IT IS an enduring assumption of modern life that as medical science advances and healthcare improves, most of us can expect to lead longer and healthier lives. More diagnostic tests, more powerful body and brain scanners, more high-tech treatments, more drugs: surely this is a recipe for longevity. Provided politicians and health insurers pump enough money into our hospitals and clinics, the benefits are bound to flow.
However, things are not that simple. My colleagues and I have found that, at least for older and sicker Americans, more healthcare does not necessarily mean more health. Our studies consistently show that patients in areas where healthcare spending is high do not have longer life expectancy. At best, it remains the same as in low-spending regions.
In short, for chronically ill older Americans, a large number of hospital and doctor visits and tests appears to reflect overuse and inefficiency, rather than useful medical care. For example, we found that a 65-year-old in Miami, where in 1996 the health insurer Medicare spent an average of $8414 per person, could not expect to live any longer than a 65-year-old in Minneapolis, where average health spending was $3341 per person.
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What is going on here? The problem is that the extra money does not go towards the sort of evidence-based care that is known to be effective, such as immunisation against influenza or the use of lifesaving drugs after a heart attack. This kind of treatment is underused in virtually every part of the US, and regions that spend more on healthcare do no better at providing it than regions that spend less. Nor does the money go towards increasing rates of discretionary surgery: things such as hip replacement operations to treat arthritis and surgery to relieve low back pain or the symptoms of benign prostate disease.
Instead, the extra spending covers more visits to the doctor and to hospital, more referrals to specialists, more diagnostic tests and more scans. What this means is that the use of such services increases the more they are available. They are essentially 鈥渟upply sensitive鈥�: more hospital beds mean more hospitalisation; more specialists mean more referrals.
These findings should alarm medical researchers and those who fund them. Everywhere people are demanding more medical technologies and services, and scientists are responding. What if their efforts are not, ultimately, producing the results they or their funders or governments expect?
A peculiar feature of supply-sensitive services is that medical science plays little or no role in determining how they are used. It is virtually impossible to find in any clinical textbook or medical journal or on the agenda of any scientific meeting even a discussion 鈥� far less any evidence 鈥� about how frequently a patient with a given clinical profile should visit a doctor or be given a diagnostic test, referred to a specialist or admitted to a hospital bed or an intensive-care unit. In this realm of scientific agnosticism, decisions seem to be guided by the cultural belief that more is always better, so the supply of resources drives the frequency of use.
This is particularly striking among the dying. During the last six months of their lives, people living in Minneapolis on average see a physician twice a month, while in Miami they see one twice a week. In Minneapolis, among Medicare patients, 11 per cent of deaths occur in intensive-care units, while in Miami the figure is 25 per cent.
It鈥檚 a problem that Britain should be taking note of. The government has recently proposed a substantial increase in NHS spending. If it is used to ensure that everyone in need receives care that works, the investment will be worthwhile. But simply increasing the number of hospitals, specialists and diagnostic resources will result in more supply-sensitive services, and it is far from clear that this will lead to better health.
In the case of discretionary surgery, Britain faces the same problem as the US: most decisions about hip replacements, back and prostate surgery and the like are made by doctors who have not consulted with patients. Until such consultation becomes routine, the treatment they get will reflect their doctor鈥檚 opinion rather than their own. Adding more surgeons to the workforce will surely increase surgery rates, but it will not necessarily ensure that patients get the treatment that is right for them.
Our findings will appear counterintuitive. But they have considerable political significance both in the US, where Republicans and Democrats are locking horns over how to increase medical care for elderly Americans who receive too little, and in light of the British government鈥檚 pledge to increase spending on healthcare. The question policy makers should now be asking is: when is more better? We need to know the answer before we pledge any more money on the back of misguided assumptions about how to improve people鈥檚 health.