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2. Pretty! This has been a really wonderful post.
   Thank you for supplying this information.

3. Justin,
   Glad you liked it. I just revisited the article and note that it has remained pretty much on point since publication, as the science evolves and more people begin to realize value.
   You are correct that it was re-published with permission and attribution on Medscape in 2009, received huge readership, and was then removed from the site. I dont know why.

4. Wonderful article. Glad it’s still available to read. I imagine you must’ve shaken your colleagues enough to make them remove the article from Medscape. Heaven forbid they should profit less from human suffering.

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6. The first two points are idiotic: eliminating CABG and PTCA and replacing it with it “intensive medical therapy” will cost at least twice as much these procedures would alone. It’s a commonly known fact that long hospital admissions are extremely costly, and simply throwing all these patients in the hospital to treat these conditions (which could take weeks), would be an immense cost detriment of unfathomable proportions. The inclusion of these two points makes the rest of the article largely irrelevant.

7. Influence can be defined as the power exerted over the minds and behavior of others. A power that can affect, persuade and cause changes to someone or something. In order to influence people, you first need to discover what is already influencing them. What makes them tick? What do they care about? We need some leverage to work with when we’re trying to change how people think and behave.
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8. Get a life! Health care is a service, just like legal, accounting and plumbing services. The problems that occur in health care would be duplicated in those professions if the stupid, centrally planned and government controlled medical and health insurance systems were inflicted on them to the extent they are in medicine.
   It makes sense to use the most efficient services, but the misdirected incentives are in place by legislation and subsidies to providers and to patients. With voluntary trade in medical care, the most efficient methods would drive out the least efficient, as they do in every market that is not under the thumb of the state.
   The problem of health care for the poor would be minimal if physician’s customers (patients) acually paid their own bills. The hyperinflation and distortion comes about because everyone wants mercedes coverage witha Yugo premium and they have no personal incentive to minimize costs. Government uses the medical system as another method of redistribution, a policy that grossly distorts the entire market.
   The solution is to get govemrnment out of health care completely. In a truly free market, the massive problems would evaporate. A relatively small number of people would be truly in need of charitable
   medical care, and that need would be filled by charitable people, of which there are many in this great society.

9. WOW! What a load of nonsense! When will we recognize the glaring evidence that economically illiterate bureaucrats just can’t run anything? Governments don’t create wealth in society, they destroy it. This is due to the simple fact that they don’t produce anything and therefore spend other people’s money. It is impossible to do good with other people’s money!!! Anyway, if you’re interested in an intelligent refutation of Dr. Lundberg’s article please read this educational piece: http://www.lewrockwell.com/orig10/scott-m1.1.1.html

10. Unfortunately, Dr. Lundberg (a pathologist, academic, professor, editor, activist), has little real-world experience. His long-term imprisonment in the Ivory Tower has let him where so many others go – Statist control of all of us, by “experts” like him.
    It is a fool who believes that others know, and care, what is best for him.
    Do not be fooled.

11. Utter tripe. Too much government intervention is the problem. Most of what you cite as unneccesary is in “mandates”, that is, in order to sell insurance in a given geogrphical area, the insurer is forced to pay for tests which may or may not benefit the patient. Get the government out of the business, (because it is, always has been and always will be a business), including licensing, “approving”, and deciding how much a given procedure is worth and let people buy the coverage they need, based on their own assesments of risk etc. This of course requires taking the improperly usurped power from the government and returning it to the people, hardly something you feel is important. End the tax favoured treatment of employer paid premiums and things will chage drstically and quickly for the better. Utilization rates are highest where there is the most government money.

12. Its time to dust off an old tried and true solution to solve a problem like healthcare that the free market cannot solve. In the past when competition was not sufficient to control prices on big ticket items like the price of electricity, price of land-line phone service, and the price of natural gas service, our state governments instituted public service commissions (PSCs) to arbitrate fair pricing. We need a PSC for healthcare to set medical charge code prices billable to the healthcare insurers. All state insurers would pay the exact same amount for identical medical service claims.
    This would stop over-charging and cost shifting. The PSC would investigate patient complaints of wrong doing and have the power to stop corruption. The MPSC would eliminate provider networks and open the door for full-blown wide-open competition among the insurance companies. Without networks and all insurance paying the same, any insurance plan could quickly enter the state, get policies certified by the state, advertise and sign-up new patients state-wide. All doctors/hospitals would be required to accept any state approved insurance.
    The state MPSC could become the healthcare champion needed to stop some of the questionable deeds mentioned above. All approved Medical Charge Codes would be listed on the official MPSC website in numerical order for all to see. You could ask your doctor/hospital for a copy of the bill sent to your insurance and actually check it for errors. If you see a mistake, the insurance company may actually pay you a reward for any money they recover.
    Since the Medical Charge Codes would be standardized by the MPSC, the insurance companies could feed this information (without patient IDs) into a common database for analysis. Effective treatments could be discerned from these data.
    For a particular set of Medical Charge Codes certain diagnostic codes would be acceptable. Extra diagnostic codes deemed as used just to confirm the original diagnosis, could be billed on a pure cost basis only – no mark-up. This would take the extra money out of excessive tests.
    The MPSC would take many of the kinks out of the current system and give us a system uniquely American.

13. Interesting post. What about the costs associated with long-term care? Another post on this blog suggests these costs total $450b or more annually – consideration of efficiency of service delivery, and careful monitoring of its efficacy cannot be ignored.
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14. as a gm union worker just retired, everyone knows what happened to the auto industry, the high cost was pushed down to the bottom of the food chain. most of these posts are doing the same thing. deja vu dbc

15. As a healthcare provider I see way too many patients complaining of a sore throat or a cough they’ve had for less than a day. The number of patients coming in on a daily basis with normal aches and pains is astounding to me. Both the urgent care and I get paid for seeing these patients by insurance companies, so I suppose I shouldn’t complain…But these frivolous visits are a big part of what is driving up the cost of healthcare.

16. Kaiser is in deep finacial trouble, not a good example.
    Cooperatives DO NOT work, failed in Florida over ten years ago. Competition DOES WORK- Public Option IS a competition strategy.

17. Americans are ENTITLED to all of those wasteful treatment and behaviours. Just try to take the candy away from a spoiled child. Use reason? That is ineffective. It takes 5 times as long for me to explain to someone why they dont need an MRI than why they do. Their neighbor certainly is more knowledgeable.

18. I agreed with Dr. Lundberg of the needs to make provision and provide healthcare coverage for the uninsured and underinsured. We still share the cost of caring for these people in Emergency room Department. Also to reduce the cost of healthcare, Physicians should reduce ordering duplicate and unnecessary diagnostic tests just to protect them from annoying law suits. Over-treatment is a big problem with cancer patients compare to other developed countries. It’s time for us to focus more on providing quality and cost-effective care.

19. Dr Lundberg identifies a number of things which should be targets for reduction in usage rates. Many, many more could be identified but Dr Lundberg does NOT identify an effective pathway to do so. Putting physicians on salary is NOT the answer. Removing incentives to work hard is NOT the answer. The Geisinger/Mayo/Cleveland examples are more driven by excellent physicians who broadly know best practices and have internal peer review than by the fee for service issue. In fact, each of these organizations do use productivity models which take into account fee-for-service activity, among other quality and productivity indicators. Changing how community, non-big-system physicians function is much, much more complex than putting folks on a non-fee-for-service system.
    Achieving change has to track the following principles: incrementalism as drastic change is too disruptive in so many ways. Amplify and expand what already works. In this case, Clinical Practice Guidelines need to be expanded vastly, need a process of generation that is continuing, well organized, and frequently updated. As a new wrinkle, like the SureScripts model which incorporates medication management within EMRs, Clinical Practice Guidelines need to become an integral add-on to EMRs/EHRs. Since EMRs are still in relative infancy, NOW is the time to influence them to implement Clinical Practice Guidelines and NOW is the time to make all EMRs Health Data Vault based. NOW is the time to insist that EMRs ALL use standard MedCin codes for as much as possible in a manner which is efficiently usable. The Guidelines need to see MedCin codes for symptoms and physical findings within EMRs, need to see coded outcomes of tests, and integrate them automatically into a Guidelines structure. They should assist with diagnosis, prompt the physician to document more effectively in a manner which supports decisions. Guidelines evaluation of medical data should be able to look at the patient’s entire health record for coded symptom, physical finding, test, and procedure outcomes data. That means that many pieces of data which are now stored as prose will need to be stored as evaluable coded information. Cardiac ejection fraction, thus, needs a coded place and outcome format. COPD needs coded parameters. Liver dysfunction and renal impairment need to be quantified in code. And the coding needs to fit virtually invisibly with the way we are encouraging physicians to document. Demographics like age need to be considered. Then, guidelines can advise on whether prostate cancer should be observed, radiated, or operated and what the benefit/risks are which are pertinent to a specific patient. Then, guidelines can inform the family of the elderly diabetic with end stage renal disease that any coronary artery procedure has a very poor outcome potential.
    For guidelines to be optimally effective in making care more appropriate, they must be an integral part of evaluating the medical record as it is being generated. Guidelines need to influence decisions as they are being made rather than being imposed hours to days later by faceless bureaucrats who demand “peer to peer” phone conferences before care will be covered. Current “peer to peer” is in fact not “peer to peer” as the person on the other end of the phone is commonly woefully under-informed. Current processes anger everyone generating excessive physician office costs.
    Please work for solutions which fit the modern direction in medicine: integrate with what is happening, enhance it, use new directions as a tool to make cost-appropriate care a reality.

