Addressing an epidemic of overtreatment

Health care costs in the U.S. are approaching 17 percent of the GDP and may be as high as 20 percent in the next few years.

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
of litigation.

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.

6 replies »

  1. Run away medical expenses. It can get ridiculous.
    Recently my wife was asked to come back in for a third doc. visit to treat a u.t.c when it was questionable as to whether or not the second follow up visit (which she did) was necessary.
    Of course even though we had an in network provider, this same physician charged $150 for each visit. Not much of a volume purchased based savings there …
    This is why costs are out of control. We would never use this doc. again. He is “wiggling the stick.” A doc. agrees to sign up with a particular ins. company(s)and agrees to charge the pre determined amounts for services rendered. They agree to these amounts in exchange for the amount of business it will bring into their office. This guy wants it both ways. Guess who pays for that? That’s right the consumer.
    Also had a doc. recently charge $69 to send over an applicant’s medical records for underwriting purposes. Huh? I used to think the usual $35 was pushing it.I’m just saying that it is a 3, not a 1 party admin process. All parties involved should respect the system instead of only being concerned with their piece of it.
    Joe Jessome
    Smart Health Insurance Inc.
    (800) 828-2950
    Mon – Sat. 9:00 till 8:00 (Est.)
    (Looks great in your favorite’s column?)
    Better Business Bureau member

  2. sorry “bad results (but high profits for medical centers and drug companies)…”

  3. Is a second opinion or an expert opinion on a suspicious lump or bump (suspected cancer) overtreatment in your paradigm?
    An mpnst/sarcoma in a child is almost literally the 100th diagnostic possibility out of 100. Is it more cost effective to develop guidelines for referral and expert evaluation or let that child die? Or do you measure the cost of treating metastatic cancer with almost guaranteed bad results (by profits for medical centers and drug companies) versus the costs of developing effective referral guidelines?

  4. I guess it’s better than the alternative- my most recent docter didn’t even seem to care about my health at all.. I think that she gets paid based on how many visits she can do in a day or something like that, so you’re in and out of there in under five minutes, feeling like nothing has been taken care of.

  5. There is an article in the New York Times today (Dec. 3, 2008) that discusses the current British policy of setting limits on how much the National Health System will spend to enable individuals to take high cost medication that may give them a prolonged life span of but not a cure.
    The organization that regulates these expenditures is called NICE (National Institute for Health and Clinical Excellence) and they have set a cap of 15,000 pounds or $22,750 to save six months of a citizen’s life. The trade off is that the money they do not spend is for example say for sick children also under the care of their National Health System. After all the pot of gold only extends so far.
    The crux of this issue is really the question of how to best distribute a limited pool of healthcare dollars The British certainly seem not only to have a handle on this but also have instituted policies that are forcing the drug companies to consider possible discounts unavilable elsewhere.
    Since spending on drugs is rising faster in the U.S. than any other aspect of healthcare expenditure the time has come to make the hard decisions regarding overtesting, overtreatment and overmedicating for one vocal sector of the population while others go without. Stronger regulation of the pharmaceutical industry regarding pricing and advertising policies could go a long way in helping to alleviate this problem.

  6. Government through incentives and other intervention can do a lot to encourage people to have a healthier lifestyle. NY City is particularly good at this: it has lowered the teen smoking rate to 8.5% compared with 20-23% nationwide and has gotten 200,000 adults (20% of adult smokers) to quit smoking thus far. NY City also has set up street vendors to sell fruits and vegetables in parts of the city (e.g. poorer parts) where these aren’t normally sold. NY City also has banned trans-fats and has a law that makes calorie counts listed on restaurant menus.
    As Dr. Halamka has pointed out in his blog, NY City has also a system for helping providers to implement a standardized EHR (in this case a modified eClinicalWorks system). Elevated blood glucose must be reported to the NY City Health Dept.
    It should be noted that NY City Mayor Bloomberg is highly involved in public health (Johns Hopkins Bloomberg School of Public Health, he has donated $375 million for anti-tobacco programs in 3rd world countries). If NY City’s example were emulated nationwide it quite possibly make a much greater impact on improving health and lowering costs than many of the other suggested ideas. Remarkably these changes in NY City do not cost so much to the taxpayer or private business — it simply requires political will to pass legislation.