What is causing the US to have the highest cost and lowest value for the healthcare dollar? Simple – it’s overtreatment.
takes many forms – from over ordering expensive diagnostic tests to the
prescribing of expensive and sometimes unneeded therapeutics.
There are many reasons for this. Here are just a few:
Incentives are misaligned. Health care reimbursement in the U.S. pays for
quantity, not quality. This means that clinicians benefit from
performing more procedures, hospitals benefit from more diagnostic
testing, and the pharmaceutical industry benefits from adoption of new
name brand drugs. If you do not believe this to be the case, spend a
day in an ambulatory care clinic or a hospital and see what goes on.
Ask any resident, fellow or attending how many tests and treatments are
unneeded. We believe that paying for wellness or paying for outcomes
will solve this piece of the overtreatment puzzle. If doctors and
hospitals had to live within a budget, diagnostic and treatment
strategies would change quickly and become less expensive for all of us
with equally good clinical outcomes.
2. We’ve attended many
gatherings where parents discuss brand name powerful antibiotics and
recommend that they become the first line drug for treatment of
anything their children complain about. “Don’t accept Amoxicillin, go
for the Augmentin or Cipro”. John’s daughter is 16 and has not ever
taken an antibiotic in her life. She’s had a few viruses, but no virus
is cured by antibiotics. Overtreatment of the pediatric population with
powerful antibiotics creates resistant organisms that make children
sicker and create a dependency on ever more powerful antibiotics. The
problem with adults is equally severe. Watch the evening news and
within an hour you’ll hear about a dozen brand name pharmaceuticals
treating diseases you’ve never heard of, but may now suspect you have.
The United States is the only country in the world that allows “direct
to consumer” advertising. We believe this advertising should be
regulated to solve this piece of the overtreatment puzzle. Those
advertising dollars end up coming out of your pocket too!
Some patients are not willing to accept risk or shared decision making
with their doctors. They want to begin the evaluation of back pain with
an MRI instead of trying a course of gentle exercise and pain medications.
Many issues do not have a clean or simple diagnosis. Eat right,
exercise, avoid caffeine/nicotine, and let the body heal itself. For
many conditions, rest and time cure the problem. Although the
health care systems of Canada and the UK have their problems, the fact
that access to expensive diagnostics is limited enables patients and
their doctors to work together on simpler evaluations and therapies as
a first step. We need to change the cultural expectation that expensive
tests are “first line”.
4. As a country the U.S. eats poorly,
avoids exercise, drinks an infusion of lattes, and then wants to take a
pill to make all the lifestyle diseases go away. Lifestyle issues
should be treated with lifestyle changes, not pharmaceuticals or
nutraceuticals. Our own experience convinced us of this. John gave up
the lattes, the super-sized meals, and began daily exercise 7 years
ago. Since that time, all his lifestyle diseases have disappeared.
Overtreatment begets overtreatment. If a lifestyle disease is treated
with pharmaceuticals, it’s likely that those medications will cause
side effects. The symptoms of side effects lead to further diagnostic
testing and more pharmaceuticals are often the result. We know several
patients who are on medications for hypertension due to overeating, H2
blockers due to excess caffeine/nicotine consumption, and several
medications to treat the side effects of their initial medications. Two
or three medications can fast become ten. We’ve suggested taking a
medication holiday with appropriate clinical supervision, redesigning
their diets, and beginning daily exercise. The answer we often hear is
that taking all those pills, having all those tests, and visiting their
clinician often is easier than changing their lifestyle.
Today on the local radio station, an attorney asked the question “have
you ever had a bad outcome or misdiagnosis? I’ve been holding doctors
accountable for 30 years. Call me and we’ll get you the cash settlement
you deserve.” There are bad doctors. There are doctors who are
unskilled at surgery or provide very non-standard care. However, most
clinicians are trying to do the right thing. Medicine is not an exact
science. It’s based on experience and probabilities. This means that
even the best clinician will miss a rare disease or an atypical
presentation of a common disease. As a country, we need to realize that
delayed or misdiagnosis will occur despite best efforts and accept a
low level of imperfect outcomes instead of forcing every doctor to
overtreat every patient in the pursuit of 100% certainty. Both patients
and doctors together must accept some degree of uncertainty or we will
continue to bankrupt our system.
Our economy has lost its
competitive edge because our healthcare costs have ballooned to extreme
levels due to misaligned incentives, overzealous pharmaceutical
marketing, expectations of high cost testing/therapeutics, excessive
administrative costs and complications due to overprescribing and fear
The diagnosis of overtreatment is simple. The
therapies are complex. We’ve proposed a few fixes above and will
continue to write this topic in blogs to come.
John D. Halamka, MD, MS, is CIO of the
CareGroup Health System, CIO and Dean for
Technology at Harvard Medical School, Chairman of the New England
Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE, Chair of the US
Healthcare Information Technology Standards Panel (HITSP), and a
practicing emergency physician. He blogs regularly at Life as a Healthcare CEO, where this post first appeared.
Dr. Rich Parker is an assistant professor of internal medicine, Healthcare Associates.