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Psychiatry
How Preventive Care Could Lower Health Care Costs
Recent articles tackle the dangers—and costs—of overmedication.
Posted January 4, 2011
As Republicans prepare to take back the House and to challenge Obama's signal achievement in providing healthcare to millions more Americans, one of the arguments we'll be hearing in the coming weeks is that the country can't afford the additional coverage. Republicans will be urging us to reinstate the infamous "doughnut hole" that, until recently, created untold worry and misery for large numbers of people on Medicare. Pre-existing conditions will somehow make a comeback (it'll be interesting to see how). And the many millions of Americans that Obama's and the Democrats' reforms have assisted will be asked, in effect, to give up their newly acquired coverage so insurance companies can continue ramping up rates for everyone else.
Although the same Republicans had no qualms about adding $850 billion to the deficit in extended tax breaks for billionaires, responsible Americans concerned about the ballooning deficit are right to be concerned about the amount of debt we're accruing. More than 3 percent of the U.S. budget ($800 million by 2020) will soon go just toward debt servicing, and health care costs--though Obama's reforms have gone some way to tackling them--are still on a clear uptick.
But while Republicans are intent on politicizing care, there are other, far-more effective ways of lowering costs that deserve more airtime, including by revisiting preventive care and some of its excesses. Those excesses not only return higher costs to patients (through greatly increased premiums and co-pays), but also can do demonstrable harm to the same vulnerable population by needless, irresponsible overmedication.
In 2008, the Lancet ran an important article, "Is clinical prevention better than cure?," whose principal author, Dr. Juan Gérvas (Equipo, CESCA, Madrid; and Johns Hopkins, Baltimore) focused on the "daily challenge" facing doctors wanting to find "the right balance between prevention and treatment." As wealthier countries in particular move from cure to prevention, in an effort to anticipate future diseases, far too little attention was being paid, Gérvas argued, to the degree to which prevention can also do serious harm, including by overmedicating, creating unanticipated side effects, and--our focus today--massively ramping up costs. Noted Gérvas, "The potential consequences of preventive measures include possible disruption of cultural and individual capacities to cope with sickness, pain, and death; increased fear and perception of illness where none exists; and clinicians' frustration over a growing list of requirements that are impossible to accommodate within the clinical visit."
Of particular interest to Tokyo-based medical professor Yuri Sato, responding in the same medical journal three months later, was Gérvas's focus on the consequences of "individuals' wishes for immaculate health," a concept that Carl Elliot addressed in Better Than Well: American Medicine Meets the American Dream (2003). For Sato, as for Elliot and Gérvas, conscious also of the unstated dangers and basic impossibility of "immaculate health" for most populations, far more attention needed to be given to the differences between relative risk and absolute risk, as well as the "relentless ... pressure [for physicians] to do more, whether in prevention or treatment."
Just one source of that pressure is direct-to-consumer advertising, which urges the worried well to "ask their doctor about" dozens of new medications offered for conditions whose severity is often greatly exaggerated. "Not all preventive activities are of equal value," Gérvas noted, drawing on still-earlier assessments of this problem, such as Ray Moynihan and Richard Smith's 2002 editorial in the British Medical Journal, "Too much medicine? Almost certainly."
I was reminded of Gérvas's fascinating article when Marc Jamoulle, a Belgian physician, shared with me last month an article he'd co-written with Gérvas and three other European practitioners. (The article, appearing in the November 2010 issue of Primary Care, has already appeared in five languages.) Extending Gérvas's earlier arguments and those of many others sharing the same concerns about prevention often doing more harm than good, Jamoulle, Gérvas, and their colleagues developed the concept of "quarternary prevention" in a bid to eliminate the vast excesses of European and American overmedication.
Quarternary ("fourth") prevention examines the "meeting point between illness and disease," they write. Beyond primary, secondary, and tertiary prevention, quarternary prevention (hereafter QP) "encompasses the consequences of the encounter between the anxiety of the patient and the uncertainty of the doctor," where overdiagnosis can often create a "false positive, with its cohort of avoidable human, social and economic costs and suffering."
Whereas primary prevention includes such essential acts as immunization against known diseases, and secondary and tertiary prevention aim to lower risk factors by screening and early detection, QP, they write in Primary Care, "is the prevention of unnecessary medicine or the prevention of overmedicalisation."
