By Lambert Strether of Corrente.
Over the past, oh, decade or so I’ve been so consumed with the battle to get everybody into the heatlh care system — “Everybody in, nobody out,” as Quentin Young puts it — that I haven’t put much energy into thinking about the heatlh care itself. After all, just because a house is energy inefficient doesn’t mean that it’s OK to leave people out in the cold. Now that single payer is no longer “never, ever,” but a program that could actually be achieved with (an enormous) level of effort, KHN’s new series, “Treatment Overkill,” which starts with Liz Szabo’s “So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients’ Ills,” provides me with a change to broaden my scope a bit, with a survey post like this one.
So I’m going to look at two issues: (1) Is overtreatment a real problem? and (2) What are the causes of overtreatment? Spoilers: Yes, and it’s complicated.
Confession time: I’m the sort of person who doesn’t get the idea of deductibles at all; I can’t understand why anyone would seek out medical treatment unless they were absolutely sure they needed it. And the reason I fear the heatlh care system is, in fact, the prospect (painful) overtreatment; the dental clinic that was going to give me full anesthesia to remove a wisdom tooth; or my nightmare of “end of life care” hooked up to a machine in a nursing home in a room with a television I can’t turn off.
Overtreatment Is Real Problem
Evidence for overtreatment falls into two categories: Anecdotes, and studies and surveys. I’ll look at anecdotes first.
“Anecdotes” isn’t really a fair word, though; most of the stories are more about entire vertical markets (for example, stents, as we shall see). Szabo starts out with this example:
When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.
“In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.
Medical research published in The New England Journal of Medicine in 2010 — six years before her diagnosis — showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.
In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison — who was over 50, with a small cancer that hadn’t spread — without considering the shorter therapy.
“It’s disturbing to think that I might have been overtreated,” Dennison said. “I would like to make sure that other women and men know this is an option.”
(Note, sadly, that Dennison immediately puts the onus on the
consumer patient to be informed; an obvious tax on time, to be paid with the patient has the least time or energy to spare, instead of looking for the systemic solution she vaguely hints at with “would like to make sure.” This impulse is a topic for another post.)
Nobel Prize Winner Bernard Lowns gives a second example in this interview (after demolishing “bed rest” for heart attack patients as “a form of medieval torture” as well):
[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Women’s Hospital in Boston] in 1960, I was asked to see a patient who was in her late 70s, demented, and had burns over 60 percent of her body. She had been smoking in bed. They asked me to consult about putting in a pacemaker, which she did not need. Furthermore, she was clearly dying, and implanting a pacemaker would only have increased her suffering without prolonging her life. I was mortified. I wrote a note urging against a pacemaker. It created quite a rumpus. If that were an isolated episode, it would be tragic. But that kind of thing happened daily.
Here is a third, and egregious example, from Health Beat:
Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn’t need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.
The Baltimore Sun broke Dr. Midei’s story in January. In February the U.S. Senate Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee released a 1200-page report..
The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company’s cardiac stents into trusting patients in a single day: “Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei’s home.” Employees from St. Joseph’s attended the feast.
(It may seem that I’m stacking the deck on causality here, but I’m really not, although it would be foolish to deny that such cases exist.)
Note again that these examples all involve treatment: Radiation treatment, a pacemaker, and stents. We’re not talking about ordering a few two many tests. (The American Family Physican supplies numerous classes of overtreatment, not just anecdotes. See Table I.) Now to the studies and surveys.
“Overtreatment in the United States,” by Heather Lyu, et al (from the Public Library of Science, and thus peer-reviewed) has induced a good deal of discusson since its publication in September 2017. From the Findings:
The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures.
Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot of stress and fear induced for no reason. And if one out of every ten treatments is unncessary, that’s rather a lot of people going to Pain City because their number came up, and not for any medical reason. Those odds aren’t quite as bad as Russian roulette, but they’e in the ballpark! I haven’t (yet) been able to find figures on the costs of overtreatment, but there have been studies done on the costs of unnecessay care. Health Affairs:
Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of total health care spending. Even the lower estimate, from the Institute of Medicine, amounts to nearly $300 billion a year. No specialty is immune from practices that lead to overuse, as a recent spate of papers in medical journals can attest. In cardiology, even using criteria that are relatively permissive, an estimated 11 percent of stents are delivered to “inappropriate patients.” At some hospitals, that rate is closer to 20 percent.
(Note that the figure of 11% unnecessary stents jibes well with Lyu’s figure of 11.1% of all procedures being unnecessary.)
I’m sure none of this is new to any medical professionals in the NC readership, but it was new to me, and may well be new to NC readers — especially those who received treatments that they retrospectively, or just now, understood to be unnecessary.
The Causes of Overtreatment
It’s clear that one cause for overtreatment is the profit motive. (I would speculate that individuals like Midei, the stent dude, are edge cases, and that the real causes are more subtle and systemic.) Quoting again from Lyu, et al.:
The top three cited reasons for overtreatment were “fear of malpractice” (84.7%), “patient pressure/request” (59.0%), and “difficulty accessing prior medical records” (38.2%)… Seventy-one percent of respondents believed that physicians are more likely to perform unnecessary procedures when they profit from them. The interpolated median response for the percentage of physicians who perform unnecessary procedures with a profit motive was 16.7%; 28.1% of respondents believed that at least 30–45% of physicians do so (Fig 2). Respondents who were attending physicians with at least 10 years of experience (OR 1.89 (1.43–2.50) vs trainees) and specialists (OR 1.29 (1.06–1.57)) were more likely to believe that physicians perform unnecessary procedures when they profit from them… Respondents’ compensation method and hospital characteristics were not associated with differences in perceptions on the profit motive associated with unnecessary care.
So, the more experienced the doctor is, the more likely the doctor is to believe that profit drives unnecessary procedures. However, the profit motive imputed to individuals cannot be the sole driver (see “DICE: Nonclinical Causes of Overtreatment” for a model that includes “Economics” without being reductive) as this letter in the British Medical Journal shows:
As a person who follows the evolution of health care policy from the vantage point of the United States, I found BMJ’s May 12 article on “Choosing Wisely in the UK” [see here; CW is an “informed consumer” model] very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a culture of “more is better” fostered by such factors as “defensive medicine,” “patient pressures,” “commercial conflicts of interest,” “payment by activity,” and the demands of “pay for performance.”
Many critics of the American health care scene ascribe the problem of irrational overtreatment unsupported by available evidence in the U.S. to precisely the same causes, and argue that the key to rationalizing American medical practice lies in adoption of the UK’s single payer, universal coverage health care system and the UK’s system of civil justice. The fact that a Choosing Wisely program is necessary in the UK, and for most of the same underlying reasons as apply in the U.S., proves that the UK has not found the panacea to achieving rational medical practice and that emulation of the UK methods of health insurance, physician payment, and civil justice will not work as a panacea in the U.S. either.
So, sadly, single payer as such is unlikely to solve overtreatment (although I can’t think of an advocate who ever said it would).
If there were one kind of doctor-patient relationship that I would like to see incentivized when single payer comes to pass, it’s this one. Again Dr. Lown:
U.S. News: Problems with America’s health care system are economic, but they are also human. What’s been lost in modern medicine?
[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.
Call me Polyanna, but I think if the health care system started treating patients like human beings, that a good deal of overtreatment would be avoided.
 Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves actual procedures performed on a patient, often surgically. In other words, lots of pain and suffering imposed to no good purpose. (Szabo’s article considers all three, but I am focusing only on overtreatment.) American Family Physicians defines overtreatment as follows: “Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. ”