We know we have to provide medical care. The question is how can we do it in such a way? So as to reduce the costs one of the questions that is rarely if ever asked is whether or not we have to provide more Medical Care and I really want to dress myself more specifically to that question the weather question rather than just making the assumption that we have to do it and then proceeded to say to how can we take her with a system to save a little money. So I'm really interested in that more base or the fundamental question of the way in which I became interest in this question. I think it is is is useful for me to talk about when I worked in her study or Walt McClure is now working. We were working on HMO issues, which I'm sure was mentioned to you. When we also worked on quality of care issues the time I left the organisation. We were focusing quite heavily on quality of care issues were trying to figure out ways to ensure the quality of medical care to me. There was a nagging question as we deliberated on the quality question. That was good Medical Care make any difference in the first place. We're not too many people seem to be interested in finding out whether Medical Care was effective.Leaving aside the question of whether or not it can be provided in a relatively and equality which was to assure quality affected this question because it seems to me all them Italy what you're talkin about his cost-effectiveness. We had only $70 to put into the system. We want to get as much help either system as we can. So we are indeed talking about a cost-effective this question the effectiveness question and found out that very few other people were interested in it. I was very little research on the doll. What there was was rather skimpy and it wasn't tied together very well so that led me into a pursuit of what research there wasn't one thinking there was about what difference Medical Care made that is to say. What is the relationship between Medical Care and he'll know that may sound like a rather simplistic question, but it's rarely ask we make the Assumption far too often at Medical Care is almost synonymous with health and we don't ask what other things may have to do with help.Well one thing led to another and I ended up writing a book on a subject which is a bit of a polemic you can tell from the title, which is the end of medicine that it's not exactly a benign contribution to literature on Medical Care the Buckle be published later on this fall by by Wiley, but that's really my interest. But because your interest of course is the cost question. I want to stay as close to that question as I can and although it may seem that I'm taking a to Broad cut at the subject as we go along when I get to the concluding part of my remarks. I do have some concrete recommendations, which I think are implemented bill at the state level to deal with a kind of thesis that I'd like to examine with you today as I've already said it's most of the discussion on the cost of Medical Care question focuses on well, we've got to do it and we know that we need to provide more and more medical care, but we're really interested in saving money. So how do we go back to saving money will not shorting anybody and I'm really more interested in the weather question. Do we really need to provide more?Do we have too much already? What are the limits of the capacity of medicine to produce Health? That's really rude to me the important question and I think it's an important policy question. My face is kind of laid out in in 4 steps to it, which I can explore with you this morning and some depth the other two, which we really won't have time to go into very much the first of all first the first is that as a public all of us we tend to equate Medical Care with health. I don't mean that if you press somebody and if you'd if you press a thoughtful position that they won't say well sure as McClure just had a few minutes ago nutrition housing things of that sort don't have something to do with hell. But basically we tend to have an initial response when we think about a health problem and say we'll sure if we got a problem we can go to the doctor for a little take care of what we tend to equate the two far too often. The second piece is that if you look at the research that has been done and more and more is being done all the time. You'll find that Medical Care is considerably less effective than is generally assume by that I mean it is has considerably less to do with health status status of the health in the population and the status of the health of individuals. That is generally assumed by people. Third that well and related to the second is really kind of corollary. And that is that it is if it is, in fact true that Medical Care is much less effective than generally assumed is it true that we may have either reached or will be reaching soon. The limits of modern medicine is it is now constituted to produce help. There are many many other way that we can go about as a society through policy initiatives Etc to produce. Hell if it's Health we care about rather than providing more Medical Care and the fourth thesis is that an examination of medical care today in some sort of a historical context will show us the medical care system we have is a highly relative one. It is not the only way to go about the business of producing. Hell it is only one way and is very limited in that respect. Now the fourth Point takes a lot of time unfortunately go to in historical examination of where we are in terms of medical care. Second and third Point second point being a medical care is far less effective than generally assumed the third one third point being that there are many other ways to examine the question of Health any other ways to approach the question of Health. I'd like to do it in this way. First of August 2nd about quality. I know that's not your focus, but I just want to make a couple of points when you look at the literature on the quality of care now leaving aside the effectiveness question. We're not asking for simply saying that it's their how well is it provided if you look at that literature you will find that Medical Care is indeed very uneven and in many instances is rather pour a couple of instances. I've