20. Good points, Judy. The root problem, it seems to me, is that doctors often don’t know with a strong degree of certainty whether “chemotherapeutic hope” is false hope or if it is a valid & reasonable approach for a particular patient (like you). The same goes for many tests and procedures throughout the healthcare industry, i.e., we simply don’t know if they are worth the side-effects, cost, risk, etc.; if there are more cost-effective approaches that will have superior outcomes in terms of QOL, longevity, etc.; or if doing nothing is best. Lacking this knowledge causes all sorts of problems, which is made worse because our system pays more for doing more, not for doing best (i.e., it does not reward delivering high value to the patient/consumer).
    The only long-term solution is to gain the knowledge we need. That doesn’t mean relying on some actuarial formula based on administrative data collected by insurance companies. It means working hard in collaborative research and practice networks across the globe to emerge that knowledge by analyzing comprehensive clinical outcomes data and then translating the resulting information into evolving evidence guidelines/protocols/pathways. In that way, we can focus on improving those guidelines over time by studying compliance rates and variance data depicting (a) when and why the guidelines are followed; (b) when they are not followed, why they aren’t; and (c) what the particular types of patients for whom the guideline works and for whom it doesn’t.
    Over time, this would address the issue you raise. How best to do and use this research is what we ought to be debating!

21. rbar — picking up after some days on the discussion of “false chemotherapeutic hope” versus of course treating aggressively if there is any chance of a benefit. I wish I could share your confidence. However, I have lived in the cancer world too long not to have seen patients fighting for tx’s that are well known and widely used, but somehow do not meet the criteria of their insurance company for coverage. I have seen patients pulled off of a treatment at the first sign of progression, when other doctors would take a more incremental approach, possibly change dosage or schedule, and perhaps reap a few more precious months from a given therapy. I have seen my onc’s notes in my chart reflecting her belief that I was within weeks of death but (thankfully) open to trying a treatment for which we never thought I was eligible (that was six months ago). I offer these anecdotes not to try to find right or wrong, but to say that the choices are nuanced, complex, and yes, sometimes excrutiating. But it makes a lot more sense to me to be as open as possible about the very important issues of QOL, side effects, benefits vs. harms, etc., than to try to reduce it to some actuarial formula. In this regard, I have found the input of patients to be at least as valuable (usually more) than anything I’ve read on a package insert or heard from a provider, and I hope I’ve been able to share information that has given other patients and caregivers a chance to make truly informed choices.

22. For healthcare reform to succeed, our country needs the right blend of principle and pragmatism, and it is foolish to prefer glorious defeat to an incremental victory. I contend that this requires (1) defining what we have to (ought to, should, must) do in order for our healthcare reform strategy be judged as principled and, at the same time, (2) defining what we can do in order for it to be judged as pragmatic. For an in-depth discussion, see this post on my blog titled “A Principled and Pragmatic Approach to Healthcare Reform” at http://curinghealthcare.blogspot.com/2009/08/principled-and-pragmatic-approach-to.html

23. I have been trying to make this point to members of Congress for the last month. They can think of nothing except expanding coverage, the big bad insurance companies as the problem and a public option as if any one or combination of those is the real problem. I recently placed an intersting article on my Blog
    http://quinnscommentary.com/2009/08/27/i-agree-with-ezekiel-j-emanuel-md-phd/
    related to an article that Exekial Emanuel wrote in the February 27, 2008 issue of JAMA. I think he has it right as well, but you hear very little about this even though he is the White House advisor on health care reform. Go figure

24. One of the main aspects in the increase in cost of healthcare is the way it is paid for through health insurance. No matter how much price control is added by physicians performing less procedures, the costs won’t be reduced until the patients are fiscally responsible for their own healthcare.
    Exposition on why healthcare is significantly cheaper in developing countries:
    http://hoothoothoot.wordpress.com/2009/08/28/obamacare-vs-indiacare/

25. I think that Dr. Lundberg’s opinion piece, and David Goldhill’s article, How American Health Care Killed My Father, in The Atlantic,(http://www.theatlantic.com/doc/200909/health-care) make eminent sense about how to control health insurance costs and improve health care. The first article is by an eminent physician who has seen the system over years from 30,000 feet; the second is by a businessman who has a functional sense of the economics of health insurance. Neither article mentions the words “conservative” or “progressive.” They are both pragmatic.
    I would add that a public awareness campaign needs to start at once. The two main messages, per these two articles are:
    * Many of us will live 8 to 10 decades. As we age we will need more and more medical interventions. Face the fact that we are all going to die some day. Recognize that thinking about, or saying the word “death,” is taboo in our culture. Determine what interventions you will want to take to prolong your life; balance that with expectations for your quality of life and your family’s needs for inheritance. Help change our culture’s expectation that each individual has a right to hope that her or his life will be saved by medical intervention.
    * Remember when you realized that you had to save money to send your kids to college because it was clear that the costs for higher education were beginning to sky rocket? You saved and were able to pay for all or a part of their tuition. Health care’s costs are sky rocketing now. The best thing you can do for yourself and your family is to start a HSA now to pay for the health care that will be necessary as you and yours age.
    ******
    It will be a hard sell. Physicians and patients are both mortals and, as Puck pointed out in A Midsummer Night’s Dream, “Lord what fools these mortals be.”

26. As for myself and my patients, we figured it out long ago. We returned to the free market, where consumers purchase what they need directly from the supplier, at a price agreed on between us, spending our own money. This is how every good and service is exchanged, except health care. Therein lies the problems.
    The entire debate for us is irrelevant white noise. Nothing to do with us.
    The solution is all around you, hiding out in the open.

27. Dr. Lundberg, and most of the respondents apparently never took Econ 101, or forgot what they were taught, or are in denial.
    There is no consumer-provider free market. Neither the doctor nor the patient can get what they want and need because they have forfeited all the money to a third party.
    Loss of consumer pricing power, as exists everywhere else in the economy, is absent here, obviously because all power rests with those who control all the money.
    Why does this reality exist only in health care? Deep thinkers want an explanation. The road to good health care for all begins with the answer to the right question.

28. Dr. Lundberg … Your item might have more validity if you had shown the numbers from peer reviewed studies to back up your assertions. Without documentation its simply political positioning rhetoric.

29. While the article oversimplifies medical care delivery and payment, much of this can be attributed to an author who, from the sound of it, does not actually treat the sick. Please feel free to correct me if I am in error, but following the dream of many MD’s today, Dr. George has found it more lucrative and less risky to leave caring for the sick to other less dignified “providers.”
    In order to lower the cost of care, these costs must be studied, scientifically. Who spends the most? When, and for what disorder? This has already been done.
    Now that this data is known (the elderly, at the end of life, for heart disease), we can make recommendations.
    Dr.George’s desire that we experience death with “dignity and free from pain,” is so sophomorically wistful. The demand of the public is always “not me, not now.” The doctor is trained to say, “not on my watch.” And so it goes. Also FYI doctors run the very real risk of being prosecuted if they are too helpful with the “free from pain” bit.
    In Dr. George’s perfect world, we would all not imitate our President’s smoking habit. We would resist the urge to overeat and under exercise. We would drive our highways without a “sip of beer.” We would not have unprotected sex with dozens of Hatian prostitutes, or trade group sex in a trailer for a hit of meth.
    But alas, it isn’t Dr. George’s dream world. It isn’t that we resent paying top dollar for the best care in the world either. It is being asked to pay for the bad judgement of others that strikes us as unfair.
    We also pay the multi-million dollar salaries of insurance company CEO’s and pay for tens of thousands of their employees who profit by COLLECTING PREMIUMS and DENYING CLAIMS. It is brilliant. Probably a great investment for some. But when $7000+ a year goes to my insurance, and precious little ever comes back to the doctor, I have to ask, are these healthcare dollars well-spent?
    Hospitals play a key role. By hiding the true costs of care from the public and publishing outrageously inflated billing statements they can markup product 7000% and not blink. A “Dr. George” fix here would be TRANSPARENCY. Force hospitals to post a menu of services with cost + prices. Let the public see how little the insurance company is paying for that visit. While we’re at it, give each American citizen a healthcare account, $700 a year, every year. From it, vouchers can be withdrawn and used for healthcare. Don’t use it? Roll it over and add to it the next year. Saves the banks, puts consumers in control of their own spending. Forces healthcare providers to compete at price and transparency. I know, it is simple minded and idealistic. Wasn’t that the point of this article?

