six out of ten? your blood pressure medication, you do take the morning of the surgery with a sip of water. okay? the other risk associated with the surgery is the risk you may need another procedure... gary feinberg: in a preoperative evaluation, it's like preparing the plane before you take off. and i want the patient to know what we're going to do in surgery. he's read a booklet about the surgery,

and i want to go over it with him step by step, as to what we're going to do. and i want a patient to understand that i'm doing surgery in a very careful, meticulous fashion, and that i recognize what the risks are, and that he is aware what the risks are. that's where i think it's really important that physicians and patients have to work together. physicians need to be the experts. they need to have the information, they need to be able to provide it, but they also have to provide it-- that information-- back to the patient in a way that helps them to be able to make a choice that's right for them. and another pothole which we've spent a good deal of time working on is how do you make critical care choices? the issue of "who decides" has always been an issue, and it comes up in at least two or three different ways. one is simply in the physician/patient relationship, and we've seen a huge evolution in this field in the last 30 years. the studies done both of patients and of physicians

in the '50s and '60s made clear that it was almost universal among physicians that they thought that the difficult decisions should be made by physicians, and patients couldn't understand them, they couldn't cope with them. gary feinberg: i think it's inappropriate to tell a patient and tap them on the near shoulder, "everything's going to be fine. i'm going to take care of you," because not all the time will everything be fine. and i think you're patronizing them in that way. ...that there has to be a deep participation by both parties in that process. and it's not one dominating. it's not giving everything to the patient and saying it's only for the patient to decide, and the doctor's a mechanic just to carry out some technical details. no. it's very much of a partnership when it works right. when i have a patient say, "doctor, do whatever you want," that's a throwback, that they don't want to take responsibility for what has happened to them as well as take responsibility, i feel, for their care.

they're putting everything in my hands, and it has to be a dual effort. and quite often, it has to be an effort not only with the patient and me, but also has to be an effort with the family. for some people, the decision is to seek alternative therapeutic approaches. dr. ka kit hui heads a program that combines both eastern and western approaches to medicine. it is very important for us to look at chinese medicine not so much in terms of the archaic language of yin and yang and five elements and... herbs and acupuncture. but it's more important to look at chinese medicine as using the systems approach to look at health care as applied to... an individual. i'm veryested to solve problems, d i thk that dfe aling traditions i'm veryested have their unique focus, strength andknesse and when i talk about integration,

i'm talking about a very flexible paradigm. like, we have trauma, no one would, you know, have second thoughts about western medicine. when we are dealing with a lot of dysfunctional states like a lot of people with chronic illnesses that do not have... attained the state of crisis, then the chinese concept of looking at the whole, the chinese concept of approaching the patient by restoring the balance, by restoring the flow, by improving the ability of the body to maintain a balance and flow would come into place. so this whole idea actually is very useful in terms of integration, that while western medicine can deal with a crisis, keep us alive... d bring chinese medicine concepts and approach in to try to restore a balance.

not just herbal medicine. you can do some tai chi, chi gong, through the massage... through acupuncture, because these are different approaches to help restore the flow and the balance and increase the ability of the body to adapt. for some people, balance can be best achieved by opting for no medical intervention at all. hyunah lee poa: you can look at medicine as a very complex and technological thing that everybody has a right to. or you can look at it that we're all on earth for a certain amount of time, we're destined to have a certain type of health, and how do we go through life with a certain poise and enjoyment until we die? so i think everyone tries to figure out what's going to be the most comfortable balance. i remember the wife of a colleague in houston who had recurrence of breast cancer, a very aggressive form of breast cancer,

who decided not to undergo chemotherapy-- a renewed bout of chemotherapy and radiation treatment-- because she concluded that the side effects and the pain of all of that, with the very low likelihood that it was going to be effective, was just something she did not want to go through. there are patients that i see who don't want any intervention, any medication, any surgery in their lifetime, and i greatly respect that philosophy. i'll be there to support them, to inform them of what's going on so that they can handle their health in the way they choose. another concern is who controls access to health care in any given situation? the classic example is, of course, the artificial kidney, the dialysis process, where there were initially very few of the machines,

