How to Rein in Medical Costs, RIGHT NOW

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    George Lundberg

    I believe that there are still many ethical and professional American physicians and many intelligent American patients who are capable of, in an alliance of patients and physicians, doing “the right things”. Their combined clout is being underestimated in the current healthcare reform debate.

    Efforts to control American medical costs date from at least 1932. With few exceptions, they have failed. Health care reform, 2009 politics-style, is again in trouble over cost control. It would be such a shame if we once again fail to cover the uninsured because of hang-ups over costs.

    Physician decisions drive the majority of expenditures in the US health care system. American health care costs will never be controlled until most physicians are no longer paid fees for specific services. The lure of economic incentives to provide unnecessary or unproven care, or even that known to be ineffective, drives many physicians to make the lucrative choice. Hospitals and especially academic medical centers are also motivated to profit from many expensive procedures. Alternative payment forms used in integrated multispecialty delivery systems such as those at Geisinger, Mayo, and Kaiser Permanente are far more efficient and effective.

    Fee-for-service incentives are a key reason why at least 30% of the $2.5 trillion expended annually for American health care is unnecessary. Eliminating that waste could save $750 billion annually with no harm to patient outcomes.

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    Currently several House and Senate bills include various proposals to lower costs. But they are tepid at best, in danger of being bought out by special interests at worst.

    So, what can we in the USA do RIGHT NOW to begin to cut health care costs?

    An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big ticket items, saving vast sums while improving quality of care.

    1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.
    2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.
    3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.
    4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.
    5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.
    6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.
    7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.

    Why might many physicians, their patients and their institutions suddenly now change these established behaviors? Patriotism, recognition of new science, stewardship, and the economic survival of the America we love. No legislation is necessary to effect these huge savings. Physicians, patients, and their institutions need only take a good hard look in the mirror and then follow the medical science that most benefits patients and the public health at lowest cost. Academic medical centers should take the lead, rather than continuing to teach new doctors to “take the money and run”.

    Physicians can re-affirm their professionalism and patients their rights, with sound ethical behavior without undue concern for meeting revenue needs. The interests of the patients and the public must again supersede the self interest of the learned professional.

    George D. Lundberg MD, is former Editor in Chief of Medscape, eMedicine, and the Journal of the American Medical Association. He’s now President and Chair of the Board of The Lundberg Institute

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    114 Comments on "How to Rein in Medical Costs, RIGHT NOW"


    Guest
    Aug 11, 2009

    Brief, easy to grasp and emminently sensible.
    Outstanding piece.
    This needs to be in pamphlet form and passed out all over the place.

    Guest
    Greg Pawelski
    Aug 11, 2009

    DITO!

    Guest
    Aug 11, 2009

    Fantastic piece. The local police will make a fortune in overtime doing crowd control dealing with the hoards of hit-men from the AMA, the AHA, ASCO & the other specialty societies, and the device companies outside George’s house. In particular #’s 1,2 5, 6, & 7 are between them responsible for maybe 30-50% of health care spending.

    Guest
    Aug 11, 2009

    This is a tour de force that should be read by every physician and, more importantly, every Senator and Congressional Representative who claims an interest in this issue. This clear and concise piece distills a lifetime of accumulated knowledge and wisdom, and should be applied for what it is, a national treasure at the service of policymakers who might actually care to shape meaningful health care reform.

    Guest
    Doc99
    Aug 11, 2009

    Last time I checked, the American Cancer Society has published guidelines which fly in the face of your recommendations. Following some of your suggestions would put physicians in harms way re: lawyers and some patients in harms way re: cancer. Rather than cause more angst, why not have the NIH commit to a multicenter trial of the cancer screenings you feel unindicated so that American physicians can find guidance?

    Guest
    Aug 11, 2009

    Thank you for a provocative piece.
    As a doctor-in-training I am often overwhelmed by what I see as inappropriate care. You’ve identified priority areas for action. The next question is how to move forward.
    In my experience too few doctors have a clear sense of the data behind much of what we do. Government and educational institutions ought to collaborate to help doctors make sense of it. That process should start much earlier than it currently does and should be more standardized than it currently is. There should also be a definitive place to easily access this research.
    Perhaps the second step is a reinvigorated primary care workforce that understands that has the incentive to practice evidence-based medicine. It’s incredibly easy to offer a patient CABG. It’s much harder to medically manage them.
    Third might be ways to reduce information asymmetry between patients and providers. It certainly won’t be easy, but in this era of health 2.0 the possibility for a more level playing field exists. We need a national conversation on what works and doesn’t, on the risks of medicine, and on end-of-life care. Ultimately the goal is for patients and providers can work together to make decisions that are truly in a patient’s interests.

