This is not a new book by any means — it was published in 2007 — but I decided that if I wanted to write about healthcare to any degree, I needed to go back to this book, which was quite eye-opening when I first read it. (I don’t think it was that long ago — I was surprised at the publication date, since most of my reading comes from the new book shelf at the library, but maybe this made its way into my hands from a reference elsewhere.)
Anyway, Brownlee is a journalist, not a medical professional, but she’s been writing about healthcare issues for a long time and does so here with authority, but accessibly. Some of the key facts from her introduction:
We spend between 1/5 and 1/3 of our healthcare dollars, or between $500 and $700 billion dollars, on care that doesn’t benefit us and, often enough, actually harms our health.
Another estimate is that 30,000 Americans die each year as the consequence of unnecessary care.
Overtreatment is due in part to defensive medicine, to be sure, and partly to unthinking routines (anecdotally: a dying patient being scheduled for a mammogram) and lack of coordination, but to a large degree to the fee-for-service nature of our health care system, in which doctors have become wealthy from all this overtreatmetn.
Brownlee begins with Jack Wennberg, a researcher at Dartmouth who studied the prevalence of various treatments across the 16 hospitals of Vermont, beginning in the 1970s, and then expanded his studies to Maine and then nationwide. He found that there was tremendous variance in how frequently doctors in different parts of the state performed procedures such as tonsilectomies and hysterectomies, in his initial research, and that the costs to Medicare varied tremendously across the country in ways that weren’t explainable by the local cost of living or by the health of patients in the region, but by how much treatment Medicare enrollees received — and that the higher rates of treatment in some parts of the country did not correspond to better health, but worse health outcomes.
Part of the reason for this counter-intuitive result is that, if a procedure is of no or negligible benefit to a patient, it can do harm simply by putting the patient in harm’s way, at risk of all the varieties of medical error, infection, etc., in a hospital environment. Plus, the more treatments a patient receives, from the more specialists, the greater the risk of lack of coordination of care.
But there’s more than that: there are procedures which are commonplace, and highly profitable, but not actually beneficial to the patient. (Now I’m skimming a bit faster as I reread.) Page 105, on angioplasties (a kind of heart surgery): “Before the most recent rigorous study published by Veterans Health Administration researchers, four large, randomized, controlled clinical trials had compared angioplasty to medical management of patients with serious heart disease, many of whom had already had a heart attack. All four studies found no difference in rates of subsequent heart attacks or death . . . The fifth study, from the VHA, confirmed those results.” But these studies haven’t caused doctors to stop their practice.
The biggest such example? high-dose chemotherapy with subsequent autologous bone marrow transplant as a treatment for breast cancer. After the first procedure in 1981, the treatment prevalence exploded. Insurance companies were forced, due to pressure, legislation, or lawsuits, to cover the massive cost, even though no clinical trials were conducted, until in 1999, results of clinical trials showed that this treatment was no better than its alternatives — more women were cured, but it was more than offset by the higher risk of dying during the treatment.
One the one hand, this has a “happy ending’ of sorts — this procedure is no longer done. But that’s just one, albeit extreme, example, of overtreatment. Other harmful treatments, or treatments without any proven benefit, continue.
This is just the first half of the book. I’ll continue with the remainder tomorrow. But here’s the key point: the image of the doctor as Doc Baker from Little House on the Praire, coming to the Ingalls’ family’s aid, is a fairy tale. People who get bent out of shape about managed care proposals or concepts of accountable care because it will disturb the sacred doctor-patient relationship are missing the big picture of what American medicine is like today: a business.
CONTINUED:
I decided to pick up where I left off instead of starting a new blog post, just to keep this all together (albeit bumped).
On hospitals:
ICUs, and hospital beds in general, tend to be filled up, regardless of how many beds there are relative to the population. For instance, both Boston and New Haven are considered to be communities well-served by hospitals/medical centers, but Bonston has 55% more beds per thousand Medicare recipients than New Haven — and the elderly in Boston spend 40% more time in the hospital than in New Haven, with no better health outcomes. The same scenarios repeats itself in similar studies done in various regions of the country. More hospital beds = more hospitalizations, without improving health outcomes, and without a sicker population to begin with.
On spinal fusions for chronic lower-back pain: 303,000 such surgeries were performed in 2004. (Remember, the book is from 2007.) No well-conducted clinical trials support the effectiveness of this surgery.
On CT scans and MRIs: there’s an explosion in the use of such scanners. 40 million CT scans in 2000. 54 million in 2004. 76 million in 2005. Brownlee doesn’t cite any studies of how many such scans were unneeded, but describes several situations in which CT scans are (mis)used: to diagnose appendicitis (the rate of misdiagnosis of appendcitis didn’t change with the advent of universal CT scanning), to diagnose a brain bleed following a head injury(standard neurological tests work just fine, and a CT scan has resulted in people ignoring the instruction to come back if they experience symptoms later, since they think the scan has guaranteed “all’s well”), as a “virtual colonoscopy” (anecdotally, citing a man whose CT scan showed lumps in the lung which resulted in a month-long, $47,000 ordeal to determine that the lumps were harmless). And the CT scans aren’t just costly, but put a patients’ health at risk: a single CT scan produces as much radiation as 200 chest x-rays, and may be part of the reason why thyroid cancer rates are rising; they’ve doubled since 1980 and are rising at the rate of 4.3% per year.
Oh, and back to heart surgeries — cautherization, angioplasty, or full-blown bypass surgery are being performed on patients who are severely impacted by heart disease, to be sure, but also on much milder cases. And besides the cost of it, there are real consequences: half of all bypass patients over 65 suffer from some form of dementia as a result of their surgery (p. 103).
There are several long chapters on drugs, and the explosion of blockbuster pharmaceuticals, which don’t contain much that was really new to me except that I was surprised at how recently drug advertising really began: only in 1997 did the FDA permit TV commercials with the current brief descriptions of side effects.
Brownlee discusses some of the “whys” though a lot of the remedies are saved to the end of the book. To a large degree, even though insurers and Medicare are penny-pinchers in a lot of ways, there are some operations, such as heart surgery and the stem cell transplants for breast cancer, which are/were big moneymakers. Some doctors/hospitals explicitly pursued profit; others simply found it a happy coincidence that the surgery that they believed in also made them rich.
(Side note: my ob/gyn practice — which is a very large practice — calls me regularly to remind me when I’m due for a mammogram. For an annual check-up, not a peep. One visit to their freestanding mammogram center tells you why: for whatever reason, the reimbursement rates must be pretty high to support such a upscale building. It’s a profit center.)
But there’s also a large degree to which doctors simply don’t have the training to understand that, even when a procedure sounds intuitively like the right way to go, it may not be. They don’t analyze studies and may even reject clinical studies — as was the case with the stem cell transplants: a conviction that they could see with their own eyes the effectiveness of the treatment, even though “their own eyes” deceived them.
And, in many cases, the doctor orders the CT scan or the MRI because it’s the easiest thing to do: it gets them out of the ER and off to radiology, for instance, or it reassures a patient who things that a simple “human” diagnostic test isn’t sufficient.
More to come when I finish the book!
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