and they had to establish the so-called "god committee" made up of people-- worthies from the community-- who had to decide which of a number of patients would get access. and the pressure there got so bad that the answer of the congress eventually was to say we want to make this a medicare entitlement. so we will pay for this treatment, and, of course, then the treatment blossomed. and today, of course, we face the issue of access and the "who decides" question with attempts to control the costs of health care. and the medical care system has really changed a lot in terms of not just offering that which you think you should get. and it sometimes becomes a new battleground that patients are faced with and having to fight for. hyunah lee poa: it's a difficult thing to even think about money when it comes to taking care of a patient. it's their one and only life, and if there's something that needs to be done to preserve or enhance their quality of life

and quantity of life, i want to do that as far as i'm able. gary feinberg: when you ask the doctor to be a managed care provider and at the same time be a physician, and they have to wear both hats, they lose their edge in being a physician. when i feel a patient needs an mri, and i have to think, well, what is the less expensive test? is there something least expensive to do? i'm not thinking then as a physician as to what's best for my patient, and i have strong difficulties with that. in any marketplace that deals with life and death issues, there is an expectation of quality. but how does a profession as immense as the medical community maintain quality control? david goldstein: we rat on our own. most organizations, most hospitals have quality committees. i'm in charge of the quality committee for our ambulatory practice of about 450 or so physicians, and so we try to create systems approaches,

and we also take incident reports and evaluate them for their merit. if somebody who had this particular operation and should have been out of the hospital in three days is still in the hospital five days later or eight days later, that's analyzed. and if there's justification for it, fine. if it's because the doctor... didn't do something or put them on the wrong medication, and then they have a medication reaction, they're told they're not doing well. and if they're not doing well often enough, and badly enough-- and sometimes that's one incident-- they're out of here. we're not dealing with widgets. we're not dealing with selling a filing cabinet or a xerox machine. we're dealing with people's lives. but we're coming into an information age where there's so much information on the internet that it's increasingly possible to learn more about hospitals, and what the alternatives are for a patient going in for a certain procedure. you can find out

whether a hospital's done well on its recent joint commission accreditation survey or done poorly. for me, i really feel that the key to a good hospital is the quality and the number of people who are there attending to me. david goldstein: what i tell my relatives who don't live in this city, and they say, "you know, this doctor told me to do this, what should i do?" i tell them to go to an academic medical center. now, are they as user-friendly as, you know, the slick private clinics out there? no, they're often not, but the science and the knowledge is there. do they invariably have the art that a good, homey, family-medicine doctor will have? no. no. i don't take any pride in the fact that we haven't been able to get everybody to have a good bedside manner, but the science is there. and sometimes it's worthwhile to just gird your belt

and accept a big academic medical center so you can get the best opinion you can. of course, i want to see diplomas on the wall, and, you know, i want to see that they've been published and all that sort of thing. but, to me, far more important is the doctor's ability to connect with me as a human being. the relationship between doctor and patient-- that human connection-- plays a role in the healing process that sometimes goes beyond degrees and scientific knowledge. marc shiffman: there are 11 residents down here at various levels of instruction, training, experience, and i try and convey to them how much of a privilege it is to practice medicine, how difficult it is to practice primary care medicine, and how much more difficult it is to practice that in a population that is indigent and a bit more needy

and less able to take care of themselves and participate in their own health care. so it becomes a daunting task. so i try to make sure that they always... are level-headed in their approach, compassionate in what they do, empathize with the patients' circumstances, and... so formulate their diagnoses and their treatments with all this in mind. there's nothing, i feel, better in the world to have, the training and the privilege and the right to take care of another human being, and i love it. could i get burnt out? potentially. i don't think i will, though. but i've seen some physicians who have. i've seen some physicians who have become bored. to me, i have a prtice here in my office, i have a surgical practice, i have a trauma practice, i have a cosmetic practice, i have pediatrics... i had the tient who you saw

who was 89, who was in the service. this is wonderful, and i think i'll always enjoy it. i really do. all right, be good. - thank you. - you're welcome. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit online at:

narrator: the life of a premature baby-- a pound and a few ounces at birth-- is saved. but the physical conditions that result from her early arrival will consume millions of dollars in medical costs before she is 18. a family of four sustains critical injuries in an automobile accident as they travel cross-country to start a new job. before the last family member leaves the hospital, they are forced into bankruptcy. and that new job? long gone. isolated cases? not at all. very real examples of what this nation faces

in the struggle to provide health care for people who need it, but can't pay for it. the figures are staggering. 44 million people in the united states are not covered by health insurance of any kind. at the same time, costs for even simple tests and procedures are rising at an alarming rate.