"The principle of ‘primum non nocere' [first, do no harm] is central to the whole of medicine," they add. But "mainly in the name of prevention, there has been an explosion of new disease labels and health care measures that warrant a rethinking of the objectives and underlying philosophy of primary care. Especially in an area of high grades of uncertainty and low prevalence of severe diseases, the most difficult thing for the physician is the decision not to pursue further action and to protect our patients from unnecessary medicine."
While "the feeling of being ill does not necessarily meet the doctor's judgment that there is a disease present,... there are more and more disease labels attached to patients who feel perfectly well." "In fact," they write, "the most common so-called ‘chronic conditions,' such as hypertension, diabetes, osteoporosis and many others, are diseases without illness."
"While the patient experiences illness," they note of these and many psychosomatic and controversial disorders, and may "feel relieved from the perceived blame of a psychiatric disorder, all [such] symptoms and illnesses widely open up the doors for endless diagnostic procedures. Most of them will have normal results, but many will have borderline or false positive results. The consequences are endless further diagnostic tests and prescriptions of never-proven therapies with well-known side effects."
One of those side effects, it goes without saying, is a massive increase in general health-related costs. Another, often labeled "disease-mongering," is the deliberate exploitation of medical and psychiatric gray areas, with interested parties pushing to expand the "disorder" to fit the largest possible population because it suits them to represent the condition as graver, more extensive, and less recognized than we've hitherto known. Working often with the notion of "unmet need" and "underdiagnosis," these interested parties (including the drug companies sponsoring the research on their product in the first place), stand to gain enormously if they can expand the pool of prospective patients/clients from chronic sufferers to include also those with mild or nonexistent symptoms.
In my work on social anxiety disorder, this type of "diagnostic bracket creep" recurred all the time, with one academic example (an article on setting the boundaries of the condition) noting that simply by adjusting one or two variables, the researchers could expand the percentage of the general population said to be affected from less than 2 percent to more than 18 percent (that is, from less than two per hundred to almost one in five).
Coincidentally, I finished reading Jamoulle and Gérvas's article just as fellow PT blogger Allen Frances posted "DSM-5 and Practical Consequences: First, Do No Harm," concerning a special issue of the Journal for the Advancement of Philosophy and Psychiatry on the messy terrain of psychiatric diagnosis. In Frances' interesting reply to UCLA-based Joseph Pierre's excellent essay "Mental Disorder vs. Normality: Defining the Indefinable," in which Pierre called "the inability to establish a functional definition of mental disorder" "a hole" at the heart of psychiatric nosology, Frances wrote in broad agreement:
"My concern is that psychiatry is rushing pell-mell to define as illness a number of milder conditions for which there are currently no treatments with proven effectiveness (other than placebo and time). This is being done on the basis of tissue-thin scientific evidence; on the recommendation of experts in each field who have an understandable bias toward expanding their special interest; and without the benefit of serious external review. There has been far too little consideration of the risks to false positives or of the societal costs of conducting what amounts to an enormous public health and public policy experiment in promoting the widespread use of medication for unproven indications."
"The premature inclusion of the largely unstudied spectral diagnoses in the official nomenclature would give [the proposed diagnoses in question] a substance beyond their shadowy deserts and feed the drug company marketing beast," the former DSM-IV editor conceded. "I believe strongly that we shouldn't attempt to extend our reach until we are much-more sure of our grasp."
In broad agreement, the full title for this post should therefore be: "How preventive care could lower health care costs--but currently does the opposite."
If "the prevention of unnecessary medical intervention" is to remain "a foundation block of medicine (primum non nocere)," Jamoulle, Gérvas, and their colleagues noted similarly last November, "the strongest means to accomplish this is to listen better to our patients." I applaud that move and don't wish to downplay its beneficial implications, especially if it prevents harm from needless medication. But what Pierre and Frances add to their emphasis, by way of complication, is both the "hole" at the heart of psychiatric diagnosis and the financial incentive to cover and conceal it, to make it seem as if it weren't there.
In short, if QP is to have any chance of succeeding in American medicine and psychiatry, given the vested interests of researchers and Big Pharma in making preventive care seem only ever beneficial, cost-effective, and harmless, listening to the patient--while important--unfortunately won't be enough. Focusing on the "hole" in psychiatric and medical diagnosis is also critical if we're to stop the juggernaut in psychiatric expansion (and cost-related increases) and regain some perspective and sanity in the health care debates.
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