Disease, Diagnoses, and Dollars is about the costs of health care and their impact on health. The U.S. health care system is the largest sector in the biggest economy, and the US spends significantly more per capita on health care than any other country, yet it ranks last among comparison nations on the major health indicators. Within the U.S., there is evidence that regions that spend more do not have better outcomes, and some evidence suggests that quality of care is lower in the regions that spend more, not less, on health care.
Robert Kaplan takes the controversial position that mass markets have been created for services that may offer little or no benefit to patients. Many of these markets are for preventive medicine, making healthy people a market for expensive pharmaceutical products and tests. These include cancer screening tests and medications to control blood pressure, cholesterol, and glucose. Kaplan forcefully argues that the overuse of medications and tests runs up the costs of health care. As more employers drop health insurance for their employees when costs accelerate, the expanded use of ineffective preventive medicine may have the unintended consequence of increasing the number of uninsured patients, potentially damaging the health of others in the community.
The concluding chapters of Disease, Diagnoses, and Dollars offer suggestions for policy makers and for patients. Methods for systematically evaluating the cost-effectiveness of new guidelines are discussed. The final chapter provides practical suggestions to enable patients to share in decisions about treatments or tests that can have uncertain benefits.
As health care costs soar there is increasing interest in examining what society and, particularly, patients receive in return for these expenditures. Optimizing Health brings together the best thinking from both sides of the Atlantic to explore these issues. It employs disciplinary perspectives from economics, ethics, philosophy, psychology, clinical practice, and epidemiology to explore various ways that value for patients have and can be determined. It concludes with a discussion of changes required in practice, research, and health care systems to maximize the outcomes received from the provision of medical care services from the patient's perspective.
The first section of the book provides theoretical perspectives from economics and systems thinking that help us to focus on how one might determine the value of medical care for patients. The next section considers the ethical and philosophical dilemmas that face developed countries in distributing medical care. How is justice served and evidence-based medicine employed to increase the value of medical care for patients?
The section on psychology deals with measuring outcomes from the patient's perspective and involving patients in medical decision making. Measuring quality of life and gaining valid quality of life information when patients cannot respond for themselves are important topics covered by these chapters. Other chapters consider ways that patients can become more involved in medical decision making with the expectation that this will increase the value of medical care for patients.
A major section of the book about clinical practice discusses problems that can reduce the value to patients of medical care. These include overdiagnosis, aggressive treatments that do not result in better patient outcomes, findings that earlier diagnosis does not always result in better outcomes, and the extent of medical error in treatment.
The final sections deal with cost-effectiveness analyses and applications of clinical epidemiology. The chapters include a number of original investigations and applications of new methodologies. All-in-all, the volume is must reading for practitioners, policy makers, and researchers who want to find in one place the state-of-the-art thinking and future directions of valuing medical care from the patient's perspective.
Wasserman Professor Emeritus of the Departments of Health Services and Sociology at the University of California School of Public Health in Los Angeles