over half of the unprotected are children. i do see a lot working people-- young, healthy, working people-- with no health-care insurance. i've had patients switching jobs and who didn't consider strongly what their health-care coverage was going to be in between jobs, and they can run into health situations. that can be devastating, because the cost of medications, the cost of visits or laboratory tests can be huge. i actually had a patient with no insurance come for a routine check-up, and some lab studies that i didn't think were very unusual add up to about $900. and i just thought... that's really ridiculous. outpatient prescription drug costs have gone up 15% to 20% in the past year, partially because of many new drugs coming on the market, partially because drug companies are advertising directly to consumers...

to increase demand for their products, and partially just because the breakthroughs in drug technology have been so profound that i think doctors and hospitals are all excited about what drugs can do. for cancer patients, some of the new drugs of taxol and herceptin for breast cancer have been profoundly effective in dealing with certain patients with certain types of breast cancer. and yet, for us, for everyone, every cycle that a patient may go through on these drugs, it can cost us $20,000 to $25,000, and we may put a patient through four or five, five cycles. wherever you look, you'll find disparities in the availability of health care. david goldstein: i mean, i work at a place where there's a beautiful, brand-new university hospital on one side of the street, and there's an older, statuesque county hospital

on the other side of the street. on one side of the street, if we need an icu bed, we call in a nurse, and we have a flexible bed. it becomes, from a regular bed or an unused bed, into an icu bed. i walk across the street to the county hospital, and there are 10 people waiting in line to get into an icu bed. if a person has chronic renal failure, the federal government will jump in and pay for that. however, a child with liver disease doesn't get covered in the same way, and that patient may struggle to find funding, whether it's through the medicaid program or some other structure to get paid. so what we find is that because there's funding inequities, we find that some hospitals are trying to increase the number of patients of the type that pay well and decrease those who don't pay. of the trillion dollars invested in health care each year, only about 55% is spent on acute care-- doctors and hospitals.

william schwartz: and the other is for non-acute care-- things such as dentistry... nursing home care, and over-the-counter drugs. now, that's scarcely mentioned as a factor contributing to the rapid rise in health-care costs. nursing homes, you hear mentioned, but this 45%, which includes all kinds of things-- research and psychologists and... opticians and... podiatrists and-- there's a huge list, it fills three pages-- that group of activities amounting to nearly 45% of health care is rising. why have the costs risen so precipitously? for one thing, the medical scene itself has changed. william schwartz: as a young physician just starting, i thought we were doing wonderful things. in retrospect, it's so clear to me now

how limited we were. and none of us could have imagined the changes that have taken place between then and now. let me give you one example: in the old days, what would happen is, if you had undiagnosed abdominal pain, we did what was called an exploratory laparotomy, which means that you open the patient's abdomen from the top of his abdomen, from his chest, all the way to the pelvis. and then the surgeon-- and i don't mean this critically, really-- but they had to poke around through the whole abdomen, feeling each organ to see if you could find something that was abnormal. most of the time it wasn't worth doing, because the risk/pain factor overrode the likelihood of finding anything, particularly if the likelihood... was remote-- relatively remote. well, think of what's happened. we'll go ahead and do an mri or a ct because it's non-invasive,

and the patient is really not put through anything terribly unpleasant-- a little claustrophobic perhaps. so the upshot is there's a number of examinations with the new technology... has increased enormously... despite the fact that the procedure is much less expensive than the one that we've managed to eliminate. in the 1950s, health expenditures comprised 5% or less of gross domestic expenditures in the united states. today, the cost of health care carves out a much larger percentage. technological advances are a factor in this increase. gerard anderson: we spend a lot more on technology than other countries. when you go to the hospital, on a per-day basis, we will spend about $1,200 a day. most othe other countries will spend about $300 or $400 a day. so, three to four times as much, and that's because we have a lot more technology

