Shannon Brownlee's commentary on the U.S. health care system has certainly made waves - it was out of stock everywhere and needed to be reprinted, just three months after its release. Now, it's back on bookshelves.

Overtreated reveals why more care is not always a good thing and the many forces behind overtreatment - like revenue targets, faulty practices that are considered routine for certain medical communities and malpractice fears. EBA spoke to Brownlee about the state of health care.

Many hospitals and health care systems, essentially have two bosses - the patient and the stockholders. Can you talk a bit about how those two groups drive cost?

Hospitals need to make money, whether they are public hospitals, whether they are for profit, whether they're not for profit. The old nuns who used to run hospitals used to say, "no margin, no mission."

So, they have to make money and they make more money in certain areas ... [like] orthopedics, neurosurgery, sometimes obstetrics and they make a huge amount of money in radiology. The reason they make so much in those departments versus the medicine departments, where you take care of people who have things like pneumonia, is the way they get reimbursed.

They're constantly trying to draw in paying patients in the areas that will produce the greatest revenue for them. The problem is that the areas that will produce the greatest revenue for the hospital are not necessarily going to deliver the care that the patients who are served by that hospital are going to need ... [W]hat patients need and what patients get are often two different things. And what patients get is driven by the number of resources in a particular area or a particular market.

Why are you a critic of consumer-driven health and are there any beneficial takeaways from the CDH movement?

Consumer-driven plans may be saving payers a little bit of money around the edges. The reason I don't like them is because they're really all about cost-shifting ... The other fault of consumer driven health care is the idea that consumers are really going to know what they need and what they don't need ... Consumers don't cut down on the care they don't need. They cut down on all kinds of care indiscriminately, and I don't think any amount of information on the Web is going to solve that problem. [T]he people who are the least savvy about their own care and their own health are also the least educated ... I think the information needs to be given to patients at the point of service.

What we really need is something some people are calling "shared decision-making." The idea being, you really have to communicate with patients about the risks and benefits of any particular procedure. This is particularly an issue in surgical procedures, and it's particularly an issue in the amount of tests. Physicians need ways to really communicate with patients. And physicians are really bad at conveying what the risks and benefits are, and making sure that patients really and truly understand them.

You're critical of pay for service; are you a proponent of pay for performance?

I am a proponent of it in theory, but the way that it is being implemented right now is not very effective and it's not getting at the core issues. All pay-for-performance measures now are aimed at under-treatment: Did you get your beta blocker when you left the hospital after your heart attack? So, they're all aimed at making sure people get the care they need.

Do you think insurance companies could step up and encourage doctors to communicate these things better?

I think they absolutely could, but they are going to have to pay for it. One of the things they have to do, and this is absolutely critical, is that they can't pay primary care physicians so badly. Medicare is at fault. Private payers are at fault. They are killing primary care.

If we want to have all those expensive chronically ill people managed properly, we can't do it by reimbursing primary care doctors so badly that they have to see 30 to 40 patients a day. You can't manage chronically ill people that way. You can't do it in a 15-minute visit when your real contact with the patient is all of five to seven minutes.

Are payments the best way to address the shortage of primary care physicians?

It's one way. Another thing that has to happen is implementing shared decision-making and there are tools out there that are patient decision aids. Physicians need to be encouraged to use these tools, and patients need to be encouraged to use these tools.

Now, in order to use them, I think physicians need to be protected from malpractice, and that's kind of a complicated story, but there are a number of things that have to change to make patient decision aids more available to patients ... I think another way to address the shortage of primary care physicians is that we need to start forgiving debt for medical school. And I think we'll need to start measuring the performance of physicians in hospitals.

The problem with measuring performance is that ... we have to find really, really good ways to measure physician's performance and take into account the severity of the cases they carry, the ability to communicate with their patients and a variety of things. It's going to take a lot to figure out how we do that.

A better way to do that is to measure the performance of larger populations, and I think that at some point in the near future, we are going to have to start thinking about paying physicians and hospitals as a group and measuring the health and outcomes of the entire population the individual hospital serves, along with all the physicians that feed into that hospital. That's a really radical idea.