Tuesday, December 2, 2008

An Epidemic of Overtreatment

This blog entry was co-authored with Rich Parker MD, Assistant Professor, Internal Medicine, Healthcare Associates.

Healthcare costs in the US are approaching 17% of the GDP and may be as high as 20% in the next few years.

What is causing the US to have the highest cost and lowest value for the healthcare dollar? Simple - it's overtreatment.

Overtreatment takes many forms - from over ordering expensive diagnostic tests to the prescribing of expensive and sometimes unneeded therapeutics.

There are many reasons for this. Here are just a few:

1. Incentives are misaligned. Healthcare reimbursement in the US pays for quantity, not quality. This means that clinicians benefit from performing more procedures, hospitals benefit from more diagnostic testing, and the pharmaceutical industry benefits from adoption of new name brand drugs. If you do not believe this to be the case, spend a day in an ambulatory care clinic or a hospital and see what goes on. Ask any resident, fellow or attending how many tests and treatments are unneeded. We believe that paying for wellness or paying for outcomes will solve this piece of the overtreatment puzzle. If doctors and hospitals had to live within a budget, diagnostic and treatment strategies would change quickly and become less expensive for all of us with equally good clinical outcomes.

2. We've attended many gatherings where parents discuss brand name powerful antibiotics and recommend that they become the first line drug for treatment of anything their children complain about. "Don't accept Amoxicillin, go for the Augmentin or Cipro". John's daughter is 16 and has not ever taken an antibiotic in her life. She's had a few viruses, but no virus is cured by antibiotics. Overtreatment of the pediatric population with powerful antibiotics creates resistant organisms that make children sicker and create a dependency on ever more powerful antibiotics. The problem with adults is equally severe. Watch the evening news and within an hour you'll hear about a dozen brand name pharmaceuticals treating diseases you've never heard of, but may now suspect you have. The United States is the only country in the world that allows “direct to consumer” advertising. We believe this advertising should be regulated to solve this piece of the overtreatment puzzle. Those advertising dollars end up coming out of your pocket too!

3. Some patients are not willing to accept risk or shared decisionmaking with their doctors. They want to begin the evaluation of back pain with an MRI instead of trying a course of gentle exercise and pain meds. Many issues do not have a clean or simple diagnosis. Eat right, exercise, avoid caffeine/nicotine, and let the body heal itself. For many conditions, rest and time cure the problem. Although the healthcare systems of Canada and the UK have their problems, the fact that access to expensive diagnostics is limited enables patients and their doctors to work together on simpler evaluations and therapies as a first step. We need to change the cultural expectation that expensive tests are "first line".

4. As a country the US eats poorly, avoids exercise, drinks an infusion of lattes, and then wants to take a pill to make all the lifestyle diseases go away. Lifestyle issues should be treated with lifestyle changes, not pharmaceuticals or nutraceuticals. Our own experience convinced us of this. John gave up the lattes, the super-sized meals, and began daily exercise 7 years ago. Since that time, all his lifestyle diseases have disappeared.

5. Overtreatment begets overtreatment. If a lifestyle disease is treated with pharmaceuticals, it's likely that those medications will cause side effects. The symptoms of side effects lead to further diagnostic testing and more pharmaceuticals are often the result. We know several patients who are on medications for hypertension due to overeating, H2 blockers due to excess caffeine/nicotine consumption, and several medications to treat the side effects of their initial medications. Two or three medications can fast become ten. We've suggested taking a medication holiday with appropriate clinical supervision, redesigning their diets, and beginning daily exercise. The answer we often hear is that taking all those pills, having all those tests, and visiting their clinician often is easier than changing their lifestyle.

6. Today on the local radio station, an attorney asked the question "have you ever had a bad outcome or misdiagnosis? I've been holding doctors accountable for 30 years. Call me and we'll get you the cash settlement you deserve." There are bad doctors. There are doctors who are unskilled at surgery or provide very non-standard care. However, most clinicians are trying to do the right thing. Medicine is not an exact science. It's based on experience and probabilities. This means that even the best clinician will miss a rare disease or an atypical presentation of a common disease. As a country, we need to realize that delayed or misdiagnosis will occur despite best efforts and accept a low level of imperfect outcomes instead of forcing every doctor to overtreat every patient in the pursuit of 100% certainty. Both patients and doctors together must accept some degree of uncertainty or we will continue to bankrupt our system.

Our economy has lost its competitive edge because our healthcare costs have ballooned to extreme levels due to misaligned incentives, overzealous pharmaceutical marketing, expectations of high cost testing/therapeutics, excessive administrative costs and complications due to overprescribing and fear of litigation.

The diagnosis of overtreatment is simple. The therapies are complex. We've proposed a few fixes above and will continue to write this topic in blogs to come.


Neelesh said...

I totally agree.
I hope americans read this and understand where they are going wrong in Healthcare delivery mechanisms.

"That the American healthcare delivery system is out of control and wasteful is a no-brainer.

Needless battery of investigations and over diagnosis, branded drugs, impractical insurance laws, free-markets approach to health care and sedentary lifestyle are all major factors in creating the current scenario.Its like a bad spiraling black hole which only sucks you into unnecessary and wasteful consumption of health services."

Neelesh said...


Tiny Shrink said...


quiltmidwife said...

Direct-to-consumer pharmaceutical advertising needs to be regulated...out of existence!

caregiver7careseeker said...

So how do we utilize health informatics to combat the forces of overtreatment arising out of a top down model of specialty care.

Unknown said...

Someone really decided to put on their thinking cap, great going! It’s fantastic to see people really writing about the important things.


Eddy said...

Would standardized ordersets help curb some of this overtreatment?

Anonymous said...