Medical Device Daily Washington Editor

WASHINGTON – If universal healthcare coverage is adopted by the U.S., it probably will come with a price: abandonment of the indiscriminate use of world-class medical technology.

That is the trade-off described during a forum last week on the role of markets in medicine, hosted by theCenter for American Progress (CAP; Washington), billing its assembled panelists as “healthcare experts from across the political spectrum.” The panelists, to a person, advocated adoption of universal coverage and also agreed that Americans will have to reduce their expectations concerning how much med-tech will be available to them in such a system.

Daniel Callahan, PhD, director of international programs at the Hastings Center (Garrison, New York), framed the healthcare issue of the day as balancing “equity on the one hand with personal choice” on the other.

An obvious model for this balance is Europe, with Callahan calling that system not an unmitigated success. “The Europeans are struggling to hang on to universal care,” he said, while the U.S. continues to examine the idea.

But he noted that Europeans enjoy a higher life expectancy than Americans and seem relatively satisfied with their healthcare systems.

In his view universal healthcare systems in Europe are “far superior” to the patchwork system in America, while at the same time acknowledging the need for market mechanisms. The impact of such mechanisms on medical culture, he said, require some compromises, noting parenthetically that healthcare economists are typically more interested in efficiency than ethics.

Citing political elements working against universal coverage, he said these are “most clearly seen in the pages of the Wall Street Journal,” adding, “I always get annoyed with the Wall Street Journal because it uses Canada as a whipping boy.”

Until the 1960s, the U.S. and Canada handled healthcare in much the same way, Callahan said. However, “Canadians are much more communitarian,” he noted, a characterization driving the nationalization of its healthcare, a notion that doesn't fly in the U.S. where citizens “are much more suspicious of government.”

He argued that using Canada's healthcare system as a weathervane for nationalized healthcare in the U.S. is not valid because Canada, like the UK, finances its healthcare by means of taxes rather than using employer/employee contributions to finance care, as in the Netherlands and France.

Universal healthcare requires “carefully introduced market mechanisms,” employed tactically rather than strategically to assemble a comprehensive healthcare system, he said.

However, an improved delivery system for Americans promises to come with a price tag, one likely to be very unpopular.

“Somewhere between 40% and 50% of healthcare costs can be traced to new technology or intensive use of existing technology,” Callahan said, arguing that the American appetite for the latest and the greatest is unsustainable. “The most startling paradox is that healthcare [technology] has improved,” with continually rising costs and “no end in sight.”

Callahan insisted that Americans would have to be willing to “set some limits on progress” if they obtain universal coverage and that corralling spiraling costs is something that “Europeans need as much as we do.”

Asked about the huge disparity in the rates of implantation of cardioverter defibrillators between the U.S. and the UK – which some observers put at a ratio of 10:1 – he told Medical Device Daily that medical societies could play a role in reining in expectations and, by implication, costs. “The traditional medical ethic can combine with the profit motive” to feed extraordinary measures that may have little real impact on public health.

Willis Goldbeck, consulting director of global public health policy and government affairs at European pharmaceutical maker UCB (Brussels, Belgium), offered a dim view of prospects for limiting the utilization of medical technology, describing the odds as “somewhat less than zero.”

Calling U.S. healthcare delivery a “very sloppy system,” he termed it “a medical repair model” rather than a method for reducing illness and disease.

Goldbeck said it is “amazing that we don't have the government as a collective purchaser” for taxpayer-financed healthcare programs.

He insisted that “markets should be looked at not as a system, but as a set of tools.” And he slammed competition in the medical marketplace as invoking winners and losers, hardly conducive to optimal outcomes for healthcare as a whole.

Goldbeck said that “the numbers, the heterogeneity” of the U.S. population make it “impossible to compare” healthcare in the U.S. with that in other nations, calling such attempts “dangerous.”

“Choice is the bogus issue of all times,” he said, adding that without meaningful information on outcomes and costs, the consumer of healthcare services cannot possibly make an informed decision on where to spend healthcare dollars.

Goldbeck called it flawed logic to expect pharmaceutical companies to solve all the world's healthcare problems. “We don't ask food companies to solve the world's food problems,” he said.

Drugmakers “give away, literally, tens of billions of dollars a year” in drugs to needy U.S. and foreign citizens.

Addressing reports that other nations do not include capital costs – such as the expenses incurred in building hospitals – in their national healthcare tabs, Goldbeck told MDD that “it is my understanding that [capital costs] are accounted for here,” but not in many overseas economies.

Jeanne Lambrew, a senior fellow at CAP and an associate professor for health policy at George Washington University (Washington), discussed Callahan's book, titled Medicine and the Market: Equity v. Choice. She faulted it as being too pessimistic about universal healthcare put in place in the U.S., saying, “It might be [here] sooner than you think.”

But Lambrew seconded Callahan's position that Americans are possessed of a “concept of infinity” where medical intervention is concerned. “We really do have this mindset” that infirmity can be evaded indefinitely.

Lambrew told MDD that she sees two reasons to believe that universal coverage is close on the horizon.

“Big business outcry is on the rise,” she said, noting the current distress of the domestic auto industry in financing worker health insurance.

And she noted, as a harbinger, Massachusetts Gov. Mitt Romney's move to impose mandatory universal coverage in his state. “When one can see the political capital [in proposing universal coverage],” she said, “this is no longer the third rail.”

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