    Guest
    Betty Rider, FACHE
    Aug 11, 2009

    An excellent piece to read as I sit watching history repeat itself on tv. Organized, well funded protestors with talking points that defy logic, have no basis in fact, and carry the message of special interests. In that context, the salient point for me in Dr. Lunberg’s artilce is: Currently several House and Senate bills include various proposals to lower costs. But they are tepid at best, in danger of being bought out by special interests at worst.

    Guest
    John Brookes
    Aug 11, 2009

    Dr. Lundberg makes some good points about doctors on the take. But his “prepare for death” philosophy strangely leaves out the miracle of preventive medicine and the benefits of health it confers. Lifestyle issues like vitmin D, diet, and smoking cessation…Be kind to your friends while you are at it.
    He wants to eliminate many of the medical tests like the PSA. Kinda go back to buggy days and embrace your death, eh? The real problem with technology may be the doctor-fda-lobby-ama medical industrial complex. Costs are inflated to enrich doctors and companies…In many cases medicare pays up to 10x what the free market price is. And as for PSA, why not improve it’s accuracy through innovation, as Henry Niman did 20 years ago, technology which the FDA and it’s industry partners have blocked?
    About soaring costs, yes, doctor enrichment is part, but only part, of the problem. The considered breakdowns I have seen show the following cost inflation factors for Medicare, a 34 trillion unfunded mandate: 20% is ongoing criminal fraud, 20% fraud by doctors, 30% inflated prices by industry-lobby-fda alliances, and 30% due to lifestyle problems of patients, like smoking and diet. The problem with eliminating expensive procedures, which has its merits, is that it does not address fully the criminality, special interests, and lifestyle costs. The corruption associated with inflated costs for medicare extends to such items as oxygen concentrators, which medicare pays up to 10x the free market price for. The corruption just seems too endemic (or is that epidemic?) to take a simplistic conservative 19th century medical doctor approach to. I can confidently say that this corruption, like any other corruption (Wall street? Chiang Kai Shek in China?) will lead to the collapse of the medical care system sooner than later. The 34 trillion unfunded mandate simply cannot be paid without eliminating the special interests, the wide-scale corruption, the medical crime, and above all, instituting emergency preventive medicine and lifestyle changes. Be prepared for a wild ride, as the criminals and entrenched interests are not going to let go voluntarily, preferring, as all corrupt people do, to ride the system down to destruction. I hope the many, many self-sacrificing and dedicated health care workers can keep their ideals alive and be not driven to cynicism or defeatism. For now, it is necessary to look evil dispassionately in the eye and clean the Augean stables.
    John Brookes
    Harvard AB Biochemisry-Psychology, etc, etc.
    Partnership for Health Care

    Guest
    Denis Barry
    Aug 11, 2009

    Some of the measures cited above are fairly draconian which will create severe problems to say the least. I do agree that finacial incentives to ‘do more’ needs to be eliminated. However, unless we also change the Malpractice situation, we will not remove a major incentive for MD’s to do more. I suggest we remove malpractice from the TORT process all together and establich objective ‘health courts’ which would not be based on “blame” in order to receive compemnsation for poor outcomes. (a system similiar to workers compensation, although, with much better execution).
    Two other cost saving suggestions would be;
    (1) Through competition or regulation, greatly reduce the cost of drugs in the domestic market.If the rest of the world can purchase their drugs for 50% less, then why can’t we?? The Global drup companies will need to increase their profit margins elsewhere in the world and reduce their prices in America. Frankly, I’m tired of susdizing drug costs for the rest of the modern world. Clearly, Legislative action would be required.
    (2) Greatly reduce the cost of overhead and profit for ‘private insurance plans’. The cuurent loss ratios are very low compared to 30 years ago. There are a variety of ways to accomplish this, but all require needed legislative action.
    The real question is, “do we have a national legislature who has the couarge to accomplish the above”. Unfortunately, we probably do not!!

    Guest
    BB
    Aug 11, 2009

    Finally, someone has a sensible solution for our broken system. I couldn’t agree more. Doctor’s should be paid for performance like every other vocation in this country. One way to do this would also be to have electronic medical records. Then there would be a vast database to see actual outcomes of patients that could lead to better treatments. We need to move toward a model of wellness in which physicians are allowed the time to figure out what is actually going on with their patient. That doesn’t happen with a 5 to 15 minute appointment.

