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Flatlined: Resuscitating American Medicine

Copyright Date: 2009
Published by: Rutgers University Press
Pages: 304
  • Cite this Item
  • Book Info
    Book Description:

    Flatlined lifts the veil of secrecy on twenty-first century health care and delves into the realities of good people caught in a bad medical system. Dr. Guy L. Clifton, a practitioner as well as a policy advocate, reveals first-hand accounts of needless tragedy, such as the young man who died after a car wreck for lack of a bed in a qualified hospital and the surgeon who was dejected by the scarcity of resources needed to enable him to perform heart surgery on an uninsured man.

    Arguing that a lack of coordinated care and quality medical practice benchmarks result in high levels of redundancy and ineffectiveness, Clifton proposes that the key to reducing health care costs, improving quality, and financially protecting the uninsured, is to reduce wastefulness, and offers a solution for achieving success.

    Flatlined sounds the warning call: By 2018 Medicare and Medicaid will consume about one-third of the federal budget. American businesses now pay three times as much of their payroll for health care as global competitors, expected to worsen as health care grows at twice the rate of the U.S. economy. Based on his years of experience in policy and medicine, Clifton offers an attainable solution through the development of an American Medical Quality System.

    eISBN: 978-0-8135-4626-1
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. List of Figures and Tables
    (pp. ix-x)
    (pp. xi-xvi)
    (pp. xvii-xx)
  6. PART ONE Why the Uninsured Should Be Covered

    • 1 Not Business As Usual
      (pp. 3-9)

      One hot Saturday afternoon in the summer of 1999 I was on neurosurgery call at Memorial Hermann Hospital in Houston, Texas, one of the largest trauma centers in the United States. Houston is the fourth-largest city in the country, and its metropolitan area is home to 5 million people. The page operator connected me with an emergency room doctor in the little town of Lake Jackson, fifty miles south of Houston, and we began a routine conversation for a busy on-call weekend.

      “Dr. Clifton, I have a forty-year-old woman who has a brain hemorrhage. The car she was driving struck...

    • 2 Unreliable Emergency Services
      (pp. 10-15)

      In the late 1970s, I was a resident physician training in a public hospital. My colleagues and I had become furious at groups of neurosurgeons in two Texas towns who often referred to us patients with problems that they said were too complicated to manage in their hospitals. Hours later, we would go down to the emergency room to receive some poor soul who was often medically unstable and had been transferred at his peril only because he lacked health insurance and could not pay.

      These abuses became so outrageous and widespread that the media took notice and alerted the...

    • 3 An Eroding Infrastructure
      (pp. 16-24)

      The value of treating emergency patients within the Golden Hour has been drilled into me since the day I began my surgical residency in 1975. The term refers to surgeons’ brief window of opportunity for saving trauma patients, and the concept has been the linchpin of what is the best emergency services system in the world, matched only by Germany’s. Yet the Golden Hour is not only metaphor but also an outside limit: the sooner bleeding is surgically stopped and blood replaced, the greater the likelihood the patient will be saved.

      This insight came slowly, and its implications have only...

    • 4 Fifteen Years Lost
      (pp. 25-34)

      Hospitals are primarily financed by private and public health insurance. Their revenues come from care of patients with (1) private insurance, (2) Medicare, and (3) Medicaid and its affiliated programs. Hospitals earn income from investment of their profits and from services such as cafeterias, parking, and medical services that they contract out, but patient care is the core business. Private hospitals finance the care of the uninsured and low-paying publicly insured patients (Medicaid) by shifting their losses to increased prices for privately insured patients. Many hospitals also receive funds from a federal program called the Disproportionate Share Hospital (DSH) program,...

    • 5 Handed Health Careʹs Leftovers
      (pp. 35-46)

      One Sunday afternoon in 2004, I sat with other members of a panel on a dais before a large audience in a Houston church auditorium, listening as a group of people without health insurance shared their experiences. I heard two stories that illustrate the predicament of the uninsured. The first was told by an attractive woman, about forty years old and a single working mother. Speaking in Spanish, she told her tale with composure but with controlled anger. Her older son was serving on the front lines in Iraq. Her eleven-year-old son had recently lost his eligibility for the State...

  7. PART TWO Why Health Care Is So Expensive

    • 6 Where We Are Headed
      (pp. 49-50)

      Medicare provides health insurance to seniors, regardless of income. The program’s cost has grown so much over the years that it will soon either burden taxpayers or place allocations such as defense spending, foreign investment, and education at risk. As happy as Medicare beneficiaries are with their Medicare, it cannot and will not continue on its current trajectory of spending. Congress has tried to control the program’s cost growth by cutting fee-for-service payments to hospitals and nursing homes, but this method will not work for much longer. Cuts in hospital payments were partly to blame for the emergency room failure...

