An Epidemic of Questionable Care

When does “low-value care” become no-value care?

Posted May 12, 2015

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“An avalanche of unnecessary medical care is harming patients physically and financially,” warns Harvard professor and surgeon Atul Gawande in an article published yesterday in the New Yorker. “Virtually every family in the country has been subject to overtesting and overtreatment in one form or another,” he notes, citing an array of persuasive and troubling research. “The costs appear to take thousands of dollars out of the paychecks of every household each year” and have come to be known as the “financial as well as physical ‘toxicities’ of inappropriate care.”

Gawande, the author of a series of bestselling books on medicine, surgery, and medical ethics, including the National Book Award finalist Complications (2002) and, from last year, the outstanding Being Mortal: Medicine and What Matters in the End, extends their theme and premises in his latest article, “Overkill,” to tackle what he calls an epidemic of “pointless medical care.” Such waste, he argues—joining concerned experts such as Dartmouth Medical School professor H. Gilbert Welch in Less Medicine, More Health (2015)—is eating up a third of health-care budgets, with negligible-to-negative results, as some diagnostic studies in significant numbers become harmful in themselves.

In a single year, Gawande notes, researchers found that 25-42 percent of Medicare patients received at least one of twenty-six inappropriate or unnecessary tests and treatments. (The list includes doing an EEG for an uncomplicated headache or a CT or MRI scan for low-back pain in patients without any signs of a neurological problem.) In the U.S. as a whole, he adds, a population of three hundred million annually undergoes “around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests.” These numbers should give anyone pause. They appear just as Reuters reports that the number of Americans using $100,000 worth of medication tripled last year.

A major cause of this epidemic of questionable care is the nation’s piecemeal payment system, which “reward[s] doctors for the quantity of care provided, regardless of the results… The system gives ample reward for overtreatment and no reward for eliminating it.” Another factor is “information asymmetry,” a term coined in the 1960s by Nobel Prize-winning economist Kenneth Arrow to describe an ongoing conundrum in healthcare: even patients seeking an array of expert medical assessments struggle to gauge the quality of advice they receive. The imbalance, notes Gawande, puts doctors “in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”

As throughout his writing, which pinpoints these complex issues with immense subtlety, humanity, and care, Gawande observes that as a doctor, he is “far more concerned about doing too little than doing too much. It’s the scan, the test, the operation that I should have done that sticks with me—sometimes for years.” All told, he says, doctors understandably are “more afraid of doing too little than of doing too much. And patients often feel the same way. They’re likely to be grateful for the extra test done in the name of “being thorough.”

Nevertheless, he concludes, merely paying more attention to how many tests are ordered, for which symptoms and ailments, and how much they cost has had a significant effect on healthcare budgets in Texas, the focus of his article, without stinting on the quality of care: “the biggest savings and improvements in care are coming from avoiding procedures that shouldn’t be done in the first place.”

“Overkill” is available from the New Yorker here.  Follow me on Twitter @christophlane