available to us in the hospital. and that's just fine, except the question is, how much of that is absolutely necessary? how much of it results in a better outcome? alex capron: if general motors is thinking of adding a new technology, putting a robot on an assembly line where they used to have a person, they're going to say, "can we make a chevrolet more cheaply using this new technology?" what we've done in health care is apply technologies, not to make another chevrolet, but to make a cadillac. so we take conditions that were previously untreatable, and we now can treat them. well, that's a good, but what we've done is sort of increased the overall level of expectation of what health care can provide. or we take a treatment that was developed for a very limited use and make it more widely available. so we have arthroscopic surgery that was intended to correct very bad medical problems for people, and now it might be used

so that the 60-year-old who has a little tennis elbow can continue to beat his grandson at tennis, rather than just saying well, maybe, at some point, not every attempt to rebuild a human being ought to be part of what we expect in society. it is not only the expectations of society, but the fact that most medical expenditures are paid by health insurance that blinds us to the actual costs of medical care. patients may not even know the total amount of a bill, unless they've exceeded their insurance limits. just in 1960, i was reading that 50% of the payments for health care came from people's pockets themselves. and now it's down to about 15%, so health insurance has covered more and more of it, medicare, medicaid. i think we're at the point where we expect health care to be paid for by somebody else. without insurance,

most people would not be able to meet the staggering bills that come with a really major illness. blue cross, blue shield, and private insurance had been around from about 1935 to about 1965, but the big change was the introduction of the federal programs for medicare and medicaid. now... the dilemma is this: the initial insurance programs like blue cross and blue shield wrote a check for whatever care the hospital and the doctor provided for the next year, and there wasn't much complaint about that... again, because there wasn't that much we could do. and while the premium was rising, we were still spending only 5%, 6%, 7% of gross domestic product-- of our resources-- on this kind of care. now we're up to... about 15%, and... that has created great concern because there are competing needs.

people paying premiums began to complain that it was too costly. business was being affected, they claimed, by virtue of too much of the money-- their revenues-- going to pay health insurance premiums, which meant that they couldn't give their employees as much of a raise as they otherwise might. by 1984, it was enough of an issue that the concept of managed care began to take hold. managed care, in concept, meaning, "let's get rid of all the unnecessary, frivolous care that we're providing." in 1970, and even early 1980, doctors ruled. doctors made all of decisions. insurance companies were totally passive. what we started to have was studies done by jack wennburg at dartmouth and others, which showed large variations in medical practice, that you were much more likely to have a cataract surgery

in one part of the country than another, or in one just small town compared to another small town. we couldn't understand the variation. it wasn't due to differences in ages or genders or even health status. nothing seemed to be correlating with it other than medical practice factor, how the doctor decided to provide care. now, at the beginning, in the '80s, it was very easy to contain costs with managed care and without anybody complaining because there was so much wasteful activity going on-- too many x-rays, too many laboratory tests, all sorts of things-- so that a thoughtful physician, working with a managed care organization could slow the rate of rising costs by getting rid of this unnecessary care... and this was very appealing. gee, we've got a magic answer. there's a lot of services that really have marginal value.

and so you'd hope that managed care could identify those and really weed out those services that have very little value to the american public. the problem is we don't know exactly which of those services have limited value and which one don't. we know that we do too many mri scans, we know we do too many ct scans, and we know we use other technology much more than other countries, and we know that it has very little impact. but for that person, that one individual who says my knee really hurts, and the doctor says a ct scan might show something, or an mri might show something, that person wants it. but here was the nasty little secret: eventually you run out of efficiency gains. eventually you run out of the... changes you can effect in order to cut costs. we can't cut out waste and inefficiency? we just cut it out. and yet the cost of health care continues to go up.

but in an imaginative scientific community, liberally supported by national institutes of health grants, by billions of dollars of research support, there is an open-ended capacity for medical advances which are going to be very costly for the foreseeable future. hi, russ. so-called efficiency gains began to strike at the very heart of the doctor-patient relationship. william schwartz: doctors, in general, i feel, do believe that they're not able to do all the things that they should do, and now the economic incentive for a managed-care doctor is very small in terms of doing more. in fact, he can be punished or penalized or dropped from the plan if he does too much in the eyes of the managed care program. so making doctors see patients for five minutes is really not helping. it's hurting. it's disaffecting to the care.