    • 7 30 Percent Waste—or 50?
      (pp. 57-66)

      Hospitals, doctors, drugs, and outpatient tests and procedures account for most of health care spending. Hospital spending predominates at approximately 31 percent of all health care expenditures, followed by payments for physician and clinical services (21 percent) and prescription drugs (10 percent).¹ Despite the overuse of emergency rooms, their cost is only a small percentage of health care spending; but the cost of patients admitted to the hospital from emergency rooms is embedded in hospital spending, and it is substantial. Outpatient tests and procedures are estimated to account for 9.8 percent of health care costs and are the fastest growing...

    • 8 Poor-Quality Primary Care
      (pp. 67-70)

      Although the story that follows is fiction, it is an accurate depiction of the results of a medical system in which patients are managed by a number of doctors, all of whom may be good at what they do. From the patient’s point of view, however, the results are not so good. The problem is a system one.

      At age seventy Ed Fitzsimmons suffered from heart disease, high blood pressure, and high cholesterol complicated by diabetes. One evening his wife heard him say, “Elaine, maybe we better go to the ER—my stomach doesn’t feel right.” The triage nurse in...

    • 9 Dangerous Hospitals
      (pp. 77-93)

      Poor management of medical resources is not only expensive but dangerous. In 1999 the Institute of Medicine publishedTo Err Is Human, a landmark book based on a study of medical errors.¹ The institute concluded that medical errors in hospitals kill between 44,000 and 98,000 people per year. According to the authors, this number of deaths is equivalent to the death toll from the crash of one jumbo jet per day, making medical error in the United States the fifth-leading cause of death (if we apply the larger estimate of victims). They also concluded that the primary problem was not...

    • 10 Violation of Dignity: The End of Life
      (pp. 94-102)

      Not only are patients’ rights at the end of life often violated, but money is also wasted. Indeed, at least a quarter of Medicare costs are spent on the last year of life.¹ This in itself is not necessarily a bad thing, but how the money is spent is another matter.

      The manner of Ed Fitzsimmons’s death, the patient we met in Chapter 8, illustrates the point. Shortly after Ed suffered his heart attack in the Episcopal’s ER waiting room, his breathing became so rapid that a tube was put into his airway and a ventilator attached, and he was...

    • 11 Unnecessary Surgery
      (pp. 103-119)

      In my clinic I repeatedly saw unfortunate patients whose stories precisely matched this fictional one. Jennifer Allen’s story helps explain why there is such a thing as unnecessary surgery.

      Back trouble ran in Jennifer’s family, and she first began having midline low back pain when she was thirty. After this episode physical therapy had helped; but because of two young children and the boring routine of regular exercise, she had not kept up with her therapy. Her back pain grew steadily worse with frequent flare-ups, and her family doctor ordered an MRI. When the report came back showing bulging, degenerated...

    • 12 Perverse Payment Incentives
      (pp. 120-138)

      Medicare and private insurance pay doctors for each service they provide, no matter the circumstances or the results. Both have historically controlled their costs by setting the price they will pay doctors per service and then cutting prices across the board when the number of services becomes excessive (regardless of whether the services are required by the patient’s condition or are just medical waste). This fee-for-service payment system has created perverse incentives in medicine. It could also be called fee-for-process.

      Everyone is familiar with how cars are priced. But what if cars were priced like health care services? Imagine that...

    • 13 Three Pathways to Hospital Profitability
      (pp. 139-156)

      This story illustrates one of the undesirable effects of rational business decisions that hospital administrators must make in order to maintain solvent hospitals. The problem is not bad people but good people working in bad systems that reward the wrong decisions.

      Jack Devoe had been the chief operating officer of a financial services company in southern California for fifteen years and was vigorous at age forty-five. After spending years in a wholly profit-driven industry, he had cashed out and now welcomed the prospect of starting anew and serving the common good. In 1998 he eagerly accepted the top financial job...

    • 14 Pharmaceuticals: Remarkable Innovation, Shameless Puffery
      (pp. 157-169)

      Americans’ average life span has increased by twenty-five years since 1900. The Centers for Disease Control concludes that twenty of those years are the result of simple measures such as sanitation, clean food and water, decent housing, and vaccination. Five years and three months of the increase are attributed to medical care, and pharmaceuticals contribute to nearly half of those five years. When doctors were asked to name the thirty most important medical therapies, they identified four classes of pharmaceuticals among the top-ten breakthroughs in medicine.¹ In their judgment, prescription drugs have played a large role in medical progress.


