Overtreated

OVERTREATED….Wow! Who knew that a simple idea like putting doctors on salary (in organized, group practices like the Mayo Clinic and Kaiser) would provoke so much discussion? Thanks for all the comments.

Today, I’m going to pick up the thread from yesterday’s wild ride and focus on the link between costs and unnecessary care, which is the central theme of my book.

One poster stated: “You can’t just say that you’re going to cut out the 5% of procedures that are harmful.” OK, but instead of focusing on harmful care, let’s look at unnecessary care (which, it turns out, is also harmful). The amount of unnecessary care delivered in this country isn’t 5 percent. It isn’t even 10 percent. It’s closer to 20-30 percent. That means we’re wasting between $400 billion and $700 billion on care that isn’t doing us any good.

How do we know this? The best work has come out of research at Dartmouth that has uncovered wide variations in how much care patients receive in different parts of the country. The Dartmouth researchers have found a two-fold difference in per capita spending on Medicare recipients in different regions.

That difference can’t be explained by variations in the price of medical services. Of course prices differ in Biloxi and Boston, but not enough to account for the two-fold variation in spending. It also can’t be explained by differences in the prevalence of illness in different parts of the country. (Yes, people are generally sicker in Biloxi than in Seattle, but that can’t account for the difference in spending either.)

The only explanation for it is that doctors and hospitals in different regions are giving Medicare patients a lot more — and a lot more intensive — care.

This wouldn’t be a problem if all that extra care was resulting in better health outcomes. It would be great for the citizens of Boston and other places where patients receive the most care. But the extra care isn’t producing better health. Studies looking at patients with specific conditions, like hip fractures or heart attacks or colon cancer, show that they aren’t living longer or even healthier lives in places where they are getting more care.

That can only mean one thing: Patients who live in regions where more care is being delivered must be getting a lot of useless care.

Most of that useless care, it turns out, is done in hospitals, and the vast majority of it consists of small procedures, the “little stuff” of medicine, as Dartmouth’s Elliott Fisher likes to call it. Like endoscopy — sticking a scope down a patient’s throat to see why he’s coughing. Like CT scans and blood tests, and little devices called vena cava filters, which are surgically implanted into a large vein in the abdomen or chest to prevent clots from reaching the lungs and causing a potentially deadly condition called a pulmonary embolism.

A good part of the useless care also consists of visits from specialists. Let’s take a specific example here. During the last two years of life, the average patient who tends to get most of her care at UCLA will see a doctor 104 times. The average patient who gets most of his care at the Mayo Clinic will see a doctor 50 times during that same period. You can think of those two patients as being basically the same at the outset. Same disease. Same prognosis. Unfortunately, those 54 extra doctor visits at UCLA didn’t make a difference in the outcome. But they did add nearly $4,000 to the average per capita cost of care at UCLA.

Is this happening because doctors at UCLA are rubbing their hands together, thinking up ways to pad their incomes by seeing patients more often? Of course not. They are doing the best job they know how.

Nonetheless, they are delivering a lot of unnecessary care — much of which is driven by the way different hospitals are organized and how the medical cultures within them evolve. But that’s fodder for another post.

Shannon Brownlee

Shannon Brownlee is senior vice president of the Lown Institute, a nonpartisan public policy think tank based in Boston. She is also cofounder of the Right Care Alliance, a network of physicians, nurses, patients, and community activists advocating for a transformed and uniquely American health care system.