30. President Obama, we are tired of the Whitehouse trying to sell us health care reform. You know, I know and the American people know this is really about more government power and control. Our biggest problem has become our government! Stop! Just stop all this nonsense! Do not treat U.S. like we are stupid, ignorant morons! Join U.S.!
    Do Not Sell Out “We the People” of the U.S.A.! We Trusted You!
    President Obama, great Presidents do Great things! They have great Honor and Integrity! We know you can do it! “We the People” know the truth! We want to hear it from you! Please join U.S.! Tell the American people the Truth! Confess! Americans are forgiving! We feel if this took place, a renewed Spirit of Patriotism could spread through our government! The American people have never lost our Spirit of Patriotism! We never will! Join U.S.!
    “Few men have virtue to withstand the highest bidder.” –George Washington
    President Obama, You owe nothing to the manipulators who bought your way into office. Those people only used you! Americans do not want to use you. People have been using you and lying to you all your life.
    You Have to Betray Them or Betray the U.S.A.! What’s Your Choice?
    Look at the people of the United States. We are real! We are good people! We are intelligent and can think! The elitist mind is really small and weak! The elitist people are selfish and twisted. We just want a President with Honor and Integrity. This is your big chance to become the Greatest President of all time! You need to lead our government by example, with Honor and Integrity! President Obama just do the right thing!
    Join “We the People” of the U.S.A.!
    “Experience has shown that even under the best forms of government those entrusted with power have, in time, and by slow operations, perverted it into tyranny.” -Thomas Jefferson
    President Obama:
    Can you stand on your own?
    Can you make your own decisions?
    Can you be a man of Honor and Integrity?
    If we have any other elected or appointed “public servant” leaders in our government who have any Honor or Integrity left inside them, they should come totally clean with “We the People”! If most of our leaders have any intestinal fortitude, then we should have a long line of them holding resignation papers in their hands or begging to ask our forgiveness! Do they no longer think they are accountable to U.S. and believe they can do whatever they please? They have developed a “spirit of insubordination” that has gotten way out of control! We no longer need employees working for us that practice malfeasance in office.
    We need laws stating that any Representative, Senator or President that has the audacity to sign any bill without reading it and fully understanding it should go immediately to jail without any bond? We must raise the bar of Integrity and Honor for our employees! Elected or appointed “public servants” need to achieve a much higher standard. How did it get so low? If they are found guilty, a 30 year minimum sentences would not be out of line! This complete lack of responsibility is a very serious issue! It’s totally scandalous, outrages and just plain wrong! It’s Criminal!
    We Must Never Again Allow Our Leaders to Have Unaccountable Trust! EVER!!!
    People are corruptible! We must always question and watch very closely everything they do! Our Freedom, Our beloved Constitution, Our National Sovereignty, “We the People” and the fact that we are a Constitutional Republic is why the United States of America is the Greatest Nation in the World! Any bad truths about our Country are the slow results of the corruptible human nature of a few individuals! Power and wealth can corrupt a person if not kept in check! After we fix our current problems, and we will, we must put in play many more “checks and balances”. We must figure out a way to completely take away the opportunity of corruption! Nothing personal – but “We the People” must always come first and be protected!
    http://www.tomdavidd.com/blog/
    “We can all commiserate forever about how bad things have been, are, and will continue to be. But I don’t think that we can afford to wait for elections in order to have our say about putting a stop to this madness. Enough, already! Let’s start talking treason, prison, and death penalties for all malefactors in government who subvert, ignore, skirt and otherwise trash the Constitution of these United States of America. Those who have sworn to uphold the Constitution and have then ignored their oaths of office are guilty of perjury and malfeasance in office.” -Stephen A. Langford (personal communication to this author)

31. Kim,
    I think I have read that piece and I believe it is wrong in several respects – in some details such as density of MRI machines (where it was admitted in the text that the US number might be too low because one facility can contain several MRIs), and wrong in the big picture because the crucial problem is not the malpractice premiums, but defensive medicine. Let me cite from Barry’s post above:
    “It is true that defensive medicine is virtually impossible to quantify precisely because the motivation for ordering a given test or procedure can be part defensive medicine, part money driven and part trying to please patient demands and expectations. I have seen cost estimates for defensive medicine that range from the very low single digits to north of 10% of healthcare costs. Nobody knows for sure.”
    I think it is probably higher than 10 %, but don’t forget, it’s rarely defensiveness alone, but also patient expectations, money driven medicine etc. that drive overutilization. It’s like saying: this marriage broke apart due to the lack of money (it’s usually more complicated than that) … several factors can be interwoven, and it may be hard to identify one clear culprit. Same with overutilization. However, I think that tort reform is a prerequisite in oder to curb overutilization, but alone it wouldn’t change much.
    You will find a few health policy wonks (Ezra Klein for instance) stating that the tort system is irrelevant … but you will find very, very few physicians saying that, and this includes the well informed and progressive ones.

32. I’d first like to reiterate that physicians’ fear of malpractice litigation is far from unfounded. My father is a primary care physician and was in court for three weeks this year at risk for losing his house for simply following the standard of care. He ultimately won the case but my guess is that others aren’t so fortunate.
    Secondly, I think it’s all well and good to talk about incentivizing medical students to go into primary care but that’s a long shot as the system is now. As a first year medical student, I just completed my federal loan counseling where I learned that to be able to pay back my student loans over 25 years I will need to be making 300,000 a year once I complete my studies. While I have every intention of going into primary care anyway, I’ll apparently also need to win the lottery.

33. I had trouble hearing and went for a hearing screening at my MD’s office. The loss on one side was so significant that she immediately sent me to an ENT and an audiologist, who in turn ordered an MRI. It turned out that I had an acoustic neuroma (clinically stable, thank God). I am being treated by a doctor at Mass Eye and Ear Infirmary in Boston, who has me undergo a contrast MRI every year to make sure that the AN has not grown. I see him rather than the local specialist because the local specialist would have had me undergoing surgery immediately, which in turn would have destroyed the remaining hearing in one ear.
    What would happen to me under Dr. Lundberg’s system? This isn’t a theoretical situation. This is my life. Would I have been denied the MRI and simply given a hearing aid? Forced to see the local doctor and been rendered deaf on one side? Possibly lost my job due to the cost of surgery and finding a temp to do my job for the six weeks I would have been out of work, not to mention the increased insurance costs?
    Yes, we have too many tests. But a vast amount of healthcare costs stems from drug company profits and insurance company bureaucracy. A Canadian-style single payer system would have allowed me to see the specialist and have my MRIs without referrals, without risking my job, and without being forced to see a doctor who tried to rush me into the operating room.
    Single payer is the only solution.

34. Do any of the people railing against malpractice suits as a root cause of health care costs ever read “Health Affairs” or for that matter the CBO report on US health care costs? Both of these rather thoroughly debunk the myth that either malpractice suits or defensive medicine have all that much to do with increased health care costs in this country. The 2005 “Health Affairs” piece by Gerard Anderson et al. is particularly helpful. When one looks at the US, UK, Canada, and Australia (all of which have similar legal systems but very different health care cost structures), the problems with the “tort reform solves health care” case become apparent.

35. rbar,
    I think I agree with you completely. Defensive medicine and the fear of lawsuits are real. But even in your comments it’s only one of many factors in our medical culture that lead to waste and excessiveness. Ours is a situation where medical errors are too common (see the IOM report to err is human), American doctors resist JACHO, guidelines, or any oversight. Our autonomy is supreme. We actually don’t get sued for the overwhelming majority of mistakes we make. Something has to give. I believe the tort system in medicine is completely unfair and counterproductive and we should change it. Democrats are not honest about this, in my opinion. However, to claim that as central to the overall health care system is hyperbolic and quite self-centered on our part.

36. Algernon and Judy, I believe you misunderstand what Dr. Lundberg is referring to.
    I am a practicing physician (not an oncologist), and I am positive that re. chemo, he is referring to therapies that are comlpetely unproven or of absolutely marginal benefit. Keep in mind that a lot of agents come with almost certain side effects and may make QOL worse.
    Re. end of life care, I have obsrved and have participated in useless efforts, “for” suffering patients in hopeless situations, and “for” patients with very limited or absent brain function.

37. Excellent comments Judy, thank you. It becomes obvious that the “ivory tower” experts are far removed from the real world. Best wishes for continuing your fight, and I can but hope my partner who has Liver Cancer stage 4 with perhaps a year to live at most, will be as fortunate as you have been. I presume that the writer is pleased with a prognosis of a year, thus saving him his tax dollars.

38. Thought-provoking indeed. It is also a piece that reveals the excruciating set of choices we may have to make to bring costs under control. I read it dispassionately until I came to the part about false chemotherapeutic hope for widespread metastatic disease. I don’t know how the latter is defined, but I almost certain fit the definition. I’ve lived on “false chemotherapeutic hope” for almost 8 years, time enough to raise my children and become an e-patient activist. Clearly, the median is not the message, and for all those who are getting an extra few months of marginal quality of life, there are also those of us who are fighting a good fight, and living a good life. Perhaps this is also an equation the wisdom of patients will help us solve — patients who understand the tradeoffs and are empowered to value quality of life may surprise the powers that be with their clear-eyed assessment of their options. We should certainly not let the fear-mongering of certain ex-governors of Alaska deter us from encouraging those conversations.

39. “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.”
    So, the answer is, instead of trying to preserve and extend life with a terminal illness, the final prescription should be for a gun to blow your brains out…….
    Until is happens to you or a person you love, best you re-think this cost saving idiotic idea. You are beyond contempt.

40. I am the son of a physician, a former pre-med student, and, as a Vietnam veteran, currently getting my medical care from the VA. Thus, I have a pretty good sense of what the author is trying to say. In my view, much of the health care industry plays shamelessly on people’s fears, and as a result is able to bill for work far beyond anything really useful. Since I have a pretty good background in biology, I find it fairly easy to guard against such fear mongering, and the VA has a similar institutional sense. They do not have any need to churn the account, and they do have real budget constraints, so they focus on good outcomes, and nothing else. Thus, I get what I consider quite good health care, it is absolutely guaranteed, and I don’t have to do any arguing with an insurance company. All I have to do to get all this, aside from being a veteran, is to be sensible about what is worth spending money on.