    • 15 Private Health Insurance: No Added Value
      (pp. 170-176)

      What has the health insurance industry contributed to U.S. health care? It enjoys a bountiful profit simply by passing along costs. In 2006 the American public, reeling from high health care costs and anxious about the nation’s 47 million uninsured people, learned that UnitedHealth CEO Dr. William McGuire had been forced to resign after allegations of stock option backdating, although he had earned more than 500 million dollars in total pay from 1992 to 2005 and held more than 1 billion dollars in stock options. The fact that he had led the company to record size and profits did not...

  8. PART THREE Reforming American Health Care

    • 16 Three Options for Covering the Uninsured
      (pp. 179-200)

      To achieve a high-performance health care system, the United States must do two things: (1) cover the uninsured and (2) reform the medical industry. The two are interrelated but separate policy undertakings. First, let’s consider the expansion of insurance coverage.

      The problem of the uninsured will not solve itself. Nonetheless, many in Washington circles, including members of Congress, believe that the states will take responsibility for covering their uninsured where the federal government has not. This delusion is fueled by a gridlock in federal policymaking and has been encouraged by Massachusetts’s recently enacted plan to cover nearly all its uninsured....

    • 17 No Coverage Expansion without Cost Control
      (pp. 201-211)

      The cost of providing health insurance for the uninsured is not trivial, but it amounts to less federal money than is spent on any other single federal program or industry subsidy. In addition to what hospitals, doctors, the public, and the uninsured themselves already spend on the uninsured, the United States could cover them for an estimated 73 to 100 billion dollars (in 2004 funds).¹ Consider that the nation spent 2 trillion dollars on health care in 2004; less than 4 percent of that figure would be sufficient to cover all of the uninsured. The cost is less than the...

    • 18 A Workable Plan for Reform
      (pp. 212-223)

      If I believed that the unaided market forces of 247 million people (the U.S. population minus those enrolled in Medicare) would drive down the cost of health care and extract waste, I would not have been impelled to write this book. But the medical industry does not operate like a conventional market. Lowering cost and improving quality are not as simple as unleashing market forces. As I have shown in previous chapters, waste and poor quality thrive because the health care system is highly insulated against external pressure.

      Hospitals by their nature enjoy a privileged position in the community; they...

    • 19 Establishing Standards
      (pp. 224-231)

      It is ridiculous that people today are undergoing medical procedures of unknown or marginal value. Even worse, such procedures—many of them probably completely unnecessary—accounted for 4 to 8 percent of hospital spending in 2005, according to my calculations.

      When researchers have doubts about the effectiveness of a common procedure in a given group of patients, a randomized clinical trial (in which half the participants get standard treatment, half the new treatment) is one way to find the answer. Such studies proved that back fusion was effective in the treatment of patients with slippage of vertebrae and that catheter...

    • 20 Prioritizing Primary Care
      (pp. 232-242)

      The Sumner Clinic is not much to look at from the outside. It is located in a strip shopping center on a busy street in the small town of Gallatin, Tennessee, about thirty miles northeast of Nashville. The clinic is managed by a general internist, Dr. Sid King. When I entered for my meeting with King, I was greeted by a trim, smartly dressed elderly woman sitting in a rocking chair near the front door of an expansive room. She was one among several patients who volunteer as greeters at the clinic.

      Inside, the Sumner Clinic did not resemble any...

    • 21 Reducing Spending on Hospitals and Specialists
      (pp. 243-260)

      The United States is paying for high-performance hospitals but not getting them. What would a true high-performance hospital look like? I interviewed Dr. Lucian Leape, adjunct professor of health policy at Harvard School of Public Health, who is a pioneer in hospital safety and quality. When I asked how he framed the difference between safety and quality, Leape said that they are always found together. He thinks of quality as involving process measures: for instance, did a patient get antibiotics before surgery? He thinks of safety as the outcome measure of quality: for instance, did the patient have a wound...

    • 22 Positioning of an American Medical Quality System
      (pp. 261-274)

      The concept of a center that evaluates technology is not new. Support for the idea has been steadily building in the insurance industry and among many policy groups in Washington.¹ What is new—and essential—is the concept of an entity that also reforms the medical industry by performing experiments in health care financing and delving into the functions of hospitals and clinics to discover efficient processes and then facilitates the teaching of how to implement these processes. What is also new is the concept of an entity that systematically fills in the gaps in knowledge needed to set benchmarks...

  9. NOTES
    (pp. 275-312)
  10. INDEX
    (pp. 313-322)
  11. Back Matter
    (pp. 323-324)