never been three recent studies which suggests something of this sort. The first of the first of those is that one out of 18 patients was hospitalized contraxen infection while hospitalized. Second study indicates that something on the order approaching 25% of all Hospital admissions are due to injuries the people have as a result of having received Medical Care. 3rd conservative estimate from the Secretary of Hud Elliott's Commission on malpractice that about 7% of all patient encounters and this is conservative estimate all patient encounters with the medical care system result in damage, which could be the basis of a successful malpractice lawsuit. Then I want to look again at the special effect of the square lay by looking at Effectiveness just by itself and I'm not talking about calling Effectiveness. What is the relationship between Medical Care and health? How effective is Medical Care in producing help if you examine it all by itself, and unfortunately, there isn't much literature as I suggested before. I wish there was a whole lot more but what you do fine when you do it, when you do examine the one that we don't know very much about the correlations of relationships between Medical Care processes and the outcomes of Medical Care honey, repeat that very important point. Medicine doesn't want a lot of things which I would describe is the processes of Medical Care the things that I've done to you as a patient when you receive Medical Care a lots of things happen, but there is very little hard evidence of a correlation between many of those processes and the outcome to the patient if we're interested in what the benefit of medical care to the patient. We don't have very much research which shows definitive correlations between Medical Care and the outcome of the patient from time to time by the way. I'll refer to a piece of research for a book or something in the course of my testimony and afterwards I will go over with Larry Fredrick's from the exact citations for this material. So the committee containment you wish as a book by Elle Cochran called Effectiveness and efficiency was written about the National Health Service in Great Britain squarely on this question the validity or shall we say the value of the pap smear one of the most hallowed sorts of Medical Care process see He suggests. There are good sound definitive correlations between what is done? Now the third one is but I want to make under the broad rubric of Effectiveness is relative Effectiveness. If there isn't much research on the effectiveness of Medical Care alone, just the medical care variable. There's very much less on the grill at impact of Medical Care Visa the other variable for example, what be nice to know and cost-effectiveness or cost-benefit turn whether an extra dollar spent on improving the quality of air or on education would produce more help than spending that same Dollar on medical care. There are a few studies which try to compare the relative Effectiveness in terms of Hell of Medical Care another variable the studies that have been done and there are very few suggest that there are more effective way that we might be spending dollars that we would not like to allocate to help. I want to stress that dollars allocated hell not dollars allocated medical care if we're interested in health, then where can we best spend the Dollar Tree quick studies at I'll just refer to as Ben estate relative. Effectiveness in terms of health of such things as the use of seatbelts versus certain cancer therapies. The suggestion is dollar-for-dollar you're better off of seat belts not null cancer therapy, but the second one is that there was a study done in a relatively remote Village in the Eastern hemisphere. The researchers were interested in finding out which of the following three variables with most likely to influence the health of the population in this was as I say a remote area where we didn't have high technical high technology medicine literacy food improved nutrition or the introduction to Medical Care in and they compare the impact of those variables in three different Villages and uniformly found the literacy was the most single important variable in producing help. Thursday I want to refer to isn't a study of air quality Visa Vie Medical Care and it said it's a kind of a typical cost effective study where their dollars to run all over the place when you can't figure out what they're controlling for and so on but nevertheless most people who know this that you think it's really quite carefully done the suggestion. There is a we could improve health health status for the population far more by improving air quality than we could buy an additional increment and Medical Care. That assessment of the effectiveness question leads to the third point that I mentioned before when I mentioned the four species that I had that third one was there are other variables are other factors, which do influence Health. What are some of them? First of all, let me say that I spent a lot of time in the last 2 years looking at this question because after examining a question of the limits of Medical Care, naturally, I was forced to examine the question of what one what then does prune juice help. If you don't think Medical Care has much to do with it, then what does tell us there isn't very much research on this either but there are some there is some research and some thinking would suggest some leads to us. Let me just to take off a few and I'll refer to certain works at the same time. The impact of noise just noise on hell is a book by Jerome Barranquilla. Tyranny of noise. The impact of light on help is a book by John hot hot called health and life among other things. Is interested in Full Spectrum Lighting versus artificial lighting. What is the relationship versus artificial light and versus Windows with block out part of the spectrum research does far as quite convincing full spectrum light does seem to be more healthy than light which is not full spectrum. This is a very good example in some way. I has been almost wholly unsuccessful in obtaining any sort of support for his research because when he says he wants to examine the relationship between light and he'll the response on the part of the federal