if it's... my wife or my child, and i know that there is a harmless procedure which could be done, and i'm insured, i want that, even if it's only 1 in 2000. but can my wish be gratified? i'm not paying for it. society as a whole is paying for it. but i say i'm insured. and this is the dilemma, and it's the one that's going to have to be faced across a wide range of medical advances over the next 5, 10, or 15 years, particularly with the emergence of molecular medicine. and that's where we're at now, where we give our physicians in the united states much less latitude than the physicians in england or the physicians in canada would have. and now what we're seeing is that it's not really controlling costs the way we thought it would. and we're seeing that it's not getting more people insured. and we're seeing that we've got a lot of unhappiness

with the population saying, "i can't go to the doctor when i want to. i can't go to see the specialist, the emergency room, whatever." the answer for some families has been to purchase a point-of-service option. william schwartz: that is, a patient can buy an insurance policy, even with many managed care companies, in which, if they choose, they can go outside the managed care system and pay, let's say, 20% or 30% of the cost for doctor and/or hospital and seek whatever care they want. competing needs, limited dollars. should more people be served a little less well, or should medical care be provided, regardless of cost, to anyone who can afford to pay for it? david goldstein: i think we need to look to ourselves and decide, what are our values? what do we cherish? what do we want? do we want to pay for liver transplants? do we want... pediatric care? can we have both?

there's not a health-care system on the face of the planet that could provide everything that everybody wants. it's in the manner of rationing care that they differ, and whether they ration care in terms of... likelihood of a procedure succeeding or reducing the impact of an illness, or do they ration care on ability to pay? those are the two major poles, and we have veered dangerously into the ability-to-pay camp, and have been there for a long time, even before managed care. and that's a hard thing, because you are saying, to some degree, who will live and who will die. where are we going to put our resources? or what are the priorities of services that we'll pay for? should childhood immunization be more or less important than paying for problems of a child with advanced cancer

or a very expensive child who's struggling in the neonatal intensive care unit? no one wants to talk about that, but ultimately, if we have limited resources, we have to make some decisions about who gets what. we may not make the right decisions, but at least we'll have had the discussion, and i think that will then open us up to moving ahead in a different way. now everyone's defending their territory in terms of they want their money and their piece. we need to say, if we could get everyone in the boat, do we want to keep building a bigger and more elaborate boat? or do we want to say, those dollars... we would value more if they were spent on education, or the environment or national defense, or... whatever. we have to go through those choices. we can't have everything we want. that's an issue that will be an issue for employees and employers. how much of your take-home pay-- what could be your take-home pay-- do you want going into medical premiums? and if you really want to put a cap on it, recognize that that will mean some things--

which are of benefit, but more marginal benefit than other things-- won't be available. the question is can we make such decisions and stick to them? alex capron: i think we could get to the point where we face those decisions and make the kinds of decisions which seem justified enough that they can stand up to those difficult cases. they won't collapse the first time a child with an appealing face doesn't get some treatment that would be lovely if he could get, because it's ranked low enough in our value system, given what benefit the child would get, that it's not going to be made available, and not have that front-page story tear at our heart strings and say, sure, give the child the treatment, because once we do that, we've, in effect, made the system unfair to other people. are there approaches or decision-making models in other countries that might prove useful? i don't think anywhere in the world are people making these decisions in what might be called a rational...

logical way. britain has been making decisions on rationing for 30 or 40 years. they've been spending only about half as much as we do on health care. and one way that they do it is to set the criteria for intervention at a much higher level than we do in the united states. for example: if someone is really uncomfortable with coronary disease and has some pain on walking and has pain occasionally at other times and it's affecting the quality of their life, that's all it takes for us to go ahead with an angioplasty or bypass graft, assuming that medical treatment isn't working. the british don't go ahead at that point. they will continue medical treatment. they will not operate on that patient until that patient is essentially totally disabled and in severe pain. and they say that is the proper medical practice. that's the standard. probing still further, dr. schwartz and his co-investigator henry aaron

found that no one over 60 in great britain was diagnosed with kidney failure. no one over 60 was on dialysis. david goldstei so they went and looked at the charts, and they find this 68-year-old man with all the values that would suggest that they had renal failure, and they said, "look, look, what about this man? what about him, why didn't he get on dialysis?" "oh, that man? he was too crumbly." "too crumbly? what does that mean?" "well, he's just too crumbly." so they went and they spoke to the patients. they said, "why aren't these patients demanding they be on dialysis?" the patients didn't demand it. they didn't have the expectation. in the united states, if bill gates has something, we all want it. wait, it doesn't matter that this man has $80 billion. we all want it. if you take an international perspective, what most countries have done is done supply controls. they've controlled the number of doctors. they've controlled the number of hospital beds.

