Overkill
An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?
http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
The conversation should have started to happen years ago.
However, there have been powerful political forces preventing it from happening beyond a superficial level:
- Current users of medical care who mistakenly think that "more is always better".
- Providers who like the added stream of revenue when people get more medical care.
- Politicians who hype up fears about "rationing" and "death panels" whenever the subject is brought up.
Add to this tech companies who would love to get you hooked to their devices 24/7 to monitor your vitals and instill anxiety by warning you every time some number spikes temporarily: call the doctor. yeah.
This is even worse with veterinary care! A recent case: my cat developed bladder stones. The local vet was categorical about getting her into $2,000 surgery. This is the cat who almost died after being spayed - she is the product of serious inbreeding and becomes really ill even after a minor issue. I called my sister, a practicing vet, for advice. Apparently, the local vet should have taken a closer look at the urinalysis and started the cat on a special diet to see if the stones would dissolve on its own. Surely enough, after eating 2 bags of very expensive food ($100), the cat is doing marvelously. And I researched the issue: dietary intervention is the first thing that should be tried in the cases like our cat’s, but it is a long process, and the vets underestimate its effectiveness.
Pretty sure any health related thing* will tell you to call you physician, since they do not want lawsuits alleging that they caused someone to fail to seek needed medical care. Of course, the side effect is extra unneeded medical care.
*Even suggestions to exercise are often accompanied by recommendations to ask your physician first, due to the possibility of medical problems when unfit unhealthy people start exercising too hard for their current level of fitness.
Pretty sure any health related thing* will tell you to call you physician…,"
True, but if that thing is hooked to you 24/7 and beeps every time your BP spikes, that adds way more unneeded stress than a simple warning.
People will do what you pay them to do. The point of Gawande’s article is that the incentives were wrong and now they’re starting to get right. It’s all common sense, but doctors didn’t used to get paid for using common sense.
I’m glad that docs (& others) will be compensated and rewarded for common sense–it might become more common than the myriad of over-testing and too many harmful procedures that reduce quality of life!
Unfortunately the answer to all this is rationalized health care, where there are specific reasons for ordering tests and procedures. Some tests have proven themselves to be worthless, like EKG’s, yet they are still ordered routinely. MRI’s are misused, they order MRIs when it is evident that the person has a sprain, for example. One of the biggest problems is that many doctors offices are now part of ‘regional health networks’ that include hospitals and diagnostic centers, so they have strong incentive, for example, to order MRI’s and other diagnostic tests, since the practice they belong to does the testing. Doctors often own MRI clinics and the like, and feed patients there from their own practice, so there is a strong incentive to over do testing, and it isn’t just CYA against lawsuits.
Then, too, we have the advertising of prescription drugs, many of them quite frankly aimed at the elderly on Medicare or at giving people the idea that the drug is a miracle drug, and what often happens in doctors offices according to studies is that the doctor will recommend a particular treatment, but then the patient will insist on the drug they saw on TV (why they allow advertising on tv and such for prescription drugs, I don’t know), or a patient will insist on a name brand drug when a generic would work just as well, for a lot less cost.
It is one of the reasons our medical system is one of the most costly in the world, but in terms of real term medical outcomes, does not rank up there in results, in terms of quality of life, longevity and other measures. We have state of the art treatments, cutting edge therapies and such, but we also have a lot of medical care that is being delivered inefficiently, being used where it shouldn’t, and otherwise is being driven by something other than the efficient treatment of disease or other health problems. Among other things, our system is weighted towards curing rather than prevention, for example there are high end medical checkups that pinpoint all kinds of things early, but that kind of checkup is not available to most people, the standard physical you get from your local doctor hasn’t changed in decades.
I’m on a forum with a lot of younger mothers. A common question is, “Should I take Snowflake to the ER or call the doctor in the morning?” This isn’t for compound fractures or obviously serious medical conditions, but more along the lines of a cold for a week, sore throat, fever for a day (controlled with tylenol), a rash. They have insurance and simply don’t want to wait. Maybe it’s a lack of common (maternal/paternal) sense, but I can’t imagine visiting the ER for something other than a true emergency.
My insurance allows 1 vision check per year. My ophthalmologist laughs - He doesn’t want to see me more than every 2 years, unless I suddenly lose my sight.
Even some of the newer guidelines on physicals are giving credence to the (mostly) male habit of seeing the doctor only when really sick.
So they are asking MDs to start practicing more the way that nurse practitioners have always practiced - interesting.
One statistic I always found galling was that one study found the patients of hospital affiliated family practice docs spend twice as much per year on healthcare compared to patients of independent docs. Hospital affiliated practices, though, are paid at a much higher rate by insurance compared to independents. The difference is forcing the independents to sell to large organizations.
I have long experience with this issue.
Reform has to start with malpractice changes because hospitals and any hospital-based doctor will be named, sometimes indiscriminately, in cases where an outcome is bad, whether the care has been spectacularly good or bad or somewhere in the vast middle. Doctors and hospitals understand a significant litigation issue becomes: why didn’t you do x? So much of what is done in a hospital is an elongated version of CYA and that ultimately becomes CYA for litigation.
The second level of reform can’t even be approached unless the first is covered because malpractice is a huge stick of an incentive and not only money but people (rationally) fear not being able to get coverage or get it an affordable price.
Let’s say for example that a person dies of cancer. When was this patient seen? When was the first test ordered? When was the follow-up? Who checked this? Who checked that? Each link becomes a way for the attorneys to attack the standard of care even if the simple reality is the person had cancer and died. I can also state without fear of being wrong that it’s pretty easy to find expert witnesses who will say this or that could or should have been done.
The second level of reform has been attempted but not well because it involves the entire method of coding for procedure. That is, any attempt to make sure certain services are bundled is countered by the very natural desire to maximize revenue and that leads to shifting codes to create more revenue and/or doing more tests to generate more billing codes. (There is of course another cost: the more people irradiated unnecessarily the more consequences of radiation, meaning both cancers and false positives that generate more tests and surgeries.) It is this billing by piecemeal that HMO’s, etc. tried to get at with capitation.
My hope is that better data analysis will generate better managing of code billing. We’re barely into the cloud era so there’s hope.
Re: Post #2, one of our cats also recently developed bladder ‘crystals’ but luckily our vet was of the same opinion on treatment as your sister, Bunsen. After a single antibiotic injection and a change to the prescription urinary health food he pretty much recovered within 3 days! Total vet bill of $250 plus the food.
Lergnom, the article is worth reading since he illustrates many instances when the unnecessary care not only costs a lot of money but tends to have a negative impact on the patient. He lists condition after condition for which there are many new treatments but no change at all in death rates.
^^I bet the profit margin on the $2,000 operation was HUGE. My sister says it is pretty much like a spaying operation, so nothing extraordinary. It pays off to be vigilant and get second opinions. My big red flag came up when the vet injected the cat with an antibiotic and then said to bring a sample of her urine for a culture the next day. WTH? What would grow in that $120 culture when the antibiotic already killed the bugs?! Needless to say, I will no longer go to that first vet. Just to warn the cat owners: not all crystals can be dissolved by prescription diets, but some can, and a urinalysis should suggest whether this would be an option.
Back to the topic of human health. 
As an aside…all of his books are amazing.