41. Leaving aside the medicolegal issues noted above, in practice it is likely difficult to “regulate” medical practice by suggesting guidelines given the amount of variability that currently exists in medical practice.
    A (perhaps the) major issue that affects nonacademic practice will likely be incentivization-how our time is valued. So what is the problem here? Lets take point number 1. For “intensive medical therapy” to occur, primary providers have to be willing to spend the time to provide advice on lifestyle, diet, exercise, etc. I would hope they already do so-but in reality many do not. So make sure the incentive system focuses on quality, not quantity. If, say, pay was proportional to the % of patients reaching certain LDL goals (“pay for performance”), then primary providers would look a little more closely at achieving goal cholesterols. Something like bundled payments would lead to increased scrutiny of those getting CABG procedures.
    By putting in a system with aligning incentives would be essential to achieving your suggested approaches. Getting more medical students to choose primary care wouldn’t hurt, either. But expecting practice to change by simply adding to primary care burdens under the current system we have is probably unrealistic.
    My viewpoint is as a primary care provider/endocrinologist.

42. Val,
    I trained in Europe (Germany and alsio some time in France) and can tell you that in the US wheer I train/practice for a decade, I have met very many physicians absolutely scared by the threat of litigation.
    It is not so much the amount of malpractice awards/settlements (as long as the doc’s property and house isn’t at stake which I believe is a rarity these days), the scary thing with litigation is the burden in terms of emotion (pride) and unpaid labour before and during trial.
    Barry Carrol above has given a very nice and IMHO scientifically adequate summary of that strong intuitive truth that is so hard to quantify (as he explains).
    Right now, a physician/resident has no incentive NOT to order tests, but many to order them (patients want thorough work up/pics). Residents can get reprimanded for forgetting/delaying something deemed important, but I can not remeber many if any instances where residents are scolded for wasting thousands of dollars (and during case based discussions an exams, considering zebra diagnoses are encouraged even if they are not really an option in the case at hand).
    As long as the people in the US do not understand that they get very little true value for their health care bucks (getting close to a fifth of the GDP), US health care is doomed … and that’s the feeling that I get from the current discussions about death panels etc. anyway …

43. Medical pools including practitioners of various specialties could help reduce costs considerably. There are many modalities, each practitioner claiming it’s the best.What about saving costs by consolidating “Back specialties”, including orthopedists,”pain management” specialists, physical therapists, personal trainers,acupuncturists,yoga specialists, meditation specialists etc.Transportation to consolidated centers could be managed by special medical vans, as we have in our area. Surely, eliminating so many offices with their expensive equipment would save millions.What about having trained counselors to help navigate the system? Many millions of dollars could be saved if this change is made.

44. I understand, Val.
    I can’t really blame the clinicians, however. A screwed up healthcare system with misaligned incentives, the belief that we clinicians can and should somehow know more than is human mind can handle (even when the evidence is clear), a strong desire for autonomy/independence (we don’t want to be told what to do), a tendency to rely on our experience coupled with the dearth of evolving personalized evidence-based guidelines, etc.—in addition to fear of lawsuits—I contend, reasons for such reluctance. But in the end, none of that really matters since we don’t have any other good options. So, I would argue that we’d be wise to learn to work together to create a new and improved model of healthcare focused on bringing high value to the consumer based on greatly expanded scientific evidence. And we ought to be active participants in garnering that evidence-based knowledge through widespread collaboration between clinicians of all disciplines and researchers. Yes, change—fear of the unknown—can be scary, inertia can be very tough to break, self-deception can blind us to how bad things really are, and even ego can get in the way of accepting new guidelines.
    The combination of a badly broken system and the forces of human nature are responsible for the healthcare crisis. I’ve been studying this for decades and see no good alternative; we must change in meaningful ways or else we’ll be watching our healthcare system (and country) continue to implode!

45. Steve,
    I am an internal medicine resident. I don’t mind good and fair tort reform but honestly I think that the threat of law suit are only partly responsible for unnecessary testing. We all know that we often order extra tests because we are less than confident or competent in our clinical thinking. Sometimes, we simply don’t have or take the time to think before we order. We can go a long way by instituting some educational reforms in our training programs and continue to devise and implement guidelines. Often times we physicians are very reluctant to change our practices even in the face of evidence. As you know, many of us go up in arms whenever someone suggest guidelines, let alone pre-printed forms. Changing physician behavior is a very difficult thing. I agree with good tort reform, but it is too often used as an excuse to take our eyes off the ball…

46. FYI: I just summarized the original posts and comments at http://curinghealthcare.blogspot.com/2009/08/quick-way-to-rein-in-medical-costs.html

47. Peter – I work closely with physicians on a daily basis and I can tell you that fear is a significant factor. Are there physicians who base their referrals on money? You bet. But there are fewer of them than you might think because contrary to the soundbites out there, not a lot of physicians own a stake in a testing facility. The ones that do have created this perception that hangs like a dark cloud over all physicians.
    Thankfully, I don’t personally know any physicians that have suffered serious career damage, but I have read enough accounts of those that have in my career.
    I don’t tout tort reform as the big cost saver that some do, but that doesn’t mean it isn’t necessary. I don’t think either of us knows enough about the situation in Texas to be able to diagnose their cost problems.

48. I think that everybody is ignoring the 800lb gorilla in the room, and that is tort reform. Almost all PRACTICING physicians agree that what drives up medical costs is defensive medicine, driven by lawyers looking to get rich. As a practicing ER physician, I know that MOST of the tests I order are not designed to find the correct diagnosis, of which about 80 percent is a good history and physical, but rather defensive in nature, to rule out the 1 in 100 or 1 in 1000 chance of the presentations being a atypical presentation of something nasty. I routinely order expensive tests for this reason,a nd the truth is, it is better to spend the patients money on testing than for them to sue you and get to spend your money. Most practicing physician, whether they admit it or not, practice the same way.
    It is amazing to hear the rhetoric about testing, and kickbacks as a cost of a and cause of ordering more tests. the truth is, most physicians dont get paid any extra no matter what tests they order or how many they order. I wold love to see some hard numbers on this, but unfortunately, since medicine is an art and a science, they would be impossible to come up with, as most of the time, it is ingrained in our training. This is why articles like the wsj piece underestimate costs, they are reliant on self reporting, and most physicians dont report defensive testing.
    Until tort reform, and I mean real tort reform is established, no practitioner will be comfortable pointing at a patient and saying “you dont need this test because…”
    Steve

49. “It’s the lingering possibility that, at any time, a physician’s career (and possibly life) could be destroyed as a result of an honest mistake.”
    Deron, why is this different just for docs? Do you know any doc where this has happened? Here in NC Duke Hosp. put the wrong set of organs in a young girl for a heart/lung transplant. As far as I know all docs are still practising.
    “That is a completely legitimate fear leading to unnecessary testing that dwarfs the figure you mentioned.”
    Even in states with tort reform, as in Texas, this has not stopped rising medical costs – which shows me it has nothing to do with fear, only money. This article seems to say doc’s fear is no longer, but they now are angry at the medical board that oversees them. I guess docs will only be happy when they are not liable for anything.
    http://blogs.wsj.com/health/2008/05/19/doctors-flock-to-texas-after-tort-reform/

50. For the most part, a sensible list, though a bit misty eyed – how many physicians are going to rein in a family’s desire to extend heroic measures to prolong life – especially when its highly profitable? Until and unless you change the fundamental incentives, you won’t change the fundamental trends.
    On a more minor note, how exactly is it that if we stop charging for MRIs on a case by case basis, there will be fewer of them overall? You might bring costs down by increasing utilization rates, which means regulating the number of machines available to a given population. But again, that requires fundamental changes, the kind of practical stuff this article ignores.

51. Thanks for very informative and revealing post.

52. As a practicing hospitalist, I am quite displeased when I read or hear current theories of why healthcare costs so much. As if the problem lies in “misplaced incentives” from hospital readmissions, or unnecessary procedures from physician profit motives. I suppose Obama & Pelosi are reviewing Ted Kennedy’s hospital admissions to find out which doctors & hospitals are merely looking to make a buck.
    While I am sure there are some examples of said behaviors, the larger part of the problem is society itself. The same segments clammoring for added benefits/programs/universal healthcare, etc are often the same patients & family members that “want everything done” despite counseling & recommendations otherwise based on the clinical scenario. It’s easier for policy makers to fault the hospital or the doctor than to point the finger at unrealistic & demanding recipients of care, who expect someone else to pick up the tab. I would gladly order fewer tests & provide fewer services when I feel they were unnecessary or inappropriate, if the necessary changes in our system could be implemented. This would take things like tort reform with economic damage caps, “loser pays” rules, medical court reviews for merit of claims, and legal protection for providers to refuse unrealistic demands of patients/family members without fear of legal entanglements & costs. Until these things happen, everyone can just look forward to paying more & more for the healthcare demands of your fellow citizens. Defensive medicine at its unrecognized best. Thank goodness most of government is served by the interests of lawyers.

53. Although I agree that mammography is overdone, you are unrealistic in expecting physicians practicing in the real world to follow your advice.
    The ACOG recommends mammography as follows:
    Age 40 – 49, every other year
    Age 50 and up, every year
    Let us suppose that an OB/GYN follows your advice and doesn’t order mammography according to ACOG recommendations. Let us further suppose that one of his/her patients develops a Stage II or higher breast CA – that is a virtual certainty given enough time.
    I guarantee you two things:
    1) The OB/GYN is at significant risk of being sued for malpractice and of losing the suit
    2) You won’t be there sitting next to him during trial
    Your advice is medico-legal malpractice.

