Over-treatment or Duck Dynasty?

In the past two weeks, while the headlines followed the suspension of Duck Dynasty patriarch Phil Robertson, the flood of medical research continued. We learned that the FDA suspects multivitamins have minimal benefit, dietary supplements might not be as safe as touted, antibacterial soap might interfere with the body’s hormonal balance. The CDC reported that attention deficit disorder diagnoses increased six –fold in the last decade, and Chicago researchers concluded there’s wide variation the quality of care black women with breast cancer receive compared to white women, especially when compared across major cities (with Memphis the deadliest!)

But the study that caught my attention most was about knee surgery, specifically repair of the meniscus, which 700,000 of us have had—in my case, multiple times. Per a Finish double-blind study of 146 patients—half whose tear was repaired and half who were anesthetized and an incision made but with no repair—a year later, the outcomes were comparable. The study team concluded “In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure” (Sihvonen et al “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear” New England Journal of Medicine 369:2515-2524, December 26, 2013). Say it aint so!!! Sham surgery???

Health care is about diagnosing and treating diseases and medical problems. It’s not an exact science, especially when complications are factored into clinical algorithms, or when a person’s medical history is hard to trace. Assessing signs, symptoms, risk factors and co-morbidities to arrive at a diagnosis and treatment plan is both art and science. That lends to the widespread variability in how much is done, and where. For example: back surgery in Honolulu is 7 times less likely than in Casper, WY for Medicare patients with similar symptoms, and so on. Where you live, therefore, determines the amount of care you get, including care that’s not necessary.  

Where the evidence is strong—where scientific research points to a treatment that works best, one would expect minimal variation and widespread adherence to a “best practice” but that’s not the case. In fact, overtreatment for unnecessary care that’s not evidence-based is widespread: 20% of the medical pacemakers implanted aren’t necessary. Same for 12% of the coronary stents, 43% of the colonoscopies, 17% of spinal fusion and 70% of hysterectomies. And it’s costly: between $210 and $226 billion annually (Institute of Medicine September 2012, JAMA August 27, 2011) more than the costs of fraud ($75 billion annually or excessive administrative inefficiency-$190 billion annually) and more than enough to provide health insurance for the 50 million lacking coverage.

So why isn’t overtreatment a centerpiece in the current health reform debate, especially if its long-term is to reduce costs while enrolling more in insurance coverage. There are five reasons:

1-Physicians resent the discussion of what’s necessary and what isn’t. Physicians spend 8-9 years after finishing college learning their trade, and thereafter face annual credentialing and peer reviews to keep their license in good standing. Last year, spending for medical services increased 1.4%, but most of that went to physician overhead instead of their incomes. They’re frustrated. Badgering from health insurers and lower reimbursement is testing their patience. The prospect of having to defend their practice patterns from inquisitive patients is simply unwelcome. And they reason it’s no one’s business to know if they profit from a referral to a surgery center or imaging facility they own, but snoopy regulators and watchdogs are making that harder. (The ACA puts constraints on physician ownership of hospitals but leaves other physician-owned enterprises in tact). Overtreatment, therefore, is a sensitive subject to physicians. None is guilty of overtreatment: trust them, don’t challenge them. And don’t forget, the lions share of physician income is still based on volume: doing more means doing better financially. Notwithstanding the promising Choosing Wisely campaign sponsored by the ABIM Foundation, the majority of physicians still prefer overtreatment be confined to physician opinion than systematically reported for all to see.

2- Medical malpractice system does not protect doctors who avoid overtreatment. Physicians and hospitals spend $14 billion paying malpractice premiums, but protection from litigation is not based on adherence to evidence-based practice. In fact, medical liability requires physicians to err on the side of overtreatment adding $45 billion annually for tests and diagnostics that otherwise wouldn’t be done. While overtreatment is excessive and pervasive overall, defensive medicine is understandable where there’s fear of plaintiff’s bar, ambulance chasing lawyers, and elements in society who view medical malpractice as a lottery system. But the excess cost of overtreatment is four times the cost of defensive medicine: it’s simply a fact that much of what’s done under the guise of “defensive medicine” is about physician preferences and unnecessary care.

3-Consumers don’t seem to care. Part of the blame for overtreatment rests with us. We trust our physicians. We think most practice per the evidence, and only 1 in 10 of us is comfortable challenging a their opinion, especially men. As a result, we agree to surgery and tests that might not be necessary often oblivious to other treatment options. Teachable moments are rare for consumers. Those with high deductible insurance might push back from tests and procedures a bit more than others, but data suggests it results in higher price sensitivity rather than a questioning of medical necessity. Families facing end of life heroics for terminal illnesses likewise face the question of overtreatment at the end of life. And ironically, many consumers prefer more to less, reasoning its best to err on the side of caution (especially if someone else is paying the bill). The fact is that overtreatment isn’t dinner table conversation, nor is its analysis central to how doctors and hospitals operate. Imagine a hospital ad ‘we do unnecessary fewer hip replacements than anyone else’ with data showing local comparisons. That would stir things up!

4-Employers aren’t focused on overtreatment…yet. Employer-sponsored health insurance covers more than 160 million Americans. But it’s rare among even the biggest employers with the richest benefits to find a HR executive armed with data about overtreatment and its costs for their company. There are lots of excuses—the insurer who handles claims is unwilling or unable to provide the data, or perhaps costs have been slowing and there’s no need to rustle feathers. But they’re excuses.  Health costs for employers will increase 6-10% annually in coming years. Historically, employers have presumed that standards of care are followed consistently and overtreatment minimal: that’s likely to change.

5- Politicians steer clear of the issue. In August 2009, a provision in the House of Representatives’ version of their health reform law proposed to reimburse physicians if one of their Medicare patients sought their advice about end of life care options. The draft language included a code to which physicians could bill Medicare for the conversation, but in the heat of political discourse, that became “death panels” and opened Pandora’s box about “government run rationing” of health care services. Political leaders cower from any discussion about overtreatment and unnecessary care. They reason it’s too risky defaulting to more comfortable topics—like fraud surveillance, administrative simplification, and price transparency.

Overtreatment is a tricky issue. It requires the capture of data from medical records so the practice patterns by clinicians can be monitored and characteristics of patients analyzed. But in the heat of the current health reform debate and with heightened public sensitivity about personal privacy and security (a la the National Security Agency’s telephone record metadata program and the hacking of 40,000,000 Target credit card transactions), there’s pushback.

As the week ended, CMS reported 1.1 million Americans had signed up for a health-care plan through the federal health insurance marketplace by December 24 and national A&E’s announcement that Duck Dynasty star Phil Robertson’s suspension had been lifted grabbed national headlines. Over-treatment didn’t get much attention.

Last week was Duck Dynasty week, but it should have been overtreatment week. It’s arguably more important to every taxpayer, employer, and individual.