agencies is that doesn't have anything to do with medical care. And he doesn't get his research support because the federal agency set up to provide research support our interest in those sorts of questions. Now a third variable is fairly obvious one one reference. I would give you here's the work of Rodger Williams of the Clinton Foundation University of Texas 1/4 air quality, and I mentioned that before when I refer to the study comparing the impact of air quality on help with Medical Care in a V and I'm just getting an electrician's now is the impact on stress at the University of Montreal has done the most interesting work. He's a physician on the impact of stress and I'll give him the staff these citations along with many others about other variables. My point is only that yes, there are many other things which influence health status other than Medical Care unfortunately don't know enough about them. But in the absence unfortunate event information, we proceed to had to spend $0.99 out of our health Dollar Eye Medical Care and the only $0.01 roughly anything else, even though the studies that have in there certainly suggest that we might be more cost-effective if we Different ways to the question that's more squarely before you and that is how you reduce medical care costs. Despite everything I've said whether it's convincing to you or not is almost immaterial but just assume for the moment that has a population. We were relatively convinced that there are other ways to approach the question and help others Medical Care despite that fact, I recognize that at 3 a.m. In the morning. If you have a child that is sick, you're going to call the doctor. That's what we do and there's nothing nothing really wrong with doing that. But what it suggests is a formidable obstacle to the kind of Reform I'm talking about because we equate Medical Care with help we tend have a panic reaction when we're sick. We don't tend to do other things that may have something to do with health and can we tend to fall back and rely upon the medical care system. There's a work by Rashi find who examines this question you tend to agree that there many of the things that influence Health perception of help is such that they need medical care and they want it more and more and more. The other point I think is in this is a selling point for us a difficult one, press one with which many people might disagree but I tend to feel that in many ways. If we continue to spend increasing amounts of money on medical care to quote follow the name Peter Sedgwick wrote an article on illness and Society the future will belong to illness that is to say if we spend money on a disease oriented system. We will find disease. Now that's sociological and subtle idle means it to spend a lot of time on it. But all I want to do is Drop That in because it's an important concept to work with but in some way or another the medical care system tends to create disease because it is itself cuz he's already in it. I spend a lot of time in the book. I wrote in a lot of time and my work on this subject thinking about how it was that we got Medical Care at the medical care system got to the place that it's in how did that happen? We can't possibly deal with it in the capsule wait a few minutes, but let me simply characterize the kind of medicine we have in a couple of sentences to distinguish it from other kinds of approaches to help. We have a highly specific highly technical highly impersonal system for dealing with health. We talked about the body as a machine in need of repair. It has a disease. It must be repaired and we make profound kinds of technical specific interventions to cure that individual as opposed to a more holistic approach to Medicine parenthetically, I think is I look at the larger question overtime wraps in 20 or 30 years. We will see a shift back to a more holistic approach to health and we now have and the kind of thing I'm talking about is related to that. I suppose the best example of a disease orientation of medicine is the hospital itself. If we think about what happens to you in the hospital and then contrast that with what we know at a visceral level almost an intuitive level what has to do with health. I think we can see how does he's already in the system is What happened to the hospital is that the assumption is largely made that we are machines in need of repair and that we are not particularly idiosyncratic. We have may have personality differences indeed. But basically when it comes to fixing us, it doesn't make any difference we can all be set into the same sort of the bed in the same sort of a room and treated the same way. I go to bed at a certain hour to get up at a certain hour have your meals at exactly the same time surgery is scheduled at the surgeons convenience. Not the patience biorhythm. Some people are not in very good shape at 6 a.m. In the morning. That's it. They're just not even some of us feel better at some times of the day than others, but the hospital tends to immobilize us for purposes of fixing us same slots. I'll be on that think of some of the things we know it a visceral intuitive level have to do with hell. Good are sunlight Recreation good food salad nutrition. I think of what happens during the hospital take them in the inverse order. We all know at the end of go to level with the food is like in the hospital leaving aside is tastelessness nutritionally. It's not very good. You get butter you get sugar you get whole milk. You got a lot of things we know I'm not a silly productive if he'll try to take the question of air or says that say sunlight and are together. How do you get outside of a hospital? If your patient when I was last hospitalized and ironically I probably shouldn't mention that I was addressing a group was to address a group in Tucson Arizona a few months ago on this very subject the effect of this medical care and it was a prestigious Conference of the clinical scholars in a clinical position to have graduated from from high-ranking medical school to have been bent have been interned giving scholarships to pursue pursue phds and scientific Fields. So they have an MD and PhD are about 400 them assembled. The program is financed by the Robert Wood