February 11, 2015
By Shannon Brownlee
Why is it so hard to make a dent in the huge volume of unnecessary health care? In the U.S., about 20 to 30 percent of the medical interventions American patients receive are useless and often harmful, and waste hundreds of billions of dollars each year.
Insurers have known this for decades. These days, many more doctors have begun to see the big picture, along with policy makers. But the medical industrial complex just keeps on delivering treatments patients don’t need, despite the efforts of many well-intentioned health care professionals and a welter of quality improvement projects, ranging from lists of “do not do” tests and treatments compiled by the Choosing Wisely campaign to alerts in electronic medical records.
A cry of frustration I heard last week illustrates why such technical fixes are not going to be enough to uproot the deeply embedded culture of overtreatment.
This cri de coeur came from a young doctor in his residency training (I’ll call him Gene, because I don’t want his preceptors at the Harvard hospital where he’s in his second year of residency to recognize him). Gene was sensitized as a medical student to the problem of overtreatment two years ago, when he attended a Lown Institute Conference on the topic.
Until that meeting, the first ever devoted to overtreatment since the 1950s, Gene had no idea how routinely patients were harmed by unnecessary care, or how much money we waste on it. Once alerted, he felt compelled to learn everything he could about the problem, and vowed to avoid hurting his own patients with useless treatments during his residency.
That has turned out to be a lot harder than he imagined. “Practicing [medicine] in a way that limits overtreatment is to practice in a way that is vastly different from the status quo,” he wrote in his anguished email.
For example, he and a patient decided together that she does not need or want a mammogram, a perfectly reasonable decision given the evidence on mammography. When he told his preceptor of the decision, Gene was instructed to order the mammogram anyway.
Why? Because the hospital’s risk management company recommends it. “The risk management company doesn’t care about this woman’s anxiety about constant testing,” Gene wrote, or about the emerging evidence on mammograms. It just cares about protecting the hospital from a potential lawsuit.
Another of Gene’s patients, a diabetic, is doing badly on an oral diabetes medication plus insulin. When Gene suggested to his preceptor that the patient go off insulin except when he has symptoms, a recommendation that’s backed up with sound scientific evidence, his plan was treated as “absolute heresy.”
Gene, not surprisingly, is feeling a bit demoralized. He wrote, “What is particularly painful is to believe in my heart that a mammogram for this woman would be harmful, and insulin in this man is harming him, and to write the order anyway.”
He isn’t alone. I could tell you about dozens and dozens of other doctors I’ve talked to, along with nurses, physician’s assistants, physical therapists and others, all of whom are feeling isolated and frustrated by their inability to swim against the tsunami of factors that drive overtreatment. (To say nothing of how hard it is for patients and families.)
Factors like greed, lack of time, overinvestment in hospital technology and infrastructure, and underinvestment in community-based care. Then there’s marketing by Pharma, laziness, fear of lawsuits, misguided patients, lack of evidence, and lack of knowledge of the evidence – to name just a few of the myriad ways our current health care system pushes everybody, patients and doctors alike, in the direction of more treatment rather than the right care.
What I’ve heard from health care professionals says to me, overtreatment won’t be fixed by Lone Rangers, by well-meaning individuals trying to buck an aspect of modern medicine that is woven into its very fabric. Because changing culture calls for a very different approach.
In an editorial last year in the Journal of the American Medical Association, Don Berwick, former head of the Centers for Medicare and Medicaid Services and one of the leading lights of health care reform was blunt. It’s time for mobilization, he wrote, “the political mobilization that ended the Vietnam War, began to deliver on civil rights, birthed modern feminism, and started down the long road toward equal rights for the LGBT community.”
Americans are probably not quite prepared to march in the streets for more just, effective, and affordable health care, but at the Lown Institute, we think many people are ready to talk about medicine’s crisis of values.
Overtreatment is so hard to weed out because American health care is organized not as a common good rooted in social need, but rather as a commodity. The overtreatment (and undertreatment, for that matter), the safety problems and costs are symptoms of a deeper malaise than cannot be healed with piecemeal technical solutions. The estimated $1 trillion wasted in our current system diverts resources that could be spent on preventing chronic disease, building healthy communities, and addressing the deep injustice of health disparities.
The “health care behemoth,” Don Berwick wrote, “is not evil; it’s just too big to change itself.” We agree. A better health care system, health justice, and health itself cannot emerge from existing strategies for improvement. Transformation is what’s needed, not just reform, and the first step is gathering people who are prepared to imagine a better system.
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