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November 1, 2000

Deficiencies in US Medical Care—Reply

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(17):2184-2185. doi:10.1001/jama.284.17.2184

In Reply: The points made by Dr Collins are well taken. My concern is that, in the current political climate, any appointed commission would fail to question the underlying reasons for our health system being the way it is.

Dr Ishida's observations are consistent with my suspicions. I have been to Japan and encouraged officials there to take a more introspective look at their health care delivery. It may be that the resistance of the Japanese people to undergo invasive interventions sets them apart from their US counterparts, who have been taught to believe that more intervention is better.

With regard to Dr Long's comments, although I have not found any published studies of the relative frequency of lawsuits for errors of omission and errors of commission, my look at malpractice claims data suggests that the latter may be more frequent. Perhaps if physicians recognized this, they would do less rather than more. A good analysis of this phenomenon is sorely needed.

Dr Pecora asks about costs of health care. Previous studies have shown that administrative costs alone in the United States constitute 24% of health care costs—far greater, for example, than in the Canadian health care system (11%).1 Profits and other nonpatient costs would further add to the percentage of costs that are unrelated to patient care.

In response to Dr White, studies have shown that board certification (as distinguished from board eligibility) has little if any relationship to higher-quality practice; it is the length of postgraduate education and the organizational arrangements of practice that are related to higher-quality practice.2 The problems that countries face with health care are largely with the system of delivery, not with the individual practitioners.

With regard to obesity, although it plays a role at the individual level, it clearly does not account for the poor health of the population. It plays no role in infant mortality. The "health disadvantage" of the US population is greater in infancy and childhood than it is later in life, which is inconsistent with Dr White's proposition that obesity accounts for poorer health in the population.

Dr Reich seems to argue that treating the sick and preventing death requires higher costs and incurs higher risk of adverse effects. In every country, physicians have the same aspirations as his, and sicker patients command more resources; the United States is not unique in this. The question is: why is the US unique in spending so much more with little to show for it in better health status? The fact is that we do not know either the magnitude of benefit or harm done by higher rates of intervention. Other countries are instituting systems to assess the magnitude of adverse effects. Japan, for example, is in the process of mandating postmarketing surveillance.3 The aim of treating the sick and preventing death need not imply increasing use of technologically innovative interventions that are not only costly but relatively inefficient, if not ineffective. Physicians in the United States ought to be in the forefront of efforts to critically examine the benefits and harms resulting from what they do.

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