54. Initial response by author:
    I am gratified by the number and sincerity/quality of the discussion participants and their points. We all together can make a difference, although once an activity becomes economically successful, its continuance seems almost addicting to the players.
    The strength of an anecdote is the extent to which the people involved really do believe that their treatment helped them. The weakness is that cannot ever know (without randomized controls) whether their experience was random or cause and effect.
    We have known for many decades that many (probably most) prostate cancers do no harm to their hosts, regardless of therapy. We are now learning that many breast “cancers” self-destruct, but we do not yet know how to tell which unsuspected lesions that are discovered by screening mammography will disappear and which have the potential to kill. But we do know that much harm is done to many women by screening mammography and the actions that result therefrom.
    George D Lundberg MD
    President and Chair, http://www.lundberginstitute.org

55. Two of your recommendations would have likely meant that I would be sitting here complacently, unaware of an aggressive cancer in my breast. Like some of the other recent commenters, I was diagnosed with Stage 1 breast cancer at the age of 60 following a routine mammogram. I had no family history. After the initial biopsy, I had an MRI that showed two more suspicious areas. One was an additional smaller cancer. Because of the location of the lesion revealed by the MRI, the treatment was mastectomy rather than lumpectomy. I also had aggressive chemotherapy, and am now cancer-free (as shown by a recent PET scan).

56. At the age of 59 I went for my routine screening Mamogram, after 30 years and with no family history, and confident that all would be well. I was diagnosed with two (2) seperate cancers. I had surgery to remove my breast last May, and they found that the cancer had not invaded my lymphnodes, I was one of the lucky ones. Without health insurance, to pay for annual health screenings, I may not have caught this in time.
    Thank god for my health care coverage. I wonder every day what I would have done had I not been so blessed!

57. Most people refuse to believe that routine cancer screening — mammography, psa, and even colonoscopy — offers little early detection benefit or improved outcome. Stopping the routine, non-indicated use of these screening exams saves billions.

58. Shortly after turning 48, my mom was diagnosed with stage two breast cancer. We had no family history of cancer. My mom was fit, active, and ate a healthy diet. There was no reason to suspect she had cancer. She was diagnosed because of a routine mammogram.
    She has been cancer free for six years. If she did not have that routine mammogram, I do not know if she would be here today.
    From my personal experience, those mammograms for women under 50 don’t seem so frivolous.

59. Andy – I don’t think the main reason for the focus on tort reform is the insurance premiums. It’s the lingering possibility that, at any time, a physician’s career (and possibly life) could be destroyed as a result of an honest mistake. That is a completely legitimate fear leading to unnecessary testing that dwarfs the figure you mentioned.

60. There’s much talk of tort reform on this thread. However, a quick look at actual numbers shows that the total medical premium paid each year by doctors in the US amounts to $6.5 billion. That’s less than one half of one percent of the total healthcare spend.
    We need to understand that the focus on malpractice originates in the legitimate frustration of doctors — but it is fueled by those with political objectives and is absolutely irrelevant to the struggle to control healthcare costs.

61. My wife was diagnosed with high-grade breast cancer in an asymptomatic breast cancer screen via mammography. She was well less than fifty at the time of diagnosis. She successfully underwent chemotherapy, mastectomy with reconstruction. Her care was handled by talented surgeons and her oncologist.
    My point: is my wife really such an outlier? Was it “worth it” to go and pay for that ‘asymptomatic’ patient’s mammogram? Do each of the above mentioned seven points have exceptions? There’s the rub. I find outliers and exceptions each week in my practice. Is it worth it? Perhaps not in the global perspective vis-a-vis health care costs, but try explaining that to someone you love.

62. Hi Guys
    We can easily fix the healthcare system, all of us working together. Let’s look at the details.
    Let’s make people responsible for their care. They pay for services out of a MSA type fund that comes from their taxes. They use the money wisely, live healthy, they get money back at the end of the year, like a refund from the IRS. If they have an unhealthy lifestyle and use the medical system more, they don’t get a refund or have to pay more from their taxes. People will choose healthcare resources wisely and use the medical system wisely. They are in control.
    Lets make everyone work who can. This will increase the amount of people paying into the system so taxes can go down.
    Lets have tort reform. All the money from lawsuits goes to the patients. The lawyers are paid costs and a small retainer. People filing frivolous suits should be made to pay the costs for both parties in the lawsuit.
    We need the typical american values if we are to solve these problems-Honesty, Dynamism, Courage. Let’s solve this problem.
    Mahesh Kuthuru, MD
    mkuthuru@gmail.com

63. I feel preventative medicine will go a long way in the long term health of our population.

64. As a physician who practiced both in Canada and the U.S. I can say that, were ancillary re-imbursement to be removed from physician services, along with improving Tort reform, and increasing physician EM re-imbursement, then a public system would be more sensible for all involved whereby physicians make decisions based on objective facts, not some bureaucrat or not influenced by profit.
    lESS WE FORGET, physicians , by improving people’s health and preventing bad medical outcomes, increase
    national productivity and hence improve the economy, much less everything else that goes along with good health!

65. Dr. Lundberg,
    While not being able to comment on your direct medical proposals, there are several general issues you address with which I agree and one with which I do not agree.
    Whenever I see proposals to change the payment structure for provider care, I ask, “How can this be implemented on a national basis?” I ask this question because the question of fees and over-utilization is not a local, regional, or specialty issue. It is endemic to the medical community.
    There are many fine comments addressing one aspect or another of your excellent post but “fee-for-service” is a leading topic. I would only comment that in many cases fees have been driven sufficiently low that servic suffers. In turn, the clearest result has been to drive over-utilization, perhaps to make up some of the differences in income.
    It’s time to look at medical fees not as the problem but as the solution. If we can assure providers that they will be paid fairly and promptly, we can relieve some of the pressure on over-utilization. In turn, if we can apply your suggestion, “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.” then perhaps we can turn the medical cost juggernaut around or at least slow it down.
    In this latter regard, I bring you a concrete suggestion for applying your reforms. At the end of the day, we must be able to implement nationally.
    The Third Way
    Amid all the partisan shouting about who should run health care, the government or private insurance, something may be getting lost. Did we leave someone out? Could there be a third party? After all, we are discussing medical care.
    Medical care is an interaction between patients and doctors. So why are we so quick to suggest that either government or private sector insurers control health care? One of the reasons we are stuck in this artificial duality is because that is what we have now. Since insurers pay for health care, they believe that they should control it. So, we have government run Medicare and private insurers such as Aetna or the Blue’s running private health care. Before we had either, however, medicine was run by the medical community.
    My grandfather was a doctor in Palmyra, NY, a small canal town in upstate New York. I think it would be fair to say that he provided his patients the best care he could, his fees were reasonable, and he didn’t prescribe treatment that was not guided by his clinical findings. He practiced mostly before private insurance and most of his patients had to pay for care out of their pockets or off the farm – chickens, peas, potatoes, etc.
    Medicine is far different today. For one thing it is often less personal. My grandfather knew many patients for a life time. Today, doctors rarely can afford the time to develop long term relationships with patients. And with the reduced and discounted fees they receive, they can’t afford the extra time.
    Medical care today is also marked by discounted fees and over-utilization. These two factors have driven the cost of medical care through the roof. We spend 17% of our gross domestic product on medical care, far more than other civilized countries.
    Getting back to the question of who should be running health care in our country, it is abundantly clear that neither the government nor private insurers have been able to control the cost of health care.
    Thankfully, there is a Third Way. Place the control of health care in the hands of the medical community. Who better to oversee how doctors are paid and whether they are providing appropriate care to their patients. Who can speak with more authority when individual doctors stray away from the course of appropriate care?
    Creating an independent, non governmental medical agency to manage and control medical care has the potential to both assure appropriate patient care and control medical costs.
    This agency could negotiate medical fees fairly, provide care guidelines, process medical bills, collect treatment data, and pay providers in a timely manner. This independent medical agency could work with doctors to help them follow appropriate treatment patterns thereby reducing over-utilization, the most important factor in lowering overall medical costs. It could bring substantial cost saving in medical losses to insurers, government and private.
    Arguments against an independent medical agency; it’s too costly, the insurers won’t like it, it won’t work. Based on my own experience working in this type of agency, I think that it will work and will shave billions of dollars off our health care bill. Could it be worse than the system we have now? Why not try it?
    This post appears at http://www.leanmedicalcare.org

66. “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.” – Does anyone have a source for these figures? Thanks.

67. Let’s start with eliminating the incentive of Congress to waste our money on pork, jets, “gold plated” healthcare, retirement benefits, etc. Paying for a massive new healthcare bureaucracy and expanding coverage will not lower healthcare costs and will continue to generational transfer of weath to current seniors from our children and grandchildren. Congress, led by Obama is OUT OF CONTROL.

68. Medicine is first and foremost a business. The proof is that as many as 99% of c-sections and 98% of hysterectomies can be avoided with conservative treatment options, or no treatment at all. Curbing the overuse of these two surgeries alone would save taxpayers tens of billions of dollars each year. That savings could be used to provide emergency medical care to the quickly growing number of uninsured Americans. See the book THE H WORD by Nora W. Coffey and Rick Schweikert for over 400 pages of juried medical journal articles and personal testimony that attest to the fact that America would be healthier with less medicine. What we need is emergency care for everyone and to stop making doctors and corporate executives rich with damaging, unwarranted surgeries.