they've controlled the diffusion of new technology. and they've been quite successful with supply controls in controlling the rates of increase in health-care spending, and keeping the levels of health-care spending down to about 8% or 9% of the gross domestic product. united states, we've taken a different approach, and we've done more demand-side controls. we've tried to make the consumer pay more, make the consumer environment more competitive, and those have been less successful in controlling health-care costs. but such controls are in themselves a form of rationing. mark laret: i don't think people have really wanted to know about the fact that there is rationing going on in the health-care system. i mean, many centers that provide liver transplants, for example, can only afford to do them if they're receiving enough compensation from whoever's paying the bills to keep the program going. these are very expensive programs. the nurses, the doctors, the blood products,

the drugs, et cetera, are very expensive. and yet... most liver transplant centers do some allocation of liver availability according-- considering criteria-- according to a patient's ability to pay. that's not broadly discussed, but the fact that a patient can or can't pay the bill is a big consideration in who gets certain services. another factor in the equation is the efficiency of the health-care delivery system itself. many hospitals today are operating at only 65% or 70% capacity. that's much too low. you want to have some capacity in case you do have a flu epidemic or a train accident or something like that. you don't want to be 100% occupied, but you really do want to be 80%, 85% occupied as a hospital. we've got an awful lot of excess capacity in the hospital industry. a lot of hospitals really do need to close.

it is particularly expensive for hospitals with trauma centers to maintain the necessary state of readiness. mark laret: a man was brought in who'd been hit in a hit-and-run accident. he was a pedestrian and he was brought in, and there must've been 15 to 16 people all ready to go, standing there when the paramedics came up and brought this man in. the blood products, the drugs, the efforts everybody focused on trying to revive this gentleman-- he didn't survive. he didn't make it. i don't know what his insurance was or wasn't, but we spent a large amount of money to provide care to that individual. that's what we do. we believe in doing that. but if we expect hospitals to have trauma centers, to be there in case it's me or my mother or my child or anyone's family member, we've got to make sure that they have the resources

to have those 15 or 16 people there, the drugs, the supplies, the equipment to keep those centers running. in the last few years, many solution strategies have been placed on the table. the fact that no definitive course of action has been adopted reflects the complexity of the issues involved. we need to make real the conclusions that a presidential commission reached some years ago, that every american has... access-- equitable access-- to the health-care system. that's a social obligation. we don't have to meet that social obligation through a government program. for many of us, we're able to get access to the health-care system through insurance which comes through the workplace. increasingly, in the last few years, as employers have recognized the high cost of health care, they've cut back on the generosity of those programs,

or changed employment circumstances so more people are working at jobs that either don't offer anyone health care or don't offer it to the part-time employees and the lowest-paid employees. gerard anderson: and most people that are uninsured are employed. almost 3/4 of them are employed, and almost half of them are employed full-time. is the responsibility of the employer to offer health insurance coverage? in most countries, it is. that's known as the social insurance system. the question is, why aren't employers in the united states required? and we need to address that issue. trying to move to a system in which... we use some of the engine of competition to try to address the price issue, and then use guarantees that no employer will have an advantage not to supply health care because those who don't will be taxed to put into a fund which would be part of the payment...

making insurance available for everyone. now, out of that process, whether we end up with a single-payer system the way the canadians have, or still multiple payers and multiple players, but everybody having, in effect, a card which says i get in the front door of health care, remains to be seen. i think ultimately we'll see all of health coverage covered under a federal plan. we'll fund it through some form of progressive income tax, a model very similar to what's offered in germany, where people opt into sickness funds and pay a percentage of their income to be covered in one of those funds. ultimately, that's where we need to get to. until we decide that we're just not willing to take that risk and have the government use the surplus or raise taxes, we're not going to make a lot of progress.

just where these discussions will end is still in question. what is not in question is the importance of a healthy population to the health of the nation. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at:

call: annenberg media ♪ by: idoña flora! idoña flora! ¿quién es? narrador: en este episodio, raquel y arturo siguen con la búsqueda de angel, el hijo de rosario y fernando. también, raquel y arturo pasan más tiempo juntos.