Johnson Foundation, which is the real sugar daddy. Am I in this area right now and I was there to speak to them on Thursday evening at 7:30 at exactly 7:30 that Thursday evening and I underwent surgery. My appendix removed because I was about to be cry the evils of surgery among other things. But at the time that I was in the hospital in Tucson, I realize that I was a brand new hospital that was no way for me to get outside. I couldn't get outside when I was up and walking. I finally found a way but I had to go through the main entrance of the hospital where to get outside. I was just take the exercise questions briefly. I did not question of doing something vigorous and I think you're crazy. I put you in a different order the hospital the hospital is a profound example of a disease orientation to medicine. Now, let me another example and then shifted the concrete kinds of proposals, which I think are workable implementable in the near future at the state level is drawn from Great Britain. And the example is a National Health Service. When the National Health Service was Great Britain some years ago. The Assumption was that if we make Medical Care uniformly available to everyone. In Great Britain that are medical care costs will eventually come down because it will produce so much help the people demand will lessen, but in fact will make everybody healthy by making Medical Care available to them and then we'll have less demand and therefore will have less cost. Of course. That's not happen. The National Health Service is virtually bankrupt have to put money in all the time. Exactly. The reverse has happened in the reason is that Medical Care does not help it cures that the individual level in some cases about a month as a population at large does not produce a healthy or population. So the National Health Service is virtually bro, we're not so far from that in this country. Now, I know that much of what I said, perhaps doesn't seem to be particularly applicable at the state level. Alright fine. It's abstract. It's interesting and provocative and so on and maybe I would tend to agree with you that what you're saying makes sense to me. What do I do? If I mean, I've got a problem. I'm a legislator. I'm a public representative on a commission whatever it may be and I've got to come up with something concrete is implementable not saying all these are implementable, but there are 11 quick ideas. I'm going to put out the phrase each with one preliminary statement. If there is a single most important variable in producing Health based on the research and thinking which has been done it is that very old thing called individual responsibility. It is assumption on the part of the individual for his or her own health. That doesn't mean you can take care of yourself. You got a broken bone. It's useful to have somebody who was able to set it. What I am saying is the Assumption of responsibility by the individual for their help rather than panicking sang. I've Got a sickness cure me I'm going to just lay here and let you do it. I'm not going to participate I don't want to do with it. You got to assume the responsible and other is research support for that a seven-year longitudinal study done in Alameda County, California by Lester UCLA and his colleagues indicates after looking at all. The things that influence Health in that population the single most important factor in producing Elvis individual responsibility now, given the things I've said There are 10 or 11 kinds of quick ideas that I just like to lay out and you can ask me about time of them. If you wish to the first is and I I got here a little bit late to determine whether or not they did and that is that one of the ways you do deal with the man is to fix the pool of resources. You're going to work with in this country. We tend to make the Assumption going back to the guns and butter kind of argument that we can in fact do anything. We pleased that we can have as much medical care. If you want to at least keep spending and spending and spending I mean Medical Care already now consumes about 8% of GNP and most people assume it'll consume 10 to 11% another 10 to 15 years or perhaps even less you something we can do it. I'm saying is one approach fix the pool at the state level. You only have so much money to spend States can be later. The federal government gets so much pressure in so many places to spend money. We don't have that much money to put apps and that's it flat out. Once you fix the size of the resource pool. It's a way of of damping demand. Second is that this is a tactical kind of suggestion rather than something that's very good. We just don't have that much money for medical care. The federal government's got all the money for medical care. We're more interested in spending our money not on financing medical care because that's being done. We're much more interested at the state level and looking at other things that will influence. He'll let the federal government through a national health insurance program, which will soon be past take care of financing medical care licensing in the things that we do but with the money we're going to spend we're going to spend on variables other than medical care which influence help for going to find out what they are going to start to put money into them going to start a support 3rd. Whatever's money the state puts in. I would say say the hospital construction of the construction of any Healthcare facilities. I would think you could read a matching program where you stay in effect for every dollar were going to put in the medical care if we're going to do it at all. We're going to have another dollar put into something else simple kind of matching program where you going to say something else over every dollar we put there were going for fifty cents hear another dollar there. Most hospitals in my experience have some space available that is otherwise being used for I don't know what kinds of meetings but it's usually on the basement and it's there. It's available. It's not being used for medical care. I would argue that requirement to be attached to any kind of Hospital financial support Weatherby Federal supporters dates for the both at those hospitals make available space for