Welcome to the RightCare Weekly, a newsletter that will help you stay on top of all the important news in the ongoing quest to move the U.S. health care system toward the right care. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important and what they mean for patients, doctors, and communities.
Big week in overuse news! Let’s get right to it.
The top story this week: An article published this week in JAMA Internal Medicine estimates that over twenty-five percent of Medicare patients receive at least one unnecessary medical test or procedure each year. The study drew on lists of ineffective treatments from Choosing Wisely, the US Preventive Services Task Force, NICE, and others. The authors found that spending on just 26 ineffective procedures amounted to at least hundreds of millions of dollars, and more likely billions. It’s important to remember the procedures sampled amount to only a tiny fraction of the overuse in the system – much overuse isn’t on discrete procedures, so this exposes one limitation of focusing on specific procedures when trying to improve care. You can read more about the study at the Washington Post and Kaiser Health News.
Breaking: as we were compiling the Weekly, the Obama administration announced its support for some use of “reference pricing” by insurance plans. The basic idea of reference pricing is that patients should be free to choose the treatment they want – but insurers and governments shouldn’t necessarily have to pay for more expensive options that are no more effective. For example, it’s been suggested as a way to deal with treatments like proton beam therapy for prostate cancer, which are far more expensive than standard treatment, but are no more effective. There are no specifics for the Obama administration’s proposal yet, but this could be an important first step toward reducing spending on invasive treatments that are no better than less-risky, less-expensive alternatives.
We missed an important story last week: Dr. Peter Bach’s heart-rending story of his wife’s death from lung cancer. The long piece in New York Magazine explores the difficulty he faced as a doctor, knowing in detail how his wife’s illness would most likely progress, but feeling too scared to share that knowledge – not wanting to take away their hope. The story includes a powerful acknowledgement of how patients and families can feel compelled to try additional treatment, because “why not?” – even knowing that it was unlikely to help and would cause additional suffering.
“As he wrote out the prescription for her to start the next treatment, what doctors call “second-line treatment,” I recalled a colleague of mine explaining the progression from first-line to second-line to third-line treatment. Each successive change brings more side effects with less chance of benefit. As my colleague put it, the cancer gets smarter, the treatments get dumber. Somewhere in this progression the trade-off no longer makes sense. Where that is may differ for each patient, but I’ve often thought that cancer doctors go well past that point.
“None of that mattered to me, the medical professional to whom all these nuances and trade-offs should. All I could think about was the blood test telling us the tumor marker was too high. With that, any dreamy conceit—that patients should be given enough knowledge that they can weigh the risks and benefits for themselves, then come to the choice that best suits them—flew out the window. Our choice wasn’t a choice. Take the chemo.”
Rosemary Gibson, author of several important books on health care and panelist at the 2013 Lown Conference, has this piece in the BMJ on “The Human Cost of Overuse.” It draws on the example of the small town of China, Maine, to show how high medical spending – driven in part by overuse – causes serious problems for local communities, and the struggles those communities face in making up the shortfall.
NPR Health News posted a column from a physician on the anxiety over cholesterol that permeates American medical culture. Although high cholesterol is a risk factor for heart disease, it has been so blown out of proportion in popular culture that healthy patients see cholesterol testing – and aggressive attempts to lower cholesterol – as an essential part of getting good health care. The author sees conversations that start with cholesterol as a way to open up conversations about other, more important issues. But the concern over cholesterol also illustrates how media and pharmaceutical messaging can interfere with the doctor-patient relationship. If patients see cholesterol testing as central to “good medical virtue,” and are skeptical of a doctor who rightly suggests that healthy patients don’t need to be overly concerned, it’s not a conversation-starter – it just makes it that much harder for those other important conversations to happen.
A new study conducted by researchers at UCLA suggests that treating early-stage prostate cancer in older men with other health problems does more harm than good.Medical News Today writes that aggressive treatments often do not help older patients live longer ,and instead can make other unrelated health problems worse. Instead, the focus for these patients should be on preserving and enhancing quality of life.
Finally, we have a couple new videos from Shannon Brownlee’s participation in the “Reform to Transform” event hosted by the Universal Healthcare Foundation of Connecticut. The videos of her talk address the three interrelated issues of overuse,underuse, and misuse of health care. Check them out!