69. 30-50% is what we can save per year in healthcare. Have you looked into the healthcare organizations! Too many Officers. The cost is not just in care but also in administrative waste, organizational efficient or there-lack-of, and so much more.
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

70. George,
    You are not the first to state the obvious, but perhaps, you are the first with national prominence to do so. Perhaps, and you do not state this, is that the volume of “unnecessary” work has increased inversely proportionally to the payments per procedure.
    George, are you working for 30 cents on the 1995 dollar not taking into consideration inflation ?
    And when was the last time you took care of a patient and had to make decisions with far reaching impact using ambiguous clinical findings?
    You do not provide a feasible path to accomplish a solution for the obvious problems There are many academic medical centers at which doctors are salaried without fee for service, yet the over utilization is high.
    It would appear that you are seeking accountable and cost effective medical care. This will be accomplished if doctors were paid appropriately to achieve that goal.
    Since doctors control how every health care dollar is spent, they should be paid out of the savings to accountably save on unnecessary expenses (but not like in the despicable capitation system of 20 years ago). Doctors should be paid to practice cost effectively rather than what is currently being done…gaming an elaborate government and insurance imposed maze of payment and medical care control gimmicks.

71. Very nice piece, though I generally like to see literature references for claims like these.
    I think knowing when to stop is a major problem in healthcare… however, this problem is NOT generated by MDs in most cases. It results from the American culture of denial of mortality. I see this in the ICU all the time.
    Lastly, we’re missing a key #8: Sometimes bad things happen to good people, and believe it or not, sometimes it’s not someone’s or some institution’s “fault” — so why can’t we have a reasonable medical malpractice tort system, with expert panels and limitations on payouts.
    Last time I looked, most trial lawyers make significantly more than the overwhelming majority of nurses, therapists, and even physicians in this country. Let’s fight defensive medicine and legal costs, too, while we’re seeing the light.
    –Evan

72. I want to make a couple of additional comments about why I think tort reform is a critically important piece of the healthcare and health insurance reform equation. It is true that defensive medicine is virtually impossible to quantify precisely because the motivation for ordering a given test or procedure can be part defensive medicine, part money driven and part trying to please patient demands and expectations. I have seen cost estimates for defensive medicine that range from the very low single digits to north of 10% of healthcare costs. Nobody knows for sure.
    What is even more important, in my opinion, it that substantive tort reform is essential if we are ever going to convince physicians to give up some of their cherished autonomy and accept some accountability for the healthcare utilization that they drive through their decisions to order tests, prescribe drugs, admit patients to the hospital, consult with patients and perform procedures themselves. If we just say, we want you to follow evidence based guidelines where they exist but the current litigation environment remains as is, we have a tough uphill battle. On the other hand, if we replace the current jury system for settling medical disputes with specialized health courts and we provide robust safe harbor protections against suits based on a failure to diagnose a disease or condition as long as evidence based protocols were followed, it should be easier to convince doctors to embrace reform, at least over a reasonable timeframe. We know that some doctors are more money driven than others and some practice more defensive medicine than others and some local and regional medical cultures treat more aggressively than others. With sensible legal reforms that allow medical disputes to be resolved fairly, objectively and consistently, it should be much easier to ask for and expect physician cooperation on the utilization issue.
    It is most unfortunate, however, that the Obama Administration and the Democratic Congress seem completely unwilling to move in this direction because they don’t want to offend their friends and big campaign contributors in the plaintiff bar.

73. FNP – John Ballard’s questions were fair questions, so I’m not sure why you found the need to get hostile. We need to ask questions like that if we want to truly develop evidence-based guidelines. Unfortunately, your reaction is an all too common reaction from physicians that face patients with questions about their treatment plan.
    Mr. Lundberg – You made a lot of great points. I would just caution that pieces like that cause more backlash because you portray physicians as being the sole cause of our high costs. I have yet to see a good balanced piece that calls out all stakeholders (including patients) at once. We will make more progress with discussions like that because you will get less violent opposition from any particular group when they see that everyone will be forced to give something up. That’s exactly why insurance companies are reacting so strongly. Washington is making them out to be the only bad guys. That is huge mistake.

74. It may be true that billions could be saved…but their are several underlying problems:
    Greed
    Stupidity
    Dishonesty
    Irresponsibility
    This is to name just a few.
    When is the US/World going to wake up and realize that when you look in the mirror, do you really like the person looking back at you?
    The tragedy is that until corporal punishment is legalized for those corporations/individuals who blatantly disregard the law, than nothing will happen.
    We try to legislate, but the establishment does not either deserve respect is a greater part of the blame.
    We can talk until we are blue in the face about this, but until an honest/open/frank discussion can be had, we will end up with a watered down bill that makes almost no dent in to the problem.

75. So Mr. Ballard, are you going to tell your doctor that you don’t a CABG when he tells you that your blood pressure is too high, your tricycerides are over 4oo, you now have diabetes and have not lost the weight that was necessary for you to ensure that you did not end up in the situation that you are now in?
    Those of us actually in healthcare to promote prevention so that we don’t get to the point where a CABG is necessary, no that the majority of patients never follow the instructions that are given to the patients we are supposed to be helping.
    The post on CA and allowing someone to die with dignity is all good and well unless that patient is your child, you sister, your brother, your parents, etc. Most people who even suggest that we NOT give chemotherapy paliative or for treatment, is someone who has never experienced it first hand. I have been blessed that my loved ones who have experienced cancer, were able to have chemotherapy and is with us today. But I have seen and watched families torn apart do to this terrible disease. And I have seen teenagers and children come back from what looked terminal. If we follow the advice of Mr. Lundberg, those wonderful people would no longer be with us.
    This “healthcare reform” has turned into a money issue only. Until you look into the face of a patient that can continue to live if a CABG is done or the next line of chemo is given, you don’t understand what you are protecting. Human life is worth all the money in the world. Any politician who has the vote for any healthcare reform, should not be allowed to vote until they have spent a minimum of a month in a hospital getting to know the people they have the vote to help and protect.
    pcp, keep ordering the tests that will help your patients.
    FNP

76. The pains are sometimes reflected as something very badly; this is a warning of some ailment which we pruned to suffer. Sometimes we feel a pain in the waist and one in one of the kidneys which we can worry about. These pains are deceptive and sometimes the importance is not relevant. For this reason it is recommendable to get a physical control to recognize the ailment that causes the pain and power and to fight its origin. The pain in the waist, that can be acute or long lasting can return as chronic and is know to medics as lumbar pain. This is a disease that strikes millions of people throughout the world; findrxonline and said that according to statistics 70% of people who have suffered at some point in their life.

77. Two-part question from a layman:
    As a new Medicare beneficiary I just had my first comprehensive physical exam in fifteen years. It includes a four-page report of blood and urine tests, echo and stress tests for the heat, and I’m lined up for a colonoscopy.
    1.) Except for being overweight and having high blood pressure I’m in good shape. Is that much testing justified in my case? And if not which could be skipped?
    2.) PSA was part of the list. Does a PSA test in a list of tests get charges any more economically than the same test ordered alone?
    (Before you go beating me up, the doctor did put me on a strict diet and medication to lower blood pressure. I know, I know…)

78. “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.”
    Great stuff to dream about Mr. Lundberg, but I’m afraid we’ve developed into a nation where it’s all about “me”.
    We’re going to have to be dragged kicking and screaming to do the right thing.

79. As a primary care physician, I make absolutely nothing if I order a PSA on a 55 year old man at a physical. I would love to have the support, guideline, whatever you want to call it to stop routinely ordering them. I personally believe the evidence suggests more harm than good from routine PSA screening.
    The conversation on the “psa controversy” is long, complicated, often confusing, and I’m rarely sure the patient fully understands the pros and cons to make a truly informed decision either way. But if I don’t order it because I want to be one of these ethical and professional physicians ahead of the curve, and the patient ends up with an aggressive cancer, I will lose sleep and likely have severe anxiety over the possibility of being sued. And I may very well be sued under such a scenario. Whether or not I would win the case is almost beside the point. Who wants to go through that?
    So I order the test. Not because I make any money (quite the contrary) But for almost exclusively defensive medicine reasons.
    The same argument can be made for the mammography issue. The same argument can be made for telling a patient with chest pains and a positive stress test that we should try pills instead of “fixing the plumbing problem” with bypass or a stent.
    Until I legitamately feel protected from the lawyers on these topics, I have a disincentive to change. And it has nothing to do with fee for service.

80. No matter what economic model is selected to give access to good care for all Americans, the essential questions concerning how to control costs, reduce litigation, provide ongoing biosurveillance for public protection—while improving care quality and safety—remain unanswered. These questions include:
    1. Who (or what) should decide if a test or procedure is unnecessary or inappropriate for a particular patient in a particular situation? Should it be the clinician, the patient, the insurance company, the government … Who?
    2. What guidelines (if any) should be followed by those making the utilization decisions? Should the guidelines be evidence-based? How will political influence of vested interests be prevented from pressuring the guideline developers, so that only sound (valid and reliable) science is used to justify the guidelines? What do we do if the necessary guidelines are not yet developed? And for those that exist, how do we assure that they continually evolve? How should the guidelines be disseminated?
    3. Should the use of clinical decision support software systems be used, or should be simply rely on the unaided human mind? If decision systems are used, should they implement patient-centered cognitive support (see http://curinghealthcare.blogspot.com/2009/06/meaningful-use-clinical-decision.html)?
    You see, if we don’t start focusing on answering these kinds of questions, we will remain in the dark about cost-effectiveness: We still won’t know what constitutes effective & efficient care. This continued ignorance means there will be all sorts of opportunities to game the system; malpractice suits will continue unabated; care will not improve significantly, and may very well deteriorate; and costs will continue to climb. In other words, we’ll be no better off than we are now, except that there will fewer uninsured and probably less crowded ER—which are certainly good things—but the entire healthcare system will remain unsustainable!!!
    As Dr. Bestermann said, we don’t have to continually research the things for which we are certain. But without having already done that research, we’d know precious little for certain! Getting together to determine where more research is needed is certainly a good start! And continually searching for more cost-effective ways to do things also makes good sense.
    So, as Margalit said, there are no silver bullets. Instead, we’ve got to “bite the bullet” and make widespread, sweeping collaborative research a top priority. Failure to do so is disastrous!