what I would call community health education programs, which should be Community controlled that to me. I think critically important possibility at the state level make that space available. Let it be community control the people get together provide films film script book seminar symposia. Provide information opportunity for information exchange and so on would take place that's in the hospital. That's the best place for it. But there is the space and there's the handle to get it for the moment free continuing education for Physicians continues. But what is generally meant by continuing education is to teach the position to become more technically proficient. When in the kind of argument I'm making is that we don't need a silent need more technical proficiency. We need to examine questions other than technical Medical Care and their impact on health consequently since Physicians are in our culture of the people who are concerned with health on a professional level. Why not make continuing education programs broader than just technical proficiency. Why not require by legislation and regulation that they include course is focused on diet and nutrition for example, the impact of air quality impact of Housing and so on positions are very able intelligent people that pick up at information very quickly. Did you Galvanize a few of them? And I start to think yes, there are things other than Medical Care is like a reformed alcoholic almost nobody come then she will become very effective in pursuing and pushing other variable or the or the program the impact of the variables on health V. I think at the state level is possible to do something with a nice a drug abuse. Now, I'm not talking about drug abuse and conventional criminal justice terms. I'm talking about drug abuse within the medical care system of a highly over and over medicated culture the average adult in the United States and Great Britain consume 225. Aspirin a year does Nestle that many but when you given it some people don't consume any that's an awful lot of aspirin and I'm not even talking about The Bachelorette some feta means Explorer impeded from sometimes you legal suppliers to to the public at the state level. I think it might be possible start to get a handle on how that happens 6th. I would suggest that we create a system of Technology assessment to assess the impact and cost-effectiveness terms of the introduction of new technology in Medical Care Now new technology comes along with me being expensive and maybe it just gets it just happens. It's introduced into the system will never be able to provide. Prosthetic knuckle joint prosthetic knee joints and so on if that's true, how do we decide who gets a new doesn't we weren't we raised the technology assessment questions afterwards. Not before 7. And this goes back to my discussion of the hospital that disease orientation the hospital hospital could certainly be built differently. They certainly could provide facilities along the lines that I suggested. They don't now and there might be some influence can be brought to bear upon Hospital construction at the state level in learning how to brush your teeth better my whole recollection of what happened in health education in public schools here in Minnesota was that I remember that it had something to do with brushing my teeth in that with you. There are an awful lot more things we know about hell that we could teach people about their bodies and how they interact with their environment are monitor that the signals and their own bodies as to whether they sick or not not to panic when you get sick, but to relax or certain things we know that think they could be very effectively through schools. And I also think of it as I suggested in the hospital bases that I suggested. Nice, I would think it would be of interest to the state to start to find out what kinds of met so-called Medical Care Health Facilities exist at the state level which are conventional hospitals are conventional medical clinics example, I know about in st-charles call the family tree, for example, there are places around that are providing specialized sorts of health programs. Will there be for venereal disease or whatever it might be free clinics of one sort or another. I'm not saying a Splinter Cell support them. But at the state level you can certainly find out what's out there in a survey base. What are the other kind of alternative systems for providing help that are actually out there in the state right now and he's a very controversial and I'll I'll say some very quickly seems to me it's important to perhaps the definition of what a provider Medical Care is examine. The provider has to be a physician or other people who have certain skills and competencies that we might deal with differently in terms of how they provide health related services. I think only of the Midwife example if you examine what happens in Europe for the use of Midwife systems versus what happens here, you'll find out any least in part why so many people in this country are increasingly interested in natural child delivery. The Midwife on the Midwife system is very simple shut it off here because we don't find a midwife is a provider 11 think about the definition of what I medical care benefit is we think now about a medical care of being a benefit being something of his vision customarily dies or something that you get in the hospital. We don't necessarily think about the things for example, if we find out if I think we will the next two years that biofeedback something I can't really go into now is highly effective tool for people to start to learn something about their own bodies and regulate certain heretofore considered involuntary processes. Then we'll if isn't even a physician using a biofeedback machine in his practice be considered to be providing a medical benefit International health insurance program. It could be that the state could develop supplementary programs at a very low cost. Well, those are Quickly stated there 11 points that I wanted to get across cuz I didn't want to give you something. I thought was workable at the state level after having given you I'm afraid of rather abstract assessment of where we are in terms of medical care and help.