    Guest
    Aug 11, 2009

    I support Dr. Lundberg’s call for an alliance of informed patients and physicians applying medical science to decision making in a way that lower costs; it is certainly part of a sensible approach to healthcare reform. I’d extend his model, however, to bring researchers and information technicians into the collaborative alliance since ignorance far outweighs our knowledge of what constitutes high-value (i.e., cost-effective) care for individual patients/consumer.
    While comparative-effectiveness studies can identify the less costly of several equally effective treatments, procedures and medications, there may be other options—some of which yet to be discovered—that are more effective, or equally effective and cost less. The only to gain and use this knowledge meaningfully is through ongoing, widespread, multidisciplinary cost-effectiveness research that focuses on: (a) determining the method of care (including self-care and professional treatment) that is most likely to be effective in preventing, managing, and treating problems a particular person’s physical health and psychological wellbeing and (b) learning how to deliver such effective care reliably and in a safe and efficient manner. This research should include conventional medicine and non-medical care, as well as complementary and alternative methods, and it should focus on personalized approaches to care.
    Included in this extensive research would be the search for answers to questions related to Dr. Lundberg’s examples of over-testing and over-treating, along with many, many more healthcare questions. Such questions would ask about who, under what conditions, and for what reasons should a particular patient ever receive:
    • Intensive medical therapy instead of coronary artery bypass grafting or invasive angioplasty and stenting (and visa versa)?
    • PSA screenings and radical surgery?
    • Mammography screenings even though under 50 (and what clinical indications would justify it for such a woman)?
    • CAT scans and MRIs to guide therapeutic decisions?
    • Chemotherapy if they have widespread metastatic cancer?
    • End of life care that includes intensive therapy?
    In addition, we have to learn how to put into action an incentive program that makes it increasingly likely such cost-effective care will be implemented.
    This, I contend, is the only rational path toward truly a high-value healthcare system. I discuss these issue in greater depth in a series of posts at http://curinghealthcare.blogspot.com/2009/08/healthcare-reforms-most-important-issue.html

    Guest
    Yana
    Aug 11, 2009

    I like this a lot. If things hadn’t gone wrong, with “new science” and new marketing science, we wouldn’t need reform.
    It is ridiculous, cruel and transparent to suggest physical therapy/rehab for a patient who is obviously on his deathbed, but I have seen that happen. On the other hand, where there IS hope, everything should be done in favor of life.

    Guest
    Russell Abravanel
    Aug 11, 2009

    I guess end of life care is something the family and practitioner need to consider. We all have heard of miracles happening, so to take a chance is a gamble but so is not taking one!

    Guest
    Aug 11, 2009

    While I do agree that over utilization is indeed a problem, I’m not certain that it is as clear cut as stopping mammograms for women under 50. Are the National Cancer Institute and the American Cancer Society wrong in their recommendations? How are we supposed to make informed decisions when the information is not clear?
    Are there some physicians that exploit the system for financial benefits? I’m sure there are, but we shouldn’t upset the whole cart because of just a few rotten apples.
    Is defensive medicine a problem? Most certainly so, so let’s fix the problem at its source instead of alleviating the symptoms.
    We all know that we are being grossly overcharged for pharmaceutical products. We all know that insurance companies realize significant profits and spend many health care dollars on archaic administration.
    Are we acknowledging our inability to tackle corporate America and Wall Street and therefore we resort to the much easier target, patients, who in the name of patriotism should forgo established guide lines for cancer prevention?
    I have no doubt that Dr. Lundberg means well and just like all of us wants to see health reform happen. But is it really necessary for health reform advocates to feed the right wing propaganda machine by constantly tying health care reform with legislating death?

    Guest
    jps
    Aug 11, 2009

    Dr. Lundberg is not legislating death. Get real. This advice makes more sense than anything coming out of Washington, that’s for sure. Shuffling costs around will not make them go away. We are all paying one way or another. And today’s technology demands we make ethical and moral decisions our parents never had to face.
    My father died of “heart failure.” But he might have lived a few years longer if he’d never treated his prostate cancer. He was burned up by the radiation and ended up with severe internal bleeding. Not good for a guy who already has heart failure. All his doctors gave him conflicting advice. The surgeon wanted to cut. The cardiologist said no way. And so forth. Everyone had an agenda.
    I’m not a physician. My agenda is my family’s health. Remember them? Health care “consumers”? Quit with the vilifying of critics and the scare tactics. Some of us are smarter than we look.