81. Congratulations Dr. Lundburg, it warms my heart to see a physician of your stature stand in the storm and have the courage to tell it like it is. We don’t need to let the perfect get in the way of the good. We don’t need to point fingers at other pieces of the system and say if they just do what they need to do, then I can do what I need to do. The people who “get it”: patients, doctors,payers, and other stakeholders need to begin to do what they can do to improve our system. Then those same people need to hold the problem pieces accountable-including the politicians. The first two points on cardiovascular disease are dead on. We don’t need more research-there are 14 studies now showing that stents do nothing to prevent heart attack in patients with stable angina who receive optimal medical therapy. 85% of stents are done in stable angina patients. Will five more studies change anything? I doubt it. No, what will change our situation for the better is having the courage to do what we need to do and having the courage to confront those interests frantic to preserve the status quo.
    The failure of leadership in our medical system is on a par with the financial leaders and politicians who just gave us the housing bubble. The medical bubble is not far behind if we don’t get this right. Thanks again, Dr Lundberg for standing up.

82. Honestly If we could follow CA and legalize weed and the taxes from THAT along will absolutely pay for anyone’s and everyone’s health care! The savings on not locking up “pot heads” and “drug dealers” -who sell weed, would then be enough also to pay for medical care. Next make cigarettes illegal. If you want to smoke tobacco you can buy it and roll your own cigarettes. All the chemicals they put into cigarettes are so harmful and worse then just smoking tobacco or marijuana. So now you have more Americans making more money on the sell of tobacco and marijuana with lowered health issues and INCREASED government revenue along with a major deduction in cost of jails and prisons to stock these nasty marijuana abusers and save mine and your tax dollars. =) People are a lot happier including nasty politicians who want more money but!!!! not all politicians want more taxs and money so they can snatch some out the coffin… JUST LEGALIZE marijuana and make cigarettes illegal or maybe not but just know that cigarettes are projected to kill approximately 17% of the global population of the world. With this information I would be more concerned about this drug with its harmful chemicals killing Americans then letting them smoke this harmful product, pay for it, then we pay there medical bill. What are you stupid? While im talking… Why is Marijuana a schedule one drug? Did you know to reach a toxic level you would have to ingest or smoke 25 POUNDS of weed within 15 mins! IMPOSSIBLE! There for this drug shouldnt even be listed as a schedule anything drug. Oh and it isnt addicting. You can not become dependent on this drug! Much to say but I have to go back to work.

83. George: As you know, I admire your work and your prose. But get real. I don’t see how you can end fee-fro-service, herd doctors into multispecialty clinics nationwide, or put them all on salary.
    I discuss the impracticality and the non-replicabilty of these thigs in my book Obama, Doctors, and Health Reform: A Doctor Assesses the Odds for Success; The Health System, From the Top-Down to the Bottom-Up, As Seen Thourgh Lens of Cultural Complexity.
    I’m equally dubious you can do away with Coronary Bypass and stents, which, along with intensive drug therapy, have reduced MI deaths from 30% to 6% over the last two decades. Until we have tort or self-referral reform, I doubt if we can reduce defensive or offensvie use of CAT scans and MRIs,
    I agree with your comments about overuse of chemotherapy in hopeless cases and death with dignity.
    Richard L. Reece, MD

84. A very important premise (whether one agrees or disagrees with the specific recommendations). What has thus far been missing in the health reform debate is the acknowledgement that every service, every procedure, starts with a physician order. Until physician incentives are aligned with what is best for the patient, nothing else really matters . . .

85. Hello
    I believe we have a problem with our healthcare system that can be reasonably fixed. We just need to use common sense and a rational approach to continue to run one of the best systems available.
    People need to pay for their healthcare. We can have a flat 10% tax to have them pay for their care. People have a choice of private or public plans. People choose the plan they want. Everyone has insurance. Nobody loses insurance. If they use the system wisely and consume less resources, they get money back. This helps them to be rational users.
    Too many people aren’t working. We should make sure everyone works who can. More people working and paying taxes, We have a robust system.
    Fix the malpractice system. All awards go to the patient, not to their lawyers. The lawyers get reasonable and predetermined fees. Malpractice caps would also help.
    We should be able to use the best technologies and practices available both in medicine and information technology boundrylessly.
    Lets all work together and see if we can help everyone and our great country.
    Mahesh Kuthuru, MD
    mkuthuru@gmail.com

86. My state’s mental health system is proof positive government cannot run healthcare.
    The only way to get the care you want and need is to control the money yourself.
    The uninsured could buy basic healthcare if they had no cell phone and no ipod expense. They have a right to their priorities, why won’t I have that same right? Do I have to quit working to be free in this country?
    I already give away a million a year in free or stolen care. I probably will do better having you pay me for all the uncompensated care I now provide, but who wants to stay here and be enslaved into debt and into comrad Obama’s America?

87. Of course, Dr. Lundberg is right, but so are Barry Carol and Dr. Weinstein.
    The big, fat, low-hanging fruit of waste that I see from my perspective as a community primary care physician, is over-utilization of specialist care. We have so many specialists and so few primary care docs that many specialists wind up doing the primary care functions that correspond to their specialty. The cardiologist treats hypertension and sends the patient off with a wink and a nod to the pulmonologist for refills or asthma meds. The pulmonologist sends the patient on to the dermatologist for rosacea and every so often the patient sees the primary care doc for a “complete physical” and referrals to the appropriate specialist for any new problem. Everybody takes their cut, is chummy in the hospital dining room, and nobody steps on anybody’s toes. The patient is happy because he’s getting “the best” care from “my cardiologist” or “my endo”. In reality, the care is fragmented, contradictory at times, and the total cost is 3 or 4 times what it should be.
    Note that the French are trying to control their costs by restricting access to specialists. It’s not just the US where it’s a problem. However, when I lurk on a diabetes forum, I’m always amused by difference in attitudes. The British diabetics always refer to their doc as “my GP” while the US diabetics always refer to “my endo”. Otherwise, they get the same care.

88. Thanks a lot Dr. Lundberg. Great, valuable and well-written piece.
    Dr. Lundberg, for the sake of this great nation, why don’t you take a lead and go on TV networks to educate the ill-informed people.
    As Dr. Dubey put it, why not “have the consumer manage the healthcare dollars” and make the data on cost and quality available to consumers; it will automatically cut the fat of ‘unnecessary procedures’. In other words, I do not need insurance for routine visits and procedures; I will need insurance only for catastrophic care. If I pay for MRI, I will absolutely make sure from my doctor that it is necessary.

89. I appreciate the comments about the truth and research. However, how do you explain our 37th. position in World Population health yet twice as expensive per capita/adjusted for income at this time when only a couple of countries are pursuing the holy grail we are pursuing (IT, information, EBM, etc). What can we learn from them? Should not we differentiate our Health from the care delivery system since Health is primarily derived from Culture (behavior) + gestational and genetic endowments? The delivery of ill health care has a small effect on overall health of the population. Why destroy a “system” that can be molded more perfectly around issues of payment alignment, fraud, free market solutions, disallow DTCA for Prescriptive meds (creates unnecessary demands), etc. So far, there is not an appreciation of what and what not our care delivery system can accomplish for our population. Take Obesity for example–please………Rob MD

90. Absolutely correct, Dr. Beller.
    Somebody is going to have to do the research necessary to establish true “evidence based” cost effectiveness and it will take time and it will take upfront financial investment. There are no silver bullets.
    Unfortunately, people come up with solutions based on existing “evidence” and as you can see in this thread alone, there are competing “evidences” for even the simplest things like mammography screening. Which one is the true evidence based recommendation? The esteemed NBCCF, that Maggie is quoting, or the equally esteemed ACS that Doc99 is quoting?
    We need to fund appropriate research, and we need to do it now as part of health care reform, if we are truly looking for a long term sustainable solution.

91. I agree with Dr. Lundberg’s basic premise. There is over utilization of procedures in the United States. Economic incentives strongly bias the case for over vs under utilization. An additional problem with wanting to practice “evidence based” medicine is that the evidence is often lacking or outdated. To say that thousands of CABG patients could/should have been treated medically assumes that we have evidence comparing long term outcome of current medical vs. current surgical therapy. We do not. The CASS data is decades old at this point. Any time you do a large long term prospective trial it takes a couple of years to design, a couple of years to enroll,at least 5 years of follow up and then a year to assess the results. By the time you have made sense of the trial it is 10 years later and both the medical and surgical therapy for the given condition has changed. So you still don’t have evidence for what is the right thing to do TODAY.
    Lastly, even if you remove physician incentive to do more, you must also remove the threat of potential litigation for doing less. Currently, if an asymptomatic patient with 2 vessel disease and normal LV function is treated medically and infarcts, the physician will be sued for not stenting or bypassing the lesions, even though the data showing superiority of that therapy is lacking.

92. Bravo!
    What’s most important in this piece is the emphasis on what physicians, nurses other health professionals can do now–without waiting for legislation.
    Before ordering an MRI, they can ask themsleves: Is this really necessary? (Patients can ask the same question when a doctor recommends a test–or yet another drug: “Doctor, I’m already taking 4 pills every day. I’m not sure I want to take a 5th–is this absolutely necessary?”
    Doctors and nurses can make sure that the patient knows that the hospital has a palliative care team–and that the patient has a chance to talk to that team about treatment options, potential benfits and risks before deciding on further treatment. Palliative care specialists also are experts at keeping patients out of pain. Too often, doctors are reluctant to hand “my patient” over to palliative care.
    Physicians–and patients– can learn more about how we over-treat heart disease by reading Dr. Nortin Hadler’s extremely well-documented book “Worried Sick.”
    Physicians who think that they should be sending all of their patients over 40 for mammograms (and women who feel guilty if they don’t go for mammorgrams) should read this statement from the The National Breast Cancer Coalition Fund : “The scientific evidence from randomized trials on the impact of screening mammography in saving lives is conflicted, and the quality of the individual trials limited. The National Breast Cancer Coalition Fund (NBCCF) believes, on the basis of recently published reviews, that the benefits of screening mammography in reducing mortality are modest and there are harms associated with screening.”
    For the full statement see Naomi Freundlich’s post here: http://www.healthbeatblog.com/2009/04/mammography-screening-a-double-edged-sword.html.
    She also quotes the American College of Physicians, which also raises questoins about routine mammographies.
    Physicians responsible for mentoring residents can go out of their way to teach their residents :”Think before you order.” Simply “counting” how many tests your hospital orders–when compared to other hospitals–can be enormously useful.
    See this hospitalist’s story about the memo that he sent to his residents on HealthBeat here http://www.healthbeatblog.com/2009/08/waste-and-inefficiency-in-hospitals-a-hospitalist-tells-his-residents-the-truth-.html
    As for fear of malpractice driving overtreatment–this is greatly exaggerated. As one of HealthBeat’s readers pointed out when commenting on the hospitalist’s memo:
    “The question is, can fear of malpractice suits really explain such signifigant varations in Medicare expenditures [when comparing 3 hospitals or cities}? It certainly can’t explain the Medicare spending variations between El Paso & McAllen counties that Atul Gatwande highlighted in his now-famous New Yorker article.”
    This is absolutely right. Conservatives who don’t want us to rein in overtreatment (in large part becuase they want to protect the profits of the for-profit health care industry that they invest in) always turn to the the “doctors have to overtreat or they will be sued–the lawyers make them do it” argument.
    That said, I do think we could handle malpractice differently– see http://www.healthbeatblog.org/2008/05/medical-malpr-1.html
    I find that physicians like this hospitalist spend much less time worrying about lawsuits–and much more time worrying about doing what it best for their patients. (Unnecessary tests and procedures put patients at risk.) And, most importantly, he is teaching his residents to do the same.
    This is how the culture of medicine will change. This isn’t something that Congress can legislate. This is something that only healthcare professionals can do.

93. We ought not to forget how little we know about what is the right care for a particular person in a particular situation. Broad-stroke generalized guidelines can do more harm than good for some people. We have neither the scientific evidence nor the human mental capacity to consistently determine which tests and treatments are necessary and which are excessive for a specific person. This makes it all too easy to justify doing too much, especially when it’s profitable to do so.
    We are, therefore, often operating in a knowledge vacuum, which means we will continue to make errors that adversely affect quality and cost (i.e., value) to the consumer. Let’s admit our overwhelming ignorance and focus on replacing it with ever-evolving evidence-based knowledge!!! This will take time and great effort, but there simply is no other rational path toward a sustainable solution. Anyone disagree with this strategy?
    The strategy I propose is neither easy to do nor does it provide a quick fix to a very complex problem. Sadly, our society tends to be enamored with overly simplified quick-fix solutions. If we had started decades ago down the rational path I’m proposing, we’d be in a much better situation now because we’d have much greater understanding of cost-effectiveness and personalized decision support.
    I’m concerned about the imbalance between (a) our extensive focus on finding ways to pay for care and (b) our minimal focus on obtaining the knowledge to make cost-effectiveness decisions based on sound research. We’d be much better off admitting how little we know and focusing on worldwide research aimed at helping us learn what we need to know about cost-effectiveness. As consumers and providers gain such essential knowledge, then we can do what President Obama says we have to do: Pay for the care that gives consumers more bang for the buck, and don’t pay for waste and inefficiency. In the meantime, any of the financial-focused strategies being offered are merely unsustainable stop-gap solutions, and we ought to be careful that they don’t diminish care quality at the expense of reducing costs!

94. Dear Dr. Lundburg and Mr. Klepper, et. al. I applaud your pointing out the “misbehavior” of “professionals” and adding what is rightous. It is good to be right with no impact, but better to be effective. All of the incentives and corruption (no anti-trust, no stark enforcement, major non economic consolidation of systems, etc) all are aligned to make money-greed. To the extent that professionals (ask orthopedists about their device stipends and “clinical trials”)can be influenced by money, they will be to some level. Are Doc’s decisions influenced other than evidence based medicine if available–you bet it is. Do they preform at a clip of 50% unnecessary high cost imaging-yup-and our culture expects and demands it. Pharma included.
    We cannot expect a metamorphosis of physicians as long as the incentives are corrupt, the culture continues to diffuse unnecessary high cost technology faster than any Westernized country at twice the pace, and Primary Care Doctors regain pride in their profession as well as comperable pay for effort and build Medical Homes (return to 75% primaries, 25% specialists to achieve balance). Most primaries are points of triage today. They need to practice to the extent of their education, training, and comfort. Specialists have 3X the rate of ordering tests (remember 50% unnecessary pre test). Not going to happen with today’s misaligned incentives to “do to patients” and not “for patients.”
    Brian, Brian, Brian–don’t get so emotional about what should be but wont happen–wishful thinking just clouds real opportunities. Ethics and practice processes will change only if the system is aligned for lower cost and quality thus resulting in more access. Let us design an insurance market with real free market dynamics–today it does not exist. If don’t want to do, I vote for a governmental plan and play a lemming
    Quote Mark Twain “You can be an idiot or you can be a congressman. Oh, I repeat myself.” There is no reform in any plan so far revealed (remind Brian that the committee plan is being kept from the public-Transparency?). No change in structure or financing that would create alignment and all working to serve the American people. Remember, if Pharma signs on, no one else should since they only have concern for double digit profits and so far it is “cool” for them. The AMA and AARP should have their mouths washed out with dial soap. Rob MD
    Rob MD

95. jps, the end-of-life discussions and the rationing discussions are emotional for most people and everybody falls back on a personal experience, just like you did, or the natural fear of mortality. The science is not exact and there are no clear cut, evidence based remedies. These fringe conversations are hurting the effort to make health care reform a reality. The discourse needs to be based on logic and numbers and dollar figures, not the “what if MY granny has a stroke” argument.
    Ethical questions do not belong in a public policy debate, and in this case, they are derailing the case for health care reform, as you can see from the right wing responses (just read the Palin article on this blog).
    All I am suggesting is that in the interest of passing some sort of health care reform, we decouple the emotional debate from the factual one.

96. For #1-2, I would like to know more from the medical experts about how easy it is to identify, at the individual patient level, who should get these procedures and who should get medical therapy instead.
    For #3-5, I think substantive tort reform is required, especially to protect doctors from lawsuits based on a failure to diagnose a disease or condition.
    For #6-7, there are issues around patient and family expectations / demands and potential tort liability if the doctor and hospital don’t “do everything” in the absence of any communication to the contrary. I think laws need to be changed to allow the default protocol in end of life situations to move from “do everything” to apply common sense depending on circumstances without having to worry about being sued.
    Back to #1-2, I had a CABG in 1999 and needed a stent (DES) in 2005 while on aggressive medical therapy the entire time. I also note that the Mayo Clinic website lists 10 strategies for lowering blood pressure without medication. I’ve been doing 9 of them, including a solid exercise regimen and a sensible diet, and I still need a beta blocker to control blood pressure. My BMI is under 22 and I’ve never been a smoker. So, forgive me if I’m a bit skeptical about the power of healthy diet and exercise regimens alone. Genetics are a significant factor for many of us.

97. The Lundberg diagnosis is on the money. But as for the short-term prescription for an “alliance,” in these hard times it isn’t realistic to expect hospitals and doctors to act against their self-interest. It would be like asking Kaiser and Mayo and Geisinger and the rest to start doing more than patients need, in order to help stimulate the economy. Nor is it clear who has the time, money and incentive to organize the alliance. No, the real prescription is to put hospitals and docs at risk TOGETHER for both costs and outcomes as soon as we can. That will be the real reform.

98. Provocative article, but putting the burden on physicians to voluntarily implement the 7 cost-cutting ideas ‘right now’ seems unlikely. Until the data precipates systemic change in protocol, and the ‘government’ provides a legal safety net, and reimbursement rewards physicians for a treatment change, how can physicians change their behavior?

99. Well written article.
    The best way to bring down the Healthcare cost is to have the consumer manage the healthcare dollars, i.e. bring free market forces to bring down the cost. Have the cost and quality data available to the consumer aka. the patient, and have then shop very similar to shopping for airline tickets.
    I have co-founded HealDeal that helps provide the solution- http://www.healdeal.com/healdeal/.
    Archana Dubey, MD

100. 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.

101. 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?

102. 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!

103. 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.

104. 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

105. 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.

106. 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!!

107. 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

108. 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.

109. 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.

110. 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?

111. 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.